Improving access to Indigenous medicine for patients in hospital-based settings: a challenge for health systems in northern Canada

ABSTRACT

In this commentary, we argue that Indigenous patients in the Northwest Territories (NWT) have a right to access traditional medicine and related practitioners as a part of the continuum of medical care. Indigenous people make up over half of the NWT population, spread over vast geographic areas with representation from First Nations, Inuit and Métis (FNIM) people. Ensuring barrier-free access to traditional medicine and providers in a culturally respectful environment is a challenge that requires structural transformation in the territorial health system. The ongoing transmission of knowledge about Indigenous traditional medicine in Northern Canada and the collective survival of Northern peoples is a testament to the applicability of traditional medicines in a self-determined wellness system. Through a discussion of the barriers to policy development and implementation, this commentary aims to elevate Indigenous perspectives and offer recommendations for integrating traditional medicines into Northern health systems.

KEYWORDS:

• Indigenous health
• Aboriginal health
• traditional medicine
• healing
• Northwest Territories
• health systems

View correction statement:

Notice of Correction

Introduction

Healthcare spending in the Northwest Territories (NWT), Canada is just over double the Canadian average per capita ($12,791 versus $6,069) [1]. Yet, residents in the NWT have one of the lowest life expectancies in Canada [2]. This is due to a multitude of complex social, economic, geographic and colonial factors [3–5]. Leaders in the territorial health system have committed to working towards equity and reconciliation in healthcare, which includes a focus on cultural safety and the incorporation of traditional medicine and healing practices [6]. Territory-wide initiatives and strategies have signalled a commitment to “building a culturally respectful health and social services system” [6] and implementing the Truth and Reconciliation Commission’s Calls to Action [6]. These reports outline a process for integrating and enhancing access to traditional care for Indigenous communities.

In the context of First Nations, Inuit and Métis nations in the NWT, traditional healing and traditional medicine are understood as a set of health practices that incorporate Indigenous understandings of health and wellness. These terms are used interchangeably, and typically refer to ceremonies, plant-based medicines, counselling and other hands-on techniques (such as massage) to promote an individual’s physical, mental, emotional and spiritual health, and well-being [7]. Our vision of equitable and culturally safe care includes the integration of traditional medicine into the territorial health system for Indigenous peoples. This, however, has yet to be realised.

In this paper, we briefly describe the role of traditional medicine in the territorial health system, identify barriers to accessing traditional healing, and discuss examples of health institutions from other jurisdictions in Canada that have integrated Indigenous and Western approaches to care. We argue that Indigenous patients should have the option to access traditional healing practices in a culturally safe environment that is free from barriers. We conclude by offering recommendations for integrating traditional medicines into Northern health systems.

Healthcare in the Northwest Territories

The NWT is a one of three territories in Northern Canada. Indigenous peoples, including First Nations, Inuit and Métis, make up over half of the NWT population, and are spread over a vast geographic area. The Stanton Territory Health Authority is the main healthcare provider for residents of the NWT and the Kitikmeot region of western Nunavut. Currently, the health authority maintains an Aboriginal Wellness Programme that provides supportive services for Indigenous patients and their families who are receiving care in the health system. Since the programme’s implementation in 2012, there has been a 63.4% increase in the number of interpretation services, kinship visits and cultural programmes offered to patients [8]. This increase suggests a keen desire from patients for these services, and suggest that needs were previous unmet or underserved.

Based on a patient needs assessment conducted in 2016 [8], and through an evaluation of the wellness programme, it is evident that there is a desire for expanded access to traditional healing practices. From 2007 to 2016 the Stanton health authority had a territorial Elders Council that provided direction to health system leaders on Indigenous-centred practices. The Council recommended that the Stanton health authority improve patient access to traditional medicine [8]. The council was disbanded, however, and little progress has been made on this recommendation.

Currently, there are no institution-based traditional healing services offered within the NWT health system. One of the barriers is that policies often do not reflect or consider cultural practices, and therefore create structural impediments to Indigenous-centric care. For example, fire ceremonies and smudging, which involve burning dried plants, such as sage or sweet grass, are important practices in many of the cultural traditions in the territory. However, because they result in smoke, fire safety regulations prohibit their use in hospital settings [7].

Health funding structures in the NWT further complicate the integration of traditional medicine into healthcare delivery. At present, the federal government transfers First Nation-specific health care funding to the territorial government rather than directly to Indigenous nations and communities [9]. This funding structure adds a bureaucratic layer that limits opportunities for community control over healthcare decision-making and service delivery. Instead, First Nations must develop contribution agreements with the Government of the NWT for all health programming [10]. Additionally, due to the lack of reserve structure in the NWT, federal programme dollars that include specific “on reserve” allocations therefore exclude First Nations in the territory by design [10].

Traditional medicine in hospital settings: examples from Ontario

In Indigenous societies across Canada, knowledge keepers such as Elders are the primary sources of expertise on traditional medicine and healing. Although the study of traditional medicine is an emerging area for academic scholarship, typically this knowledge is shared through oral traditions and in apprenticeship [11]. Recent studies in addictions medicine and mental health have examined outcomes for patients utilising traditional approaches to wellness [12,13]. Due to the stark differences in the dissemination of knowledge (oral versus written) in Indigenous and Western health systems, it therefore creates barriers for the implementation of traditional medicine practices in Western dominated settings.

Across Canada, some jurisdictions have begun to recognise the value and necessity of integrating traditional medicine into care for Indigenous patients. In Ontario, for example, several large, primarily non-Indigenous hospitals have made considerable progress on integrating traditional healing into mainstream services. These hospitals are geographically dispersed in mostly urban centres (Toronto, Sudbury and Thunder Bay), with the exception of a hospital in Sioux Lookout (Table 1). Despite the somewhat distinct settings, these hospitals share several common features with respect to the integration of Indigenous medicine (Table 1). All have full-time employed Indigenous Patient Navigators, and the majority of institutions have policies to guide the use and accessibility for smudging ceremonies. The policies also specifically outline the staff support and resources that are in place to carry out each ceremony [14–16]. Furthermore, all the institutions have an Indigenous advisory council/board that provide support and direction to staff on culturally respectful, competent, safe, and holistic services that could be provided for Indigenous patients and their families. The Aboriginal Community Advisory Panel at St. Michael’s Hospital in Toronto is the first of its kind in the city and has proven to be effective in increasing dialogue between Aboriginal and non-Aboriginal peoples on issues concerning the delivery of health services [17].

Table 1. Outline of current practices in Indigenous wellness services in four distinct health institutions in Ontario

Although the examples from Ontario are instructive, increasing access to traditional medicine and healing services in these hospitals was not without challenges. For example, both in our collective work and in addition to the conversations with contacts at the respective centres mentioned, a collective barrier noted related to the disclosure of information related to Indigenous medicine. Physicians were concerned that if patients had access to Indigenous medicine there could be a negative perception of Western medicine. Health care providers were also concerned about the possible negative interaction between traditional medicines and pharmaceutical treatments. It was noted repeatedly and collectively, however, that when cultural needs were addressed by Western health providers, patients expressed that they felt empowered in facing their health problems and found comfort and familial support when they were treated with traditional medicine.

Discussion

Conventional biomedical ideologies and cultures have shaped healthcare policy, have often silenced Indigenous voices, and marginalised community input into system design [18,19]. Addressing cultural safety in the NWT health system includes addressing the power relationships between service providers and patients, the majority of whom are Indigenous people [20]. Culture and traditional healing practices are a source of identity, confidence, resilience and strength for Indigenous peoples, and have an important role in promoting individual and community health [7]. Through examination of the dynamics of healthcare relations in a post-colonial context, we must open the space for dialogue surrounding the use of Indigenous traditional healing to move closer to transformative practices in the NWT.

A closer examination of successes in other jurisdictions may help provide insight into how Indigenous healing practices can be better integrated into healthcare in the NWT. To ensure the development of adequate self-determined healthcare policy surrounding access to traditional services is achieved, an interdisciplinary approach needs to be taken. All sectors of the health system working together in a state of co-production with both patients and communities is critical to making progress in Indigenous health equity and sovereignty. This will require a structural breakdown of power dynamics enveloped in Western bureaucratic process to be brought to the forefront of discussions in relation to traditional medicine delivery. The essential role for physicians, nurses, and other health professionals in hospitals in the North should not be minimised in this power dynamic of care delivery; therefore, there is a need for improving knowledge and practice of cultural safety in professional medical and allied health education.

The noted restraints and accumulated barriers experienced in developing Indigenous wellness services can be rooted in the effort of trying to fit an Indigenous model into a non-Indigenous Western system. Indigenous culturally based interventions are often defined by a Western methodological approach, governance structure, and fiscal reporting requirement which constrains and changes the programme itself. Utilising an Indigenous methodological approach, governance structure and reporting approach, and thereby adapting the Western system to this approach and structure, would be a truly self-determined model with a higher degree of success. As such, collaboration is needed to decrease dissonance between hospital-based healthcare providers and Indigenous-medicine providers when developing policy to limit implementation barriers [21].

To continue to advance work in this area, we recently helped lead a grassroots initiative to develop an Aboriginal Wellness Centre (AWC) in the territorial capital, Yellowknife. The Centre would complement hospital-based services, and include cultural services, such as traditional medicines, access to traditional food, youth activities, regular fire and other cultural ceremonies. As a demonstration project related to the Wellness Centre initiative, we organised an urban land-based healing camp which includes many of the same activities, though on a smaller scale.

An integrated healthcare system in the NWT has the potential to be a model for hospitals elsewhere in Canada. Such a system could provide formal standards of practice for physicians and allied healthcare providers in dealing and working with traditional providers. For example, formal referral networks could be set up to ensure inter-professional referral between Western and Indigenous systems is achieved. Cross-cultural training could be introduced into hospital rounds to ensure more well-rounded understandings of Indigenous health concepts among providers. Training dollars could be invested in ensuring traditional healing practices are passed down to the next generation. Lastly, a Territorial Elder’s Council should be re-instated following a traditional Indigenous governance structure to oversee the development and implementation of traditional- medicine access in and outside of NWT centres.

Conclusion

In the current health system, health inequities and barriers to accessing traditional medicine and healers persist not only in the NWT but in many places of Canada. Promising practices that have been successful in other Canadian institutions provide valuable lessons that can be adapted to the Northern context. To reach this goal, the NWT needs to acquire a higher level of self-determination in healthcare services and processes that support the co-production of knowledge between territorial governments, NWT First Nation, Inuit and Métis governments, in addition to Indigenous wellness sectors. The process of advancing holistic Indigenous healing systems becomes an act of reconciliation when plans are co-developed and accommodate traditional- and culturally based practices in addition to biomedical approaches to health.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

None.