The following post is a reflection I contributed to, along with three other physiotherapists, after attending a conference on the Six Nations reserve. We wrote it for the CPA Global Health Division’s monthly e-blast and they were kind enough to let me re-post it here. Thanks to Miriam Beatty, Katie Gasparelli, and Corey Kim for their work with this as well!
On November 27th and 28th 2015, four physiotherapists attended a formal gathering of healthcare providers, Traditional Healers and Knowledge Keepers, representatives from Child and Family Services, the judicial system and political representatives. Six Nations hosted the event as a first step toward reconciliation after two families (one from Six Nations of the Grand Territory and one from New Credit of the Mississauga’s) were brought before a judge in the Ontario court system for a decision to discontinue chemotherapy for their respective children.
One year ago, Justice Gethin Edward ruled that an 11 year old Onkwehon:we (Mohawk term for original people) girl could not be forced to undergo chemotherapy and could choose to use other treatments including Traditional medicines and ways of healing. Despite the favorable decision for the family, the experience further fractured the relationship of local Indigenous communities with mainstream western medicine.
The conference began with Traditional opening remarks; a tradition of the Haudenosaunee people performed by Leroy Hill. He also presented the Two Row Wampum Treaty Belt, a description of which can be found below. On the first day, we heard from the Minister of Health and Long Term Care, Dr. Eric Hoskins, as well as, Six Nations Council Chief Ava Hill, and president and CEO of Hamilton Health Sciences Robert McIsaacs. Each pledged to work in partnership to heal the relationship, and work towards a more inclusive health care system. Justice Gethin Edward provided some insight to the group regarding his decision last fall to support the right for Indigenous People to choose the best healthcare option, including Indigenous health practices. On this day, we also heard from the mothers of the children who had cancer. Their stories were moving, and helped to ground the audience and remind us how our actions and words, as health providers, impact our clients and their families.
“The Two Row Wampum Belt symbolizes the relationship of the native people (Onkwehon:we) of North America (Turtle Island) with the Whiteman (Raseron:ni). One purple row of beads represents the path of the native’s canoe which contains their customs and laws. The other row represents the path of the Whiteman’s vessel, the sailing ship, which contains his customs and laws. The meaning of the parallel paths is that neither boat should outpace the other, and the paths should remain separate and parallel forever, that is, as long as the grass grows, the rivers flow, the sun shines, and will be everlasting, and they shall always renew their treaties”. (Jake Thomas Learning Centre, 2014-2015).
On the second day, the Director of Health Services at Six Nations presented the Haudenosaunee Wellness Model. This model offers a framework that supports a different approach to care than the bio-psycho-social model common in mainstream Canada. Their model uses four key concepts: Belonging (trust), Mastery (opportunities for success), Independence (manage their own path), and Generosity (feeling valued); and emphasizes that Traditional knowledge, medicines and practices have the potential to create wellness within the community. We also heard from a panel of Indigenous physicians and how they are incorporating Traditional Healers, and Traditional Medicine People and practices into their medical practice. They shared their ideas about the barriers and facilitators to harmonizing these different perspectives. The afternoon provided the opportunity for group discussions on topics such as decolonization, relationship building, pathways to traditional medicine, cultural competency, Indigenous medicine practitioner training and creating a safe space.
This conference provided a safe space for conversation to begin between Traditional Healers and Knowledge Keepers and Western health care professionals. Below, we reflected on various topics that each of us took away from the experience.
1) Respect: What does it look like? (Veronica)
One word that resonated long after the conference ended was the word respect. It is a common buzzword. But what does respect actually look like in a relationship between two cultures that have such a bitter past? This conference was a starting point for answering this question. Respect is expressing your hurts without blaming. Respect is acknowledging and sincerely apologizing for the hurt that has occurred. Respect is learning more about each other’s cultures, traditions, and history (the good and the bad) with a spirit of curiosity, not superiority. It does not mean, however, that you have to agree with it. Respect is agreeing to disagree sometimes, but at least not disagreeing due to ignorance or a lack of knowledge. Respect is working with each other to develop collaborative solutions that satisfy both parties, not compromises where neither party is satisfied. Respect, as a health care professional, is recognizing all your patients as unique human beings worthy of love and belonging no matter where they come from or what their life is like. There needs to be respect between cultures, within communities, within families, with ourselves, and with our environment. We are not there yet, but at least we have started the journey.
The following story from the conference is a great example of how open, respectful discussions can lead to collaborative solutions that both cultures are happy with:
A Traditional Midwife’s family member was scheduled for surgery to remove a tumor, and was taking traditional medicine in the days leading up to the surgery. This traditional medicine was important to take because it helped to contain the spirit of the tumor, according to Indigenous beliefs, so that it did not spread to other parts of the body. By combining the two approaches, it is thought that the surgical intervention would be more successful and reduce the risk of relapse.
The Western doctors were concerned about potential interactions between traditional medicines, and those western medicines required for the surgery. They wanted to know what was in the medicines. This is a legitimate concern as interactions can occur. The traditional midwife recognized and respected this. At the same time, she recognized that it is not appropriate in Indigenous culture for Traditional Healers to share what they put in their medicines. For Traditional Healers, there are no set medicines or formulae – everything is individualized based on the person’s spiritual, mental, emotional, and physical state.
Being familiar with navigating the Western healthcare system, the Traditional Midwife came up with a solution that respected both parties. She asked the western doctors what ingredients would cause interactions and should not be included in the traditional medicines. She then took that list to the Traditional Healer, who confirmed that those ingredients were not in the medicines she used. Knowing that, the Western doctors felt more comfortable with the family member taking the traditional medicines. The surgery was performed successfully a few days later.
2) Reflective Listening: Are we really listening to what is important to our clients? (Miriam)
During the conference, I was challenged to consider alternative reasons for the chronic illnesses that my clients live with on the Six Nations reserve. With illnesses such as Type 2 diabetes (T2 DM), I am quick to assume the client may have had a sedentary lifestyle, or a poor diet, or both, combined with other cardiovascular risk factors. One of the speakers shared their theory of why T2 DM has become so prevalent:
“We have lost the sweetness in our life [loss of relationships, loss of traditions, past and current hurt], so sugar has been added to our diet to fill this loss”.
A number of speakers challenged us to consider alternative root causes for different chronic illnesses by sharing the current impacts of intergenerational trauma, such as substance abuse and PTSD. When we ask questions, how often do we give clients space to share deep hurts and losses? To be honest, I can be tempted to overlook or avoid asking these types of prompting questions, as I feel like I need to be time efficient…but what does the client need to voice?
Since the conference, I have been trying to be intentional and ask clients questions that may seem irrelevant, yet necessary to develop trust and help me understand them as a person. Examples include asking about their cultural heritage and involvement in spiritual practices. This can enable someone with T2 DM to share the important things in their life, rather than only their physical activity levels. Thinking about the quote above, the speaker challenged us to consider asking people what they can do to bring the sweetness back into their life. By building a trusting relationship with the client through asking questions and reflective listening, we can begin as a team to target their concept of wholeness and wellness. We need to begin with the desire to listen; to listen to what the client is really saying, and to show them we are interested. Through reflective listening, we can participate in adding sweetness back into their life by showing genuine kindness and compassion.
3) Cultural Competency and Cultural Safety (Katie)
As an Indigenous person raised within a mainstream community, trained in a Western health profession who has returned to her community, I consider myself comfortable in both worlds. Working at Six Nations has allowed me the opportunity to learn about myself, my culture and to explore the harmonization of this new knowledge into my Western based education. Given this view, I’ve come to feel that cultural competency is perhaps not the best term to describe what the ultimate goal of harmonizing Indigenous ways of healing and Western health practices. The Indigenous Physicians Association of Canada explains that cultural competence is the, “skills, knowledge and attitudes of practitioners” (IPAC & CPSC, 2009). The concept of cultural safety goes one step further, requiring self-reflection. The ability to reflect on your own beliefs and behaviours is one component of developing safe and effective practice. Cultural humility is another term I’ve recently begun to explore which provides a construct for providers to develop culturally safe care. One of the tenets of this construct is the ability to reflect on power imbalances that might exist and to engage in a process that eliminates the imbalance (Tervalon & Murray-Garcia,1998). It’s important to mention here that the client is the one who determines whether or not you are providing ‘safe service’.
Providers may be looking to cultural competency training to be given ‘the right approach’ to use with Indigenous clients. The reality is there is no particular list of things you can ‘know’ to ensure you are practicing in a culturally safe way. Rather, the ongoing process of critical reflective practice will help develop a culturally safe approach. This requires a change in how we practice, and that means behaviour change.
Looking back at my experience in chronic disease management, behaviour change is not easy and it takes time. Ultimately, it will not happen if the client is not interested or invested in the outcome. Similarly, a change in behaviour among healthcare staff to improve cultural competency will not happen if they are not interested or invested in the outcome. This first requires a change in thoughts about behaviour. My fear is that improving cultural competency within health care staff requires not only a change in behaviour, but also a change in thoughts about behaviour. The process of behaviour change requires time and support from leaders to help their front line workers. It requires conversations like the ones many of us engaged in at the conference. Our current healthcare system is already overburdened and I am not optimistic about this change occurring within workplace settings. However, I realize that this conference was the beginning of an ongoing conversation we must now have with local and regional leaders in our healthcare system. Indigenous Health Representative position within the Global Health Division of the CPA is a vehicle for engaging the physiotherapy profession in these conversations. So maybe change is possible…
4) Building Patient Advocacy through Cultural Humility (Corey)
I am still learning much about Indigenous culture and what advocacy truly means. I have not yet had exposure to Indigenous patients, but in previous years, I have volunteered at summer camps on reserves. Even though I had a sense of the issues important in these communities, I did not realize there was so much depth to their culture. I asked Katie after one of the sessions if there should be cultural training course for physiotherapists that work with Indigenous peoples. She agreed that it is important to understand the impact of colonization and suggested that there are online resources for study. But a course these would not be able to understand and respond to the different values of each nation. I reflected on this thought as I listened to members of the Indigenous community, as well as several health care professionals, who shared their great insights during these sessions.
One key element of the Indigenous value system is language. One of the community members challenged the word “resiliency”, stating that the word insinuated a people who had been scathed and are recovering. Instead he urged people to use “cultural strength” as it portrays that the community has positively adapted. Certain words in Indigenous languages can mean more than one thing, and to define health itself requires that we not only address the body, but mind and spirit. Relationships are of great value and deeply related to health. Rather than provide a treatment, we were encouraged to build positive rapport as a means of helping our Indigenous clients connect to the next person on their life journey. Body language, facial expressions, and kindness to others permeated the conversations of the day. But it was the phrase “critical reflective practice that really caught my attention.
The question was raised as to how we could learn cultural competency. One of the participants stated that critical reflective practice is the key to learning cultural humility. It was described as understanding where our knowledge has come from and to examine it; taking our preconceived notions and comparing it to what is true. We can thus change by understanding the other person’s perspective and treat them as they want to be treated. This really struck me and welled up a sense guilt of my previous interactions of patients and people of different cultures. However, through further conversation, someone shared that guilt should be used to motivate and fuel collaboration moving forward.
Advocacy can begin with deconstructing colonization by concentrating resources to be more effective and understand what Indigenous cultures truly are. To build advocacy there must be champions inside and outside of Indigenous communities to share culture on a deeper level. At the end of the conference I noticed a graphic on the one of the tote bags we received. I asked Miriam what it was and she mentioned it was a Two Row Wampum. The parallel bars of this decorative piece to me represented communication as a two way street. We must align ourselves and work together for a common direction and purpose by truly understanding each other. Once aware of our prejudices, we can then challenge them for positive change.
Resources to learn more about Indigenous Health
Six Nations Conference Brantford Expositor Article
8 Steps Toward Addressing Indigenous Health Inequities
Two Row Wampum treaty belt
More about Indigenous Culture and Colonization
The Indigenous Physicians Association of Canada and the College of Physicians and Surgeons of Canada, 2009. First Nations, Inuit and Metis Health Core Competencies for Continuing Medical Education; Winnipeg & Ottawa.
Tervalon, M. & Murray-Garcia, J. (1998). Cultural Humility Versus Cultural Competence: A Critical Distinction in Defining Physician Training Outcomes in Multicultural Education. Journal of Health Care for the Poor and Underserved, 9(2) pp. 117-125.
Veronica Wong received her Physiotherapy degree from McMaster University in 2015. She is passionate about health promotion, critical thinking, and all things related to pain. Her interest in Indigenous health began with a placement she had with Six Nations Health Services. She knows that she also has a role to play in the process of reconciliation and would like to continue to learn how she can best fill that role. She currently works at a private practice in Brantford, Ontario.
Miriam Beatty also received her Physiotherapy degree from McMaster University in 2015. She is currently working with the Health Promotion team on the Six Nations Reserve, which is enabling her to pursue her passion to provide holistic care at the individual, group and community level. Miriam is passionate about working in culturally diverse settings, and has taken learned more about Indigenous health throughout her academics. She is honored to participate in the process of change, harmonizing Indigenous and Western medicine.
Katie Gasparelli graduated from the University of Ottawa in 2004 and worked in various communities in Northern Ontario during the first few years of her career. She has been working at Six Nations Health Services, for 6 years in the community and more recently into an administrative role with the organization. She is the Indigenous Health Representative on the Global Health Division executive.
Corey Kim graduated from Western’s MPT program in 2015. A passion for physiotherapy and cultural diversity lead him to the Global Health Division at Congress. He is now a member of the GHD Communications Subcommittee and after his final placement in Cape Town, he is now preparing for his next opportunity as a global therapist. Corey works in Seaforth, Ontario.