Indigenous-led health care partnerships in Canada
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* Lindsay Allen
* Andrew Hatala
* Sabina Ijaz
* Elder David Courchene
* Elder Burma Bushie

KEY POINTS
*   Indigenous Peoples in Canada benefit from regaining access to and strengthening traditional cultural ways of life, including health and healing practices.

*   Many Indigenous communities are working to strengthen cultural healing practices that were marred through colonization and oppressive government policies.

*   Indigenous-led health care partnerships provide innovative models of interprofessional collaboration, be it in community-based healing lodges, remote clinics or urban hospitals.

*   Emerging evidence suggests that Indigenous-led health service partnerships improve holistic (inclusive of mind, body, emotion and spirit) health outcomes for Indigenous Peoples, as well as access to care, prevention uptake and adherence to care plans.

Too many First Nations, Inuit and Métis Peoples in Canada face alarming health inequities, subpar access to health care, and culturally discontinuous services — a legacy of the sociohistorical realities of colonialism and racism that included systematic suppression of traditional Indigenous health knowledge and healing practices.1–4 The 2015 Calls to Action of the Truth and Reconciliation Commission of Canada underscored an urgent need for full health care rights for Indigenous Peoples, the elimination of health disparities, antiracist decolonization of the health sector, and self-determination in use of and access to traditional knowledge, therapies and healing practices. 1 Indeed, Call to Action 22 states, “We call upon those who can effect change within the Canadian health care system to recognize the value of Aboriginal healing practices and use them in the treatment of Aboriginal patients in collaboration with Aboriginal healers and Elders where requested by Aboriginal patients.”1

Indigenous knowledge and healing practices endure today, despite colonial policies and continued systematic oppression. Exemplary Indigenous-led movements that centre on traditional Indigenous knowledge have become an important feature of the Canadian medical landscape, promoting cultural activities, self-determination, governance, language, medicine and wellness.5–9 With an aim to foster reconciliation efforts, we analyze unique and innovative Indigenous-led health partnerships in Canada, considering the benefits that such partnerships can hold for physicians, Indigenous communities and Canadian society more broadly.

## Why are Indigenous-led partnerships needed in Canada’s health systems?

First Nations, Inuit and Métis Peoples in Canada continue to encounter major barriers to accessing and using health services in Canada, be it through racism, aggression, disrespect, differential health care, language discontinuity or lack of trauma-informed care.2,3,5,7,8,10 Because of the dominance of a biomedical approach to health care, Indigenous Peoples all too often encounter health care systems that are not reflective of or grounded in cultural worldviews or definitions of health they uphold.5,8,10 Mental health services, in particular, are often incongruent and culturally unsafe, which limits peoples’ access to sustained mental health support.5,6,8,10,11 Intergenerational traumas stemming from the ongoing legacy of colonization — such as those incurred through the Indian residential school system and subsequent mass waves of child apprehensions, referred to as the “Sixties Scoop” — drastically exacerbate mental illness and addiction experiences, often referred to as “soul wounds” requiring care beyond a solely biomedical or physical approach.8,11,12

Canadian physicians receive minimal training in preventive medicine — including cultural, spiritual, psychological, social, historical, political and community-specific aspects of Indigenous patients’ needs. Healing specialists, Knowledge Keepers and Elders who are skilled in understanding and working within Indigenous cultural worldviews and determinants of health are increasingly needed in medical partnerships, decision-making processes and patient care.5–8,11,12 Elders David Courchene and Burma Bushie hold that a predominantly biomedical approach to health simply fails to address an Indigenous patient’s myriad needs in an integrated and holistic manner.9 Courchene is founder of the Turtle Lodge Central House of Knowledge in Sagkeeng First Nation, and cofounder and member of the Elders’ council, along with Elder Bushie and other community leaders, of the Giigewigamig Traditional Healing Centre at the Pine Falls Hospital in Manitoba. Indigenous-led approaches to health care as exemplified by Turtle Lodge and the Giigewigamig Traditional Healing Centre are needed because they effectively address the health inequities that have arisen from complex historical and contemporary traumas faced by many Indigenous communities.2 They are also more responsive and culturally appropriate to revive, support and strengthen the worldviews and lifestyles underlying diverse conceptions of health and wellness, particularly in terms of nurturing the spirit.5–8,11,12

Beyond Indigenous communities and Elders, there are many in Canada desiring more capacity for interprofessional partnerships with Indigenous communities. Ninety percent of physicians surveyed in northwestern Ontario some years ago, for example, felt Indigenous healing played an important role in psychosocial health.13 In fact, most physicians interviewed as part of studies in Ontario and British Columbia welcomed opportunities to learn more about traditional healing, to work with Indigenous healers and to have healing in hospitals.12,13 A more recent environmental scan in BC, and studies in Manitoba, Ontario and on the east coast suggest that Indigenous Peoples want more access to traditional healing and Indigenous-led health services.5,8,12–14

## What are Indigenous-led health partnerships?

There are several unique and innovative examples of Indigenousled health service partnerships in Canada (see Box 1 for an example). Interprofessional models of health care are frequently conceptualized along a spectrum of varying degrees of collaboration, often focused on the levels of integration of diverse healing practices into existing biomedical systems and structures.5,6,15 In these models of understanding, Western medicine and knowledge systems often remain the standard for comparison, for ethical guidelines and for making claims of efficacy, and therefore retain power. Indigenous-led health partnerships, however, are autonomously grounded in traditional Indigenous knowledge — maintained and upheld by local Elders, healers and Knowledge Keepers — rather than being grounded in Western medicine, structures and knowledge. These partnerships bring in or are supported by biomedical knowledge and expertise as desired. Some challenge assertions that Indigenous medicine can be appropriately integrated into biomedical practices because of the cultural frameworks and limitations of biomedicine — including assumptions and biases about mind–body dualism; rigid power hierarchies; and forms of reductionism, individualism or materialism that, regardless of diversity, are entirely absent from traditional Indigenous knowledge.16 Martin Hill and several Elders, healers and Knowledge Keepers assert that biomedicine can be integrated more appropriately into Indigenous healing practices and knowledge systems, which are by nature more inclusive of the physical, emotional, mental and spiritual aspects of health and health care.5,6,8,11,16

Box 1: #### **Turtle Lodge — an example of an Indigenous-led model for wellness**

In restoring traditional Indigenous knowledge and practising self-determination in community health, the Turtle Lodge has built a network of partnerships with health care providers, administrators, Elders, healers, Knowledge Keepers, political leaders, youth, community members and international visitors. Turtle Lodge hosts frequent events (e.g., round tables, ceremonies, conferences and gatherings) to address health issues in a traditional way as an autonomous, sustainable Centre of Excellence. — Elder Dr. David Courchene, Turtle Lodge Central House of Knowledge, Sagkeeng First Nation

## Do Indigenous-led partnerships improve health outcomes?

As unique Canadian examples of health care integration, Indigenous-led health partnerships can improve access to care, adherence to care plans and many health outcomes. Table 1 outlines several models (e.g., coordinated, multidisciplinary, interdisciplinary and integrated), geographies (e.g., urban, rural and remote) and settings (e.g., clinic, hospital and health centre) that highlight leading innovative examples and evidence of improved health outcomes for Indigenous-led health partnerships in Canada. A recurrent theme in the Canadian Indigenous health literature is one of “culture as cure,” which holds that, when health interventions in Indigenous communities are holistic and informed by cultural knowledge or local spiritual worldviews, they are more likely to achieve success and advance wellness.5,7,8,11,13

View this table:
[Table 1:](http://www.cmaj.ca/content/192/9/E208/T1)

Table 1: 
Examples of Canadian Indigenous-led partnerships and health outcomes*

International examples of Indigenous-led health partnerships have also incorporated traditional Indigenous knowledge and culture. The Nuka System of Care, for example, respectfully designed in response to the desires of Indigenous Peoples who use and own it, has incorporated traditional Indigenous knowledge and cultural services over the past 30 years in Southcentral Alaska.30 A 2013 review of the Nuka system partnerships over a 10-year period highlighted improvements in various health indicators, including reduced emergency department use by 42%, reduced hospital days by 36%, reduced staff turnover by 75%, increased childhood vaccinations by 25%, and increased patient and client reports of satisfaction in cultural safety at 94%.30 Similarly, there is evidence of improved health outcomes where Indigenous-led partnerships were developed in Japan, China, South Korea, India, Vietnam, Nicaragua and Australia.31–33 Table 2 highlights several international partnerships and health outcomes that can inform Canadian practice.

View this table:
[Table 2:](http://www.cmaj.ca/content/192/9/E208/T2)

Table 2: 
Examples of international Indigenous-led partnerships and health outcomes*

## How do we measure evidence among Indigenous-led partnerships?

Western-trained, epidemiologically minded physicians tend to emphasize numerical evidence to justify efficacy and new medical research.40 As Walter and Andersen asserted, “There is a belief in the veracity of statistical evidence within the political and policy realms of our nation-state institutions only infrequently extended to qualitative research and, we argue, to Indigenous qualitative work in particular.”40 Whereas Walter and Andersen argued the need for Indigenous statisticians to fill a methodological gap in this area, many Indigenous scholars and Elders maintain that it is problematic, either quantitatively or qualitatively, to have to “prove” traditional Indigenous knowledge in terms of the dominant Western research paradigm and culture.5,8,12,16,40 As Elders Courchene and Bushie remind us, using Western tools and frameworks to evaluate or validate traditional Indigenous knowledge is a problematic colonial approach that assumes superiority of one cultural worldview, knowledge system, or paradigm over another, and negates the many treaty relationships that exist between sovereign nations. Indeed, seeing traditional Indigenous knowledge and cultural practices only through the eyes of evidence-based Western medical science may limit an ability to appreciate the potential benefits of those practices on their own terms, including their modes of efficacy, goals of the therapeutic encounter, unique holistic forms of cultural evidence, and aspects of spirituality that are typically outside the realms of what is easily observable and quantifiable.41 Indeed, as Waldram argued, “The use of biomedical concepts and the English language in examining traditional medicine tends to obscure the form and function of the latter” and that “even the basic concepts of *traditional* and *medicine* are fraught with Eurocentrism and English-language biases” that may be “very crude approximations, at best, of complex Indigenous thought.”41

Given that the available evidence of improved health outcomes of Indigenous-led medical partnerships remains limited, future research, such as scoping or systematic reviews informed by holistic (inclusive of mind, body, emotion and spirit) frameworks, are needed to better measure and assess partnership efficacy in Canada and globally. Being mandated by the Canadian Institutes of Health Research as a standard for Indigenous health research and ethics since 2011,42,43 Etuaptmumk, or a “two-eyed seeing” framework, in which health practitioners and researchers are called to operate through both Western (one eye) and traditional Indigenous knowledge (another eye), could be a useful approach for future practice, partnership and evidence-based research that aims to re-adjust power imbalances and involve traditional Indigenous knowledge, including its holistic values and frameworks, modes of operation and standards of efficacy.

## What are key concerns and recommendations for future partnerships?

In considering the troubling history between Indigenous Peoples and European-settler Canadians, problems of unequal and oppressive power relationships between Indigenous and non-Indigenous health practices cannot be ignored.3,6,8,13,16 In Asia, Australia and Nicaragua, for example, where traditional medicines were integrated with Western medicines beginning in the 1950s (in Asia) and 1970s (in Australia and Nicaragua), there were issues with domination, extraction and loss of crucial aspects of the medicinal systems of minority groups.31–33 Having experienced similar conditions in Canada, Indigenous healers and Elders are sometimes reluctant to build partnerships with physicians out of concern about the potential overharvesting of plant medicines, disrespectful treatment, cultural appropriation, commercialization, unbalanced funding schemes, tokenism and loss of autonomy.5,6,8,11 Furthermore, from the patient’s perspective, a survey conducted in eastern Canada reported that 92% of the Indigenous respondents who use traditional medicine feared disclosing this information to health professionals. 6 Better understanding is needed on how to protect Indigenous medicines, healing practices and knowledge in their full integrity while developing and promoting self-determination in Indigenous-led health care services and systems that foster culturally safe spaces for patients, Elders and healers.5,6,8,11,12

To further advance future health systems partnerships in Canada, the Indigenous Physicians Association of Canada recommends placing value on Indigenous medicines equal to that placed on biomedicine, being open to patients’ disclosures of use of traditional medicines, building relationships with Indigenous healing practitioners, Knowledge Keepers and Elders, supporting the work Elders and healers do in the community, consulting, making referrals, recognizing Indigenous holistic health definitions and indicators, learning local languages when working in Indigenous communities, engaging in antioppressive training and cultural humility professional development, and taking opportunities to experience and support local ceremonies, such as sweat lodges or sundances.5,44 Beyond simply working with Elders as members of care teams, several authors argue for the leadership of Elders in guiding health care systems and practice, hiring Indigenous health personnel, respecting various Medicine Wheel teachings as holistic conceptual models of health, efficacy and wellness, and, ultimately, strengthening community ownership, autonomy and self-determination toward fully Indigenousled health services.5,8,11,12 Jaworsky, writing from a settler-physician’s perspective, also argued that non-Indigenous physicians need to examine how they benefit from colonialism, to see and understand colonialism as a determinant of health, and to challenge the pervasive paternalism, racism and power imbalances that colonialism and biomedicine have propagated.45 Further recommendations and suggestions for future practice and research in these areas are summarized in Table 3.

View this table:
[Table 3:](http://www.cmaj.ca/content/192/9/E208/T3)

Table 3: 
Suggestions for health care providers, managers and researchers

## Conclusion

Indigenous-led healing movements reflect concrete steps in the efforts to advance health equity for Indigenous Peoples in Canada. Yet as the Truth and Reconciliation Commission of Canada reminds us,1 more work in these areas demand continued attention. As the recognition of Indigenous knowledge and healing practices in Canada continues to grow, biomedical settler-physicians will likewise benefit from increased consulting, engaging and collaborating.5,8 It is also important to note that Indigenous Peoples can embody culturally complicated, mixed and integrated identities with critical insight into what collaborative health and healing services partnerships can mean.1,2,4,5 Addressing health inequities requires a deeper understanding of the diversity within and across First Nations, Inuit and Métis communities, as well as how different models of Indigenous-led health partnerships can respond to context-specific service needs.5,8

If the swell of efforts of Elders, Knowledge Keepers and healers can be supported by the larger medical community, and if barriers to full health care rights for Indigenous Peoples can be lessened or removed, then systemic racism can be overpowered and health equity can more easily be approached.5,11,12,14 In the context of a global society, we view these Indigenous-led partnerships as opportunities for people from different cultures, health systems and worldviews to benefit from learning about and accepting each other. The challenge of Canadian medical practice and health care for the years to come will involve learning from Indigenous-led movements and building partnerships to improve health outcomes and equity for Indigenous Peoples, and for all.

## Footnotes

*   **Competing interests:** Sabina Ijaz is a board member for and volunteer at Turtle Lodge Central House of Knowledge, and is a volunteer medical consultant at Giigewigamig First Nation Health Authority and Giigewigamig Traditional Healing Centre. David Courchene is the founder and executive director of Turtle Lodge Central House of Knowledge and a member of the Elder Council of Giigewigamig First Nation Health Authority. No other competing interests were declared.

*   This article has been peer reviewed.

*   **Contributors:** All authors made substantial contributions to the conception of the work, the drafting, editing and critical review of the manuscript, approved the final version to be published, and agree to be accountable for all aspects of the work. Lindsay Allen and Andrew Hatala took the lead at drafting the first version of the manuscript. Sabina Ijaz, David Courchene and Burma Bushie provided important conceptual contributions and substantial work at editing and reviewing subsequent drafts. David Courchene and Burma Bushie ensured cultural protocol was followed during the consultations involving and work regarding the manuscript.

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