Indigenous Health Leadership: Protocols, Policy, and Practice

Tonya Gomes, MA, RCC Alannah Young Leon, PhD candidate Lee Brown, PhD. Abstract Introduction This article describes the process of the Vancouver Coastal We acknowledge that we live, work, and study as Health’s Aboriginal Health Practice Council (AHPC) who guests in the unceded territories of the Coast Salish provide policy direction to Vancouver Coastal Health peoples. We believe it is our responsibility to demon- (VCH). The AHPC operates within the unceded territories strate this acknowledgement through active ongoing of the Xʷməθkʷəy̓əm, Skwxwú7mesh, and Tsleil-Waututh Nations in what is now known as British Columbia, engagements with local Indigenous communities by Canada. The council consists of Aboriginal Elders, creating respectful relationships. This includes our knowledge keepers, community members, and VCH staff responsibility to follow local Indigenous protocols who work collaboratively to develop and implement best in our health leadership practices. We extend our health care practices for Aboriginal people. Working within respect by working with the local Indigenous Elders local Indigenous protocols to create policy for service delivery this council operates under the assumption that and knowledge holders to cultivate a reciprocal, re- to improve health outcomes it is incumbent for VCH to sponsible relationship that honours the spirit of the create appropriate methods of access to Aboriginal health Treaties and reflects a truth and reconciliatory prac- practices. The council facilitates Aboriginal leadership in tice as a means to making right relationships.1 policy development informing health care practitioners Right relationship is the foundation for us to on how they can support Aboriginal clients’ right to create access to culturally appropriate health sys- culturally appropriate Aboriginal health care services. The article describes the processes employed by the tems. In this article we provide an account of the Aboriginal Health Practice Council. These processes offer Aboriginal health practice council’s work and share a methodology for non-Indigenous organizations serving the story of working from Indigenous Knowledge Aboriginal peoples to implement Indigenous community- holders’ protocols to policy and practice; our jour- based research principles, protocols, and practices central ney thus far. We also acknowledge the work of in the provision of effective, culturally appropriate health many Indigenous scholars around the world who care. Keywords: Aboriginal community health, Indigenous are working with local Indigenous Elders and know- knowledge protocols, health policy, protection of ledge holders in order to cultivate a reciprocal, re- Indigenous knowledge, human rights health care practice, sponsible relationship as a means to making right culturally relevant health education, cultural competency, relationships and providing access to culturally ap- cultural harm restorative practices, Indigenous pre- propriate health systems (Marsden, 2005; Ahuriri- research protocols. Driscoll et al, 2008; Kirkmeyer et al., 2009; Reading

1 The Government of Canada and the courts understand treaties be- tween the Crown and Aboriginal people to be solemn agreements that set out promises, obligations, and benefits for both parties. We dedicate this work to beloved Xʷməθkʷəy̓əm (Musqueam First Hunting, fishing, and gathering plants for food and medicinal pur- Nation) Elder and educator Norman Rose Point, Papep (1933–2012), poses are examples of Aboriginal inherent rights. Aboriginal peoples who generously provided her practical wisdom to the Health Practice also have the right to maintain their distinctive cultures and to live Council. We acknowledge her tireless work in creating space for in accordance with their own customs and laws. Treaties are con- respectful reciprocal relationships in education health contexts. her sidered mutually beneficial arrangements that guarantee a co-exist- vision truly encompassed the seven generations of which she often ence between the treaty parties. http://www.treaties.gov.bc.ca/. We spoke. We also offer our deepest appreciation to the members of the acknowledge that not all nations are in formal treaty relationships practice council; their leadership, courage, generosity, and love embody and that modern day treaties have a differing circumstances but that the spirit of Indigenous teaching protocol principles. Hyska OSiem. living as a good relative is an imperative we intend to operationalize.

© Pimatisiwin: A Journal of Aboriginal and Indigenous Community Health 11(3) 2013 565 566 © Pimatisiwin: A Journal of Aboriginal and Indigenous Community Health 11(3) 2013 Indigenous Health Leadership: Protocols, Policy, and Practice 567 et al., 2010; Smylie et al., 2009). Many of these re- sess the short and long term effects of the Indigenous patient outcomes. This happens when policies follow Vancouver region of VCH approached Tonya Gomes, searchers have shown that right relationship and re- protocols on policy process. local protocols. It is our hope that this process of pro- an Indigenous female facilitator from Guyana search involves a complex decolonizing process that Decolonizing our health care processes involves tocols to policy will also contribute to the resurgence South America and one of the authors of this arti- involves reconciling settler and Native relations. As addressing the effects of colonialism as evidenced in of healthy leaders and community processes. cle. Tonya, who was living and working with the Linda Smith (2005, p. 88), describes Indigenous re- the national and international indices that suggest In this article we will highlight the steps taken urban Aboriginal community, was asked to form search, the decolonization project involves a transformative change is required for health care.3 in our methodology to allow non-Indigenous organ- the Aboriginal Health Practice Council. Aboriginal

the unmasking and deconstruction of imperial- Our leadership is committed to understand how izations serving Aboriginal peoples to implement Health Services wanted to establish a process for ism and colonialism in its old and new formations we are all implicated in the ongoing injustices com- Indigenous community-based research principles, addressing Aboriginal peoples’ clinical services; and alongside a search for sovereignty, for reclamation mitted towards Aboriginal peoples and to explicit- protocols, and practices central to the provision of although VCH saw the initial task of the practice of knowledge, language and culture and for the so- ly address cultural harm and redress as required in effective, culturally appropriate health care. We con- council as developing clinical guidelines for health cial transformation of colonial relations between International Human Rights instruments.4 The prac- textualize the work in the political framework of the care service delivery to urban Aboriginal commun- the native and settler. tice council documents the process of how we are time and outline the process of our work: protocols, ity members, Tonya articulated the need to have Jeff Corntassel’s (2012, p. 86), work on decol- guided by a collective of local Indigenous health care principles of engagement, living the work, policy in Aboriginal leadership guide the work. This required onization, cultural restoration, and resurgence leaders. We outline how we make space for the in- practice, and research. We end with some issues, the building of right relationships with the local of Indigenous knowledges links the struggles of terface of decolonization and resurgence and we sug- challenges, and recommendations. land based and urban Aboriginal peoples. Indigenous freedom to the everyday acts of all gest that we cannot do this effectively without lead- Before accepting the responsibility of creating peoples to restore sustainable relationships to lands ership from Indigenous knowledge and protocols. Context the health practice council, Tonya followed place- and resources. This is particularly true of Idle No In resisting imposed structures of thinking, out- The BC Tripartite First Nation Health Plan (First specific cultural protocols and engaged in a series More where, for example, limited access to fresh dated systems and service delivery models and mov- Nations Leadership Council, 2007), agreed to by the of consultations with local traditional knowledge waters will affect the health of all peoples.2 ing towards reconciling and recovering the sense of BC First Nations Health Council, the BC provincial holders. She asked about the possibility of creating For Native peoples surviving on the fault-line of connection with the peoples of this land as our rela- government, and the Canadian federal government an Aboriginal health practice council with represen- the intersection of gender; race; and class violence, tives, as treaty peoples, we began to build right rela- includes principles of respect and recognition of tation from local Indigenous nations. She want- marginalized both in the dominant society and in tionship. This is the first phase of our informal (pre) cultural health practices: “Cultural knowledge and ed to find out their thoughts about the work and their communities, the meaning of deconstruction; research process. Community readiness and the ap- traditional health practices and medicines will be re- if she was the appropriate person to facilitate it. sovereignty; and reconciliation can start with rep- propriate facilitator of the process are all factors that spected as integral to the well-being of First Nations” Tonya followed local Indigenous protocol principles arations of settler relationships (Young and Nadeau, contribute to the success of a decolonization process. (p. 3). In this ten year trilateral agreement, all three of the Coast Salish peoples and presented cultur- 2005). Health care providers in their position as set- The process of moving from local land based cultural parties have committed to action in four priority ally appropriate gifts to spiritual leaders in the lo- tlers can actively educate or decolonize themselves as protocols to policy requires the engagement of local areas: governance; relationships and accountabil- cal unceded nations: xʷməθkʷəy̓əm, Skwxwú7mesh, a contribution to building right relationships. One Indigenous protocols to inform the policy making ity; health promotion and disease; and injury pre- and Tsleil-Waututh. She asked their permission to aspect of this decolonizing process is the creation, process. We suggest that Aboriginal health leadership vention. This agreement created the framework for ground the council’s work in protocols, ceremon- through leadership from Indigenous peoples, of pro- is demonstrated through collective cultural efficacy Vancouver Coastal Health (VCH) to look to First ial principles, and frameworks and she participated cesses for access to culturally appropriate health care providing resources to enable Aboriginal peoples, Nations and Aboriginal leadership in creating health in cultural ceremonies with them to discuss their systems. who are often marginalized in inner cities, to par- care services.5 The question from the Indigenous thoughts and recommendations. The Indigenous Many others around the world have cultivat- ticipate in their health care choices with improved community on ethically engaging with First Nations knowledge holders recommended having appropri- ed relationship and consultation with Indigenous 3 Understanding Health Indicators, a report developed by the First and Aboriginal communities in ways that would de- ate cultural representation on the council to provide peoples, however, we have been unable to find an- Nations Health Center (2007b), gives examples of First Nations colonize imposed health structures and support and input regarding health issues that affect the local models and cultural frameworks to expand and understand indica- other Indigenous clinical practice council within tors for health and well-being that are culturally relevant and reflect respect the resurgence of Indigenous knowledges nations and guidance on their protocols and cere- a health authority and we believe this work to be First Nations knowledge at all stages. needed to be addressed. monies. The Indigenous knowledge holders also said 4 See www.un.org/esal/socdev/unpfii/en/drip.html ARTICLE 31 that while they would see how the work evolved, the first of its kind to be documented in this re- 1. Indigenous peoples have the right to maintain, control, protect and gion. While we are presenting decolonizing research develop their cultural heritage, traditional knowledge and trad- Protocol Principles: First Steps it was Tonya’s responsibility to continue to engage itional cultural expressions, as well as the manifestations of their in annual consultations, and that this would be the engagement processes for policy development for sciences, technologies and cultures, including human and genetic In 2008, in response to the Tripartite Health health care services for Aboriginal peoples, we un- resources, seeds, medicines, knowledge of the properties of fauna Plan priorities, Aboriginal Health Services in the foundation of a reciprocal relationship between all and flora, oral traditions, literatures, designs, sports and traditional derstand that more research will be required to as- games and visual and performing arts. They also have the right to parties. 5 Vancouver Coastal Health (VCH), one of the five health authorities 2 The Idle No More grassroots movement, started by four Aboriginal maintain, control, protect and develop their intellectual property As a way to maintain accountability and sus- within British Columbia, provides health services to 15 First Nations women in Canada, protests the creation of new and modified fed- over such cultural heritage, traditional knowledge, and traditional (12 rural, two subrural) and the urban Aboriginal population of tainable relationships with citizens of the local First eral laws that harm Aboriginal rights and put the environment at cultural expressions. Vancouver (http://aboriginalhealth.vch.ca/first-nations-and-aborig- risk. For information on the laws see Land, Bradley & Zimmerman. 2. In conjunction with indigenous peoples, States shall take effective Nations and Aboriginal community knowledge inal-communities/). Olthuis Kleer Towhshend LLP. Dec 2012. Toronto Ontario. measures to recognize and protect the exercise of these rights. 568 © Pimatisiwin: A Journal of Aboriginal and Indigenous Community Health 11(3) 2013 Indigenous Health Leadership: Protocols, Policy, and Practice 569 keepers Tonya committed to the ongoing ceremon- establish relational protocols and terms of reference guidelines, protocols, and policies; identifying op- meeting with acknowledgment of the local ter- ial principles and processes required for centring to frame the work. portunities for practice improvements and address- ritory and prayers and songs as an integrated the practice council‘s work in Aboriginal health ing these opportunities using Aboriginal frame- process. leadership and for engaging Indigenous health care Principles of Engagement works; developing evidence based and/or culturally • Aboriginal sovereignty: the council agreed systems. The foundation of the council’s work is In the urban setting we were mindful that the ma- based indicators that support integrated processes to uphold and promote Aboriginal self-deter- informed by this pre-engagement practice ethic in jority of the council members are visitors to this for Aboriginal, Euro medical, and alternative health mined sovereignty and acknowledge Aboriginal which we take direction from Indigenous knowledge territory and remain committed to the making of practices; and identifying education needs of VCH inherent rights. keepers and follow local protocol principles to begin staff specific to working with Aboriginal people.7 good relationships — in effect, they are guided by • Protocol: As a council we must practice proto- any new work relating to the creation of service de- the commitment of being a good relative. As the col, not just talk protocol. livery policy to Aboriginal peoples. How we take council membership reflected the diversity of the Decolonizing our Practice: • Culture: We agreed to make the time to have direction is outlined in the visioning section of this urban Aboriginal population, we needed to have re- Principles of Practice cultural values woven through the work every article. lational protocols on how to work together in ways Decolonizing our practice reflects Indigenous day (addressing dynamics of bringing oral From these beginning consultations, Aboriginal that aligned with cultural protocols and principles. principles and practices as central to Aboriginal protocols to administrative polices). Health VCH, urban Aboriginal community members We knew that to accurately engage in a decolonizing health leadership in improving the health status of and Elders from the local nations initially created process and reflect Indigenous knowledge systems, • Indigenous pedagogy: to remain as true as Aboriginal peoples and reconciling colonial impos- a health practice council, based in local protocols we needed to develop principles of engagement by possible to Indigenous ways of knowing, doing, ition of structures that largely do not benefit the and principles, to develop clinical practice guide- following the protocol existent in ceremonial cul- and teaching. We knew that as a group we were health of Aboriginal communities (Kelm, 1998). lines for health services to urban Aboriginal people. tural practices. We agreed to begin with local land- dealing with more than the “genocide of a gen- We knew that working within the intersections Indigenous Knowledge systems and mainstream based cultural protocol principles. Following the eration’s identity” (Horn, 2007), and that the of Indigenous and mainstream medical health sys- medical practices were to be addressed within these recommendations from the Indigenous knowledge majority of us had personal understanding of tems would make how we came together in rela- frameworks. However, once the council agreed to keepers to have representation from local Aboriginal the impacts of colonization. We agreed to hold tionship and how we negotiated the language in our base their work on the recommendations from the health leadership we invited local Elders to co-chair space for each other while working through work critical. For instance, the term “medicine” has Tripartite agreement, it quickly became clear that the council. Our practice principles and policy en- the process of decolonizing mainstream health multiple meanings throughout health systems. We the task of the council would be to create policies sures that the Elder co-chairs are paid regular con- languages and re-indigenizing the language we knew we would be weaving threads of understand- for VCH staff to make space for Indigenous health sultant fee for sharing their expertise. used to reflect Indigenous world views. ing between multiple cultures while dealing with knowledges within the health care system and to fa- Discussing principles of engagement enabled • Centring Aboriginal health leadership: intellectual property rights of Indigenous knowl- cilitate access to Indigenous health care.6 The ten- the council members to establish terms of reference We agreed to seek on-going consultation with edges (National Aboriginal Health Organization, sion became how to build right relationships with for their meetings. We established that the coun- Aboriginal communities on how Aboriginal cul- 2008; Martin-Hill, 2003), Aboriginal sovereignty, the urban and local Aboriginal leadership based on cil would consist of a minimum of fifteen mem- tural values, beliefs, and languages can inform indigenized education, and decolonizing practices local protocols and principles of decolonization and bers, meet monthly from September to June, and health care service delivery for Aboriginal peo- to make space for Indigenous health care leader- resurgence while concurrently creating policies and be co-chaired by an Aboriginal Elder from a local ple. ship. We saw that we had to reference larger legal processes to guide VCH. The council was then struc- Nation. Of these members, three quarters would be frameworks informing our work: international hu- • Reciprocal sharing: To provide educational tured to provide guidance from urban Aboriginal of Aboriginal ancestry, represent Aboriginal health man rights on Indigenous peoples as well as treaty and learning opportunities for Aboriginal and heath leadership and align with the United Nations leadership, and the urban Aboriginal population. and inherent constitutional rights (United Nations non-Aboriginal communities by presenting at Declaration on the Rights of Indigenous Peoples We drew our membership from three strategic areas: General Assembly, 2007; Canadian Constitutional Act forums and networking with other Aboriginal (2007), to facilitate appropriate policymaking. VCH staff; VCH Aboriginal Community Partnerships; 1867/1982; Government of Canada, 2000). Holding councils across health authorities to “restore and Aboriginal urban community members and or- Aboriginal Health Practice Council all of these frameworks, and situating ourselves with connections severed by colonization” (Alfred, ganizations. The qualifications for membership in- VCH Aboriginal Health extended invitations to the Corntassel’s (2012), recognition, protection, and the 2005, p. 45). cluded people with demonstrated commitment to Vancouver urban Aboriginal health leadership mem- regeneration and restoration of sustainable relation- The council’s next steps were to spend sev- Aboriginal health and social issues. bers and VCH employees to discuss a framework for ships, we established, through practice, foundational eral months researching and networking with There are a total of fourteen guiding action items developing the Aboriginal Health Practice Council principles to guide our partnership work. people and organizations about the work being in the terms of reference and we list four points here. (AHPC) and the first meeting was held in October These principles are: done in Aboriginal Health internationally, nation- Each item is situated in the position of recognition, 2008. One of the first tasks of the council was to • Ceremony: Our work always begins in cere- ally, and provincially to gain a clearer understand- protection, and regeneration of Indigenous know- mony and guided by local Elders we begin each ing of what constituted “best health care practices” 6 To improve health outcomes and access for Aboriginal people health ledges: developing, implementing, and evaluating care systems need to create appropriate access to Aboriginal health for Aboriginal people and to align their work with 7 The AHPC Terms of Reference are internal documents to Vancouver systems. evidence and culturally based practice standards, Coastal Health. VCH’s framework of health care. 570 © Pimatisiwin: A Journal of Aboriginal and Indigenous Community Health 11(3) 2013 Indigenous Health Leadership: Protocols, Policy, and Practice 571

We brought in speakers from the BC First Living the Teachings participate in providing cultural education if it im- from the local nations to be speakers as part of the Nations Health Council, researched the Tripartite proved relationships with health care practitioners forums. The council will continue to utilize these Agreement and First Nations Health Blue Print During the course of the first year, the council had and increased access and positive health outcomes forums and other educational opportunities with- (2005), and participated in community forums on four strategic goals: education and training; clinic- for Aboriginal people. After the initial gathering, in VCH for Indigenous knowledge translation and Aboriginal health care, mental health and addic- al practice protocols; Aboriginal self governance in we spent several months with the knowledge keep- transfer. The council will be part of future aspects tions, and cultural competencies. We researched the health services; and culturally competent services. ers reviewing and revising information. They estab- of the Aboriginal Health Strategic Initiatives tiered work of various Indigenous and Aboriginal health We highlight the work accomplished in each area in lished that we needed to highlight local medicines education plan for VCH. This will continue to centre organizations such as the Indigenous Physicians the sections below. before including imported medicines. The tradition- Aboriginal health leadership in informing VCH pro- Association of Canada, National Aboriginal Health Education/Training: Building Cultural al medicine brochure was finalized in June 2010. gram development and service delivery.9 Organization, First Nations Nurse’s Association, and Competencies This brochure is now available for VCH health care the Northern Ontario Medical University. Last, we • Companion Document practitioners, clients, and the general public. Clinical Practice Protocols identified two areas in the VCH Aboriginal Health • Aboriginal leadership in health care • Traditional Medicine Brochure Gatherings and forums and Wellness plan to target in our first year: As part of our on-going consultation through proto- • Acknowledgment of First Nations traditional • Gatherings and Forums 1. Increased access to health care services. col and ceremonial frameworks, the council host- territory 2. Inclusion of traditional practices in health care. ed a number of gatherings of First Nations and Companion document • Cultural competency Focusing on these areas, the council then adopt- Aboriginal traditional knowledge keepers and health The council reviewed and made recommenda- • Ceremonial use of tobacco and smudging medi- ed the goals of Aboriginal Health Services Vancouver practitioners. Our focus was to build extended re- tions to the “Aboriginal Health Services Vancouver cines and our work plan for the first year included creat- lationships with traditional knowledge keepers and Companion Document” for understanding health • Working in respectful partnership with ing a guiding vision and identifying protocols (clin- health practitioners. We saw this as an opportun- service provision for Aboriginal people in BC. The Aboriginal Elders ical guidelines), core competencies, and education.8 ity to share the work the council had been doing. document provides a brief introduction of his- Our overarching focus, after establishing our vision Traditional knowledge holders and practitioners • Transport to sweat lodge torical and current contexts that outline some of statement, advanced to developing guidelines to in- who actively engage with health systems attended. Our first step in identifying and creating clinical the key components shaping health standards for crease cultural competency of all VCH staff while These have been rare opportunities to gather togeth- practice standards for service delivery to Aboriginal Aboriginal people and provides links for more in- building avenues to incorporate Aboriginal perspec- er. The knowledge holders represent the diversity of clients in this section of our work plan was to define depth information. It includes information on the tives of health. Six months after the formation of the urban Aboriginal population in Vancouver and a framework for the practice standards. We were provision of federal health benefits, determinants of the council we finalized our first goal with the cre- their willingness to participate in this process may clear that we would provide standards (what the health, and leads into current agreements regarding ation of our vision statement. indicate an intersection of community readiness council saw as protocols) that would enable VCH self-governance in health care. and Vancouver Coastal Health’s commitment to staff to create a culturally safe environment within take action to support both systems of health care. Vision statement Traditional medicine brochure Vancouver Coastal Health and provide opportun- From this gathering, the council and VCH agreed to The council identified a need to develop educational ities for Aboriginal clients to access culturally appro- We, the AHPC of VCH, believe in Aboriginal self- consult with urban knowledge keepers on a regular brochures to share with Aboriginal clients of VCH priate and relevant care. The opportunities to access governance and self-determination in health care basis (2–4 times a year) to increase cultural educa- and we honour traditional wisdoms and practices. and VCH staff to build cultural understanding of cultural services were to be part of individual health tion opportunities for VCH staff and clients. To date, We will work to provide the inclusion and avail- some of the knowledge of Aboriginal peoples. To plans and were to be documented that way. Through the council has facilitated or helped facilitate five ability of traditional practice within all commu- acknowledge the traditional territories of the Coast the establishment of these guidelines we began to such gatherings, including a provincial First Nations nities including mainstream health care systems Salish peoples, and the diversity in the urban setting, build structures within VCH to support a cultural while strongly advocating for and safeguarding Traditional Healers’ Gathering led by the First we asked knowledge keepers from the x m k y m, services model, where, if requested by Aboriginal cultural practices. We commit to act as cultural ʷ əθ ʷə ̓ə Nations Health Authority in 2011. Skwxwú7mesh, Lil’wat, Fountain, Cree, Dakota, clients, Aboriginal traditional health practitioners diplomats to both Aboriginal and non-Aboriginal The council also participated in forums on health care providers, globally and locally, and will Anishnabe, and Cherokee Nations to join us in a would be part of the Aboriginal client’s interprofes- cultural competency held by Aboriginal Health uphold Aboriginal traditional values of respect, in- circle. We shared with them our vision statement, sional health team. Strategic Initiatives (AHSI) for VCH health care staff. tegrity, wellness, caring, and reciprocity. work plan, and intention to provide opportunities We also wanted to be clear that we would respect 8 Aboriginal Health Services Vancouver has four strategic operational AHSI holds these forums on a yearly basis as part of Aboriginal intellectual property rights (Martin-Hill, goals: self-governance in service coordination — building structures for cultural education. They shared some of their for Aboriginal leadership in determining health service delivery and their overall educational plan to build cultural safety recommendations from past experiences working 9 The facilitator, as a VCH staff member, has an on-going responsibil- practice; education and training: cultural competency training and within VCH. The council shared protocols, policies, ity of sustaining right relationships. This is done through reciprocal promoting Aboriginal models of wellness; culturally relevant and with multiple health systems. The knowledge keep- relationships and participation in community events and cultural informed services: through the Aboriginal Wellness program and and some of their other work such as the compan- ers used the circle as an opportunity to network ceremonies in ways that community understands and acknowledg- the eleven urban contracted services and Aboriginal Health practice ion document of selected papers and the traditional es. Without this on-going commitment the facilitator risks perpetu- standards: developing clinical practice guidelines and/or protocols and exchange information on working with dif- ating colonial approaches and acting against the transformation of for service delivery. medicine brochure. We also invited several Elders ferent medicines. After discussion, they agreed to settler/Indigenous relationships. 572 © Pimatisiwin: A Journal of Aboriginal and Indigenous Community Health 11(3) 2013 Indigenous Health Leadership: Protocols, Policy, and Practice 573

2003; National Aboriginal Health Organization, of teaching through storytelling. Throughout all of vide an acknowledgment of the nation of the land ces Aboriginal Elders will bring. Aboriginal Elders 2008) regarding cultural ceremonies and practices. the Aboriginal Health Clinical Practice Guidelines, we are holding our meetings and gatherings on and stimulate life for those who are sick or unwell and We would not teach ceremony in our guidelines and we agreed to include storytelling as a model of pre- invite Elders to provide welcoming prayers, songs, the presence and wisdom of Aboriginal Elders can we would not depict actions VCH staff needed to senting information. We included stories and words and stories. This policy is to provide information to help to improve the health of Aboriginal people and do as part of ceremony; in fact, we would state that from the council members’ experiences, to depict VCH staff on the protocols regarding acknowledge- benefit the Aboriginal circle of life. VCH staff would not facilitate any cultural ceremony, the teachings in the guidelines. ment of traditional territories and the invitation to Working with an Aboriginal Elder is a recipro- even if they were willing to do so, unless it was part Addressing the aspects of education, self-gov- First Nations to welcome us to their hereditary land cal relationship that benefits all persons involved. of their own Aboriginal cultural background and ernance, and cultural competency and inclusion when we are hosting events, meetings or gatherings. The purpose of this guideline is to convey the value, they were asked to do so by Aboriginal clients. Their (the promotion of Aboriginal models of health and respect, honour, and love which Aboriginal people job is limited to providing access to cultural services wellness) the council has developed six protocols. Culturally competent services have for their Elders and that Aboriginal Elders are for clients. The work of the council is to provide poli- Excerpts from these protocols are provided below. Raymond Obomsawin (2009), in The Central Issue of an integral and crucial part of the holistic wellbe- cies to assist them in providing access. Culture, states “Culturally competent care results in ing of Aboriginal people. These guidelines are in- 10 Aboriginal leadership in health care improved health outcomes for Aboriginal peoples; tended to provide VCH staff a deeper understanding Policy Statement The purpose of this protocol is to establish a frame- increased self-determination of own health care; of ways of being in relationship with all Aboriginal work to secure and entrench Aboriginal voice in increased client satisfaction; and enhanced access We started with a policy statement for all of the Elders and traditional healers. all areas of health services (within VCH) where an to health care services.” Aboriginal peoples are sig- guidelines. Our scope of practice at this time includ- Aboriginal context enhances health practice, espe- nificantly overrepresented in almost every area of Ceremonial use of tobacco and smudging medicines ed Aboriginal health, addiction and HIV/AIDS servi- cially in the area of knowledge transmission. VCH poor health status compared to any other group Many Aboriginal ceremonies throughout North, ces in VCH Vancouver community: recognizes that Aboriginal people need to be cen- in Canada. Large gaps in health status exist. Life ex- Central, and South America involve the ceremon- Addiction, HIV/AIDS & Aboriginal Health Services tral in the identification, development, and deliv- pectancy rates are lower, infant mortality rates are ial burning of traditional plants and medicines. promote a culturally safe health care framework ery of health services to Aboriginal people. This in- higher, and hospitalizations for mental health issues This ceremony, often called a smudge ceremony, is and publicly recognize Aboriginal sovereign rights, cludes any knowledge transmission or translation of including suicide can be five times the national rate. a holistic health practice used for prayer, offerings, including the right to incorporate Aboriginal cul- Aboriginal health care practices and the implemen- Health problems such as diabetes, HIV/AIDS, FAS/E, cleansing and healing of mind, body, emotion, and tural health care practices into current health care services. Provision of culturally safe care is in align- tation of culturally competent health care services tuberculosis, hepatitis, smoking and substance spirit. Cleansing ceremonies can also include the ment with the Canadian Charter of Rights and accessed by Aboriginal people. VCH acknowledges abuse affect Aboriginal people at a higher percent- brushing off of people with medicinal branches or Freedoms and the United Nations Declaration on that Aboriginal people are the knowledge keepers age than other residents (Aboriginal Health Practice boughs. This policy respects the range of traditional the Rights of Indigenous Peoples. Culturally safe of their life experiences and, in this way, they pos- Council, 2010a). practices and facilitates the inclusion of these prac- health care incorporates the individual accessing sess the inherent right to articulate how and what Developing a cultural safety lens for VCH will fa- tices into the current health care system. VCH health health care to be the judge of what constitutes rele- knowledge is generated and transmitted to health cilitate positive learning experiences for health care care providers are to respect the right of Aboriginal vant health care, including the right for Aboriginal people to access traditional ceremonies, health care providers regarding their health and wellness. staff to build meaningful skills and awareness in de- people to choose these practices and are obligated to practices, Aboriginal Elders, Traditional Healers livering services to First Nations, Inuit, and Métis create the opportunities and environments to sup- Acknowledgement of First Nations traditional and/or Traditional medicines. peoples. Cultural safety an outcome of culturally port access to these ceremonies. territory competent practices and ensures that the recipi- We also agreed to have a “need to know” sec- Vancouver Coastal Health provides health care servi- ents of care are the ones providing feedback on the Transporting Aboriginal clients to sweat lodges tion in each guideline where we would include in- ces to fourteen First Nations communities through- services they receive. Cultural safety highlights the The sweat lodge ceremony is a traditional cere- formation to situate the need for the protocol. We out the province of British Columbia and to a di- power dynamics in health care and seeks to address mony practiced by Aboriginal peoples throughout would include historical and current social realities verse urban Aboriginal population. As we work in inequities through the promotion of culturally com- Turtle Island. The sweat lodge is a sacred place where and/or overviews of practices across nations to help Aboriginal communities, we seek to acknowledge petent practices (Indigenous Physician’s Association people of all nations may come together for heal- clinicians and health care workers contextualize the Aboriginal rights and title, including the sovereign of Canada, 2008). ing and prayer and is often referred to as the womb work. historic rights to the land where we provide our ser- of Mother Earth. Sweat lodge is also about purifica- We built a section called “Teaching through vices. We recognize the importance of the inherent Working in partnership with Aboriginal Elders tion, healing, and balance, balancing all four aspects Stories” into each VCH clinical practice guideline spiritual connections Aboriginal people have to this Elders of Aboriginal communities are the central of human life: the spirit, the heart, the body, and to reflect Indigenous ways of teaching and learn- land and in respect and awareness of this, we pro- carriers of Aboriginal ways of knowing and being. the mind. Many Aboriginal people have suffered ing. We worked with a Squamish Nation consult- 10 All protocols listed here are internal documents to VCH. Only Aboriginal Elders come from many different na- displacement, disconnection, isolation, and trauma. Ceremonial use of Tobacco and Smudging Medicines, Working in ant/knowledge keeper (Skwxwú7mesh Sníchim Partnership with Aboriginal Elders and Transporting Aboriginal tions and are diverse in their teachings and healing Part of the healing aspect of Aboriginal ceremonies NexwsUtsáylh, 2009), to help us indigenize our pro- Clients to Sweat Lodges are signed off for all of VHC Vancouver pro- practices. It is imperative that health care practition- is about experiencing being loved and respected, of grams. Most of these are currently completing the process of becom- cess and speak to cultural practices and protocols ing regional policies for VCH. ers understand the context and variety of practi- being part of a family, of being united with the past, 574 © Pimatisiwin: A Journal of Aboriginal and Indigenous Community Health 11(3) 2013 Indigenous Health Leadership: Protocols, Policy, and Practice 575 present, and future generations and with all living itional territories and the welcoming to the trad- Practice Council’s Work (2012) developed by the council. In person vis- things (all our relations). The sweat lodge ceremony itional territories by First Nations peoples for VCH Policy and Protocol Development Data/Research its allow engagement of proper cultural Establish best practices frameworks review of existing protocols/ guidelines is about finding your place in the circle of life, the public events, the renaming of VCH executive forums Regionalize polices and protocols protocols for meeting and requesting as- identify and implement family of Aboriginal people (as Aboriginal people to reflect local Indigenous language, and collabora- research initiatives sistance as demonstrated by the initial Data management agreement are the wisdom keepers of these ceremonies) and tively held cultural awareness days for health care process of seeking leadership for the pos- the family of all people. practitioners hosted by local First Nations. Building sible formation of the practice council; it Improve health VCH health care providers are to respect the on this work, the focus for 2013 is to regionalize the and health also creates space for mutually beneficial access for right of Aboriginal people to choose these practi- council’s membership to include First Nations and Aboriginal dialogue and partnership. community ces. The purpose of this policy is to provide prac- Aboriginal people from across the fourteen First members Face to face right relationship build- tical guidelines to VCH health care practitioners who Nations and the urban Aboriginal communities to ing will build long term working rela- are escorting or providing transportation to a VCH which VCH provides services. The council will also tionships in which health authorities,

Aboriginal client to attend a sweat lodge ceremony. assist with the creation of the VCH culturally compe- Cultural Services Model Education Aboriginal peoples, traditional know- 13 Gatherings with Traditional Sustainable tiered cultural Competency The council sees these six guidelines for practice tent and responsive strategic framework, and con- practitioners Education Plan ledge keepers, and practitioners can build as protocols in Aboriginal pedagogical frameworks tinue to develop policies/protocols, and education sustainable relationships with Data Base of Information and strong, collective service models that Indigenous Health leadership Resources-Website Aboriginal Health Practice Council and processes (Battiste, 2002). During the creation that will expand into research initiatives. Collaboration on culturally Cultural Competency Forums will engage traditional practitioners and competent and Responsive Planning Priorities Meetings, presentations to general of the guidelines, it became clear that what we were One of the first research areas for the council is Framework 2012 community, Health Authorities Aboriginal communities to increase cul- developing were more policies for service delivery to explore methodologies for bringing together best tural competency and encourage appro- than actual hands-on clinical practice guidelines and practice ideas and models for improving the health Research priate participation of non-Aboriginal health care that as policies, these would inform practice on a of Aboriginal people by promoting and including The council’s work is guided by the ethics in health providers while building a wide resource partner- regional basis and not be limited to practice in VCH’s Aboriginal traditional perspectives and practices of research with Aboriginal peoples (Indian and ship of Aboriginal health providers. Vancouver community. We now have a process to health and wellness. Literature reviews, communi- Northern Affairs, 1996; First Nations Centre, 2007a). The council will look at the following questions establish these documents as VCH regional policies. ty engagement and visits to several innovative and Stating Aboriginal concerns of a lack of commun- to guide further research: What policies support Aboriginal communities must guide improving leading Aboriginal health agencies have already ity involvement and consent, OCAP (First National Aboriginal leadership in health care, including ac- the health outcomes and access for Aboriginal people. taken place to lay the foundations for this research. Centre, 2007a, p. 5), advocates that research must cessing traditional knowledge keepers within mul- It is crucial that VCH, through the Aboriginal Health White Horse General Hospital, Alaska South Central “respect the privacy, protocols, dignity and individ- tiple health systems? Are health policies built from Practice Council and other community led initia- Foundation, Anishnawbe Health Centre, and the ual and collective rights of First Nations. It must also Aboriginal protocols moving all of us forward in tives, continue the process for Aboriginal leadership Puyallup Tribal Health Authority are a few of the derive from First Nations values, culture and trad- “restoring the connections that define Indigenous in health care and participate where appropriate in places visited with models in health service delivery itional knowledge.” The council includes the aspects consciousness and ways of being” (Alfred, 2005, p. the protocol, principles, and ceremonial frameworks to Aboriginal peoples and well developed working of self-determination of First Nations governance 45), and in doing so, restoring Indigenous peoples to develop clear and ethical polices for practice. We frameworks supporting Aboriginal traditional prac- and Aboriginal control over information in mutual- to positive health status and healthy communities? wish to establish a decolonizing guiding framework titioners and medicines. The Council is now able to ly evolving partnerships with any research initiatives on how VCH can work with Aboriginal knowledge review culturally appropriate interdisciplinary re- they will be part of. Issues and Challenges keepers and health practitioners to improve health search as identified by the BC ACADRE,14 NEAHR Vancouver Coastal Health and the practice As the work continues to broaden, the council needs outcomes for Aboriginal people while increasing BC,15 and Ownership, Control, Access and Possession council recognize the importance of following eth- to work with VCH to identify indicators on the de- culturally competent practice. (OCAP) (First Nations Centre, 2007a). This research ical and cultural protocol principles in engaging gree of change in the culturally competent practices with Aboriginal communities. In conducting the re- Policy in Practice will also follow the First Nations Health Authority of health care practitioners in VCH. They will also and the Provincial Ministry of Health guidelines for search for building a cultural services model based need indicators of Aboriginal people’s experience The council is encouraged by the impact of their culturally appropriate data management protocols on these protocol principles, a decision was made of access to health services and partnerships in the work, such as the recognition and engagement of with health authorities. to ask to work in collaboration with the then First contexts of ongoing impacts of colonization (race, Indigenous ceremonies for Aboriginal clients within 13 The Culturally Competent and Responsive Framework is a deliver- Nations Health Council of BC. Collaboratively, it was 11 class, and gendered violence, in patriarchal systems), VCH facilities, the creation of All Nations Healing able in the Partnership Accord agreement signed by VCH and the decided that the facilitator, co-chair of the practice governmental changes, funding priorities, and shift- rooms in health care settings,12 the now commonly First Nations Health Authority in May 2012. 14 Aboriginal Capacity and Developmental Research Environment council, and a member of the First Nations Health ing personnel. practiced acknowledgement of First Nations trad- (ACADRE) Network, was created by the Canadian Institutes of Council would visit several leading Aboriginal health Health Research (CIHR) (2002). BC ACADRE, like its seven provincial 11 These Indigenous ceremonies include spiritual ceremonies such as counterparts, fostered collaborative research with postsecondary in- organizations to ask for assistance in creating a cul- Summary Pipe and Yuwipi ceremonies with VCH hospitals and health centers. stitutions, Aboriginal and non-Aboriginal organizations. turally appropriate and Aboriginal led model of ser- 12 The All Nations Healing rooms, in two large urban hospital settings, 15 The Network Environments for Aboriginal Health Research (NEAHR) The Aboriginal members of the council intend that have been created with extensive consultation with the local First (2007) Centre’s focus on exploring critical Aboriginal health issues, vice delivery and to share the policies and education the work will ensure the enhancement and protec- Nations. capacity development for Aboriginal research across Canada. 576 © Pimatisiwin: A Journal of Aboriginal and Indigenous Community Health 11(3) 2013 Indigenous Health Leadership: Protocols, Policy, and Practice 577 tion of Indigenous knowledge as a health leadership Aboriginal Health Services Vancouver Coastal Health. by Mary Hurley. Law and Government Division. Aboriginal Health Research. http://cahr.uvic.ca/ process that does not impose external ideologies or (2008). Strategic Goals. Internal document. http://publications.gc.ca/collections/Collection-R/ wp-content/uploads/2010/09/CAHR_02078_ expropriation and/or the selling or misrepresenta- Vancouver BC. LoPBdP/EB/prb9916-e.htm. GlobalHealth2010Report_OUT_web.pdf. tion of Indigenous knowledge. The council leader- Alfred, Taiaiake G. (2005). Wasase: Indigenous Pathways of Horn, Gabriel. (2007). The genocide of a generation’s Skwxwú7mesh Sníchim NexwsUtsáylh. (2009). ship role has navigated educating colonial systems Action and Freedom. Toronto: Broadview Press. identity. In MariJo Moore, ed., Genocide of the Mind: Squamish Nation Education Department. Personal about how to reciprocally engage with Indigenous New Native American Writing. New York: Thunder’s Correspondence. Vancouver, BC. Ahuriri-Driscoll, A., Baker, V., Hepi, M., Hudson, M., Mouth Press/Nation Books. health models, protocols, and processes. More re- Mika, C., and Tiakiwai, S (2008) The future of ron- Smith, L.T. (2005). Building a research agenda for search is required on how Indigenous protocols and goa Maori: Wellbeing and sustainability. A sum- Indian and Northern Affairs Canada (1996). The Royal Indigenous epistemologies and education. principles can be sustained while supporting self- mary. Christchurch: Institute of Environmental Commission Report on Aboriginal Peoples. http:// Anthropology & Education Quarterly, 36, 93–95. doi: determined governance and resurgence projects Science and Research/Ministry of Health. 22. http:// www.aadnc-aandc.gc.ca/eng/1100100014597/1100 10.1525/aeq.2005.36.1.093 for the maintenance of the people’s holistic health www.esr.cri.nz/SiteCollectionDocuments/ESR/ 100014637. Smith, T.L. (2005). On tricky ground: Researching the leadership. This article describes the processes of PDF/RongoaMaoriSummaryReport.pdf. Indigenous Physician’s Association of Canada. (2008). native in the age of uncertainty. In N. Denzin and attending to right relationships employed by the Battiste, M. (2002). Indigenous Knowledge and Pedagogy First Nations, Inuit, Métis Health: Core Competencies. Y.S. Lincoln, eds., The Sage Handbook of Qualitative Aboriginal Health Practice Council and offers a use- in First Nations Education: A Literature Review with The Association of Faculties of Medicine of Canada. Research. Third edition. Thousand Oaks, CA: Sage ful methodology for non-Indigenous organizations Recommendations. Ottawa: Indian and Northern http://www.afmc.ca/pdf/CoreCompetenciesEng. Publications, pp. 85–107. serving Aboriginal peoples to assist them in imple- Affairs Canada. pdf. Smylie, J., Kaplan-Myrth, N., McShane, K., Métis Nation menting Indigenous health leadership when work- British Columbia First Nations Leadership Council. (2005). Kelm, M. (1998). Colonizing Bodies: Aboriginal Health of Ontario-Ottawa Council, Pikwakangan First ing with community-based preresearch principles, First Nations Health Blueprint for British Columbia. and Healing in British Columbia. Vancouver, BC: Nation, and Tungasuvvingat Inuit Family Resource protocols, policies, and practices. Submitted to the Assembly of First Nations. http:// University of British Columbia Press. Centre (2009). Indigenous knowledge transla- In the context of Idle No More social movements www.fns.bc.ca/pdf/HBprintBC150705.pdf. tion: Baseline findings in a qualitative study of the Kirkmeyer, L and Valaskakis, G. (2009). Healing Traditions: we are also aware that this process includes the pro- pathways of health knowledge in three Indigenous Canadian Constitution Act (1867/1982) Section 35. Mental Health of Aboriginal Peoples in Canada. tection of Indigenous knowledge; for example on communities in Canada. Health Promotion Practice, Ottawa: National Working Group on education Vancouver, BC: University of British Columbia Press. how plants and food medicinal knowledge is navigat- 10(3), 436–446. and the Minister of Indian Affair. http://laws.jus- ed in institutional spaces. We continue to be guided Marsden, D. (2005). Indigenous wholistic theory for tice.gc.ca/eng/Const/. Simpson, L.R. (2004). Anti-colonial strategies for the re- health: enhancing traditional-based indigenous by the following questions: how can we effectively covery and maintenance of indigenous knowledge. Corntassel, J. (2012). Cultural restoration in international health services in Vancouver. PhD Dissertation. position our work to contribute to the restoration American Indian Quarterly, 28(3), 373–384. of sustainable Indigenous relationships to lands and law: Pathways to Indigenous self-determination. https://circle.ubc.ca/handle/2429/17209. Canadian Journal of Human Rights, 1(1). http:// The BC Tripartite First Nation Health Plan. (2007). health care education? How can our everyday acts Martin-Hill, D. (2003). Traditional Medicine in www.corntassel.net/culturalrestoration.pdf. First Nations Leadership Council, Government inform a decolonizing health leadership process? Contemporary Contexts: Protecting and Respecting of Canada and Government of British Columbia. We hope documenting how local Indigenous proto- First Nations Centre. (2007a). OCAP: Ownership, Control, Indigenous Knowledge and Medicines. http://www. http://www.gov.bc.ca/arr/social/health/down/tri- Access and Possession. Sanctioned by the First naho.ca/documents/naho/english/pdf/research_ col principles have guided our practices will inform partite_health_plan_signed.pdf. other health education, health policy development, Nations Information Governance Committee, tradition.pdf. Assembly of First Nations. UN General Assembly. (2007) United Nations Declaration and preresearch contexts. National Aboriginal Health Organization. (2008). An ——— (2007b). Understanding Health Indicators. Ottawa: on the Rights of Indigenous Peoples: Resolution Adopted Overview Of Traditional Knowledge And Medicine National Aboriginal Health Organization. http:// by the General Assembly. A/RES/61/295, available References And Public Health In Canada. http://www.naho.ca/ www.naho.ca/documents/fnc/english/FNC_ at: http://social.un.org/index/IndigenousPeoples/ Aboriginal Health Practice Council. (2008). Terms of documents/naho/publications/tkOverviewPubli- OCAPInformationResource.pdf. DeclarationontheRightsofIndigenousPeoples.aspx. Reference. Vancouver, BC: Vancouver Coastal Health cHealth.pdf. First Nations Leadership Council. (2007). The Tripartite Young, A. and Nadeau, D. (2005). Decolonizing bodies Authority. Vancouver Coastal Health Aboriginal Obomsawin, R. (2009). The Central Issue of Culture First Nations Health Plan. Assembly of First Nations, in Indigenous women: The state of our nations. Health Services. (power point presentation), National Aboriginal British Columbia’s Provincial Government and the Atlantis: A Women’s Studies Journal/Revue d’etudes ——— (2010a). Companion Document of Selected Papers. Health Organization. Aboriginal Health Strategic Canadian Federal Government. http://www.gov. les femmes, 29(2), 13–22. http://www.msvu.ca/at- Vancouver, BC: Vancouver Coastal Health Aboriginal Initiatives: Cultural Competency and Inclusion bc.ca/arr/social/health/down/tripartite_health_ lantis/vol/292pdf/292young.PDF. Health Services. Conference. Vancouver Coastal Health. Vancouver, plan_signed.pdf. ——— (2010b). Traditional Medicine Brochure. Vancouver, BC. Alannah Young Leon is a PhD candidate in the Faculty BC: Vancouver Coastal Health Aboriginal Health Government of Canada. (2000). Parliamentary Research of Education at the University of British Columbia. She is Reading, J., Perron, D., Marsden, N., and Edgar, R. (2010). Services. Branch. Aboriginal and Treaty Rights. Prepared Anishnabikwe and Opaswayak and her work documents Global Indigenous Health — An Opportunity for the ongoing resurgence of Indigenous principles. Canadian Leadership. Victoria, BC: Centre for Alannah’s qualitative research examines a tribal centred 578 © Pimatisiwin: A Journal of Aboriginal and Indigenous Community Health 11(3) 2013

Indigenous Elders pedagogy in rural land-based health Dr. Lee Brown is a member of the Cherokee Nation, education programs. She explores mechanisms that Wolf Clan, and is the Director of the UBC Institute of restore Indigenous health care systems and how local Aboriginal Health at the University of British Columbia. Indigenous protocols regenerate Indigenous health He is the co-author of The Sacred Tree, and has also worked education and revitalize Indigenous centered concepts of at the Round Lake Native Healing Centre in Vernon, BC leadership. for over three decades. He is an author and culturalist and [email protected] revitalizes Indigenous foods and plant as medicines at the IAH Indigenous Gardens and is internationally renowned Tonya Gomes, MA, RCC, of Amerindian and Caribbean for his Indigenous knowledge leadership. Black descent, and is the Clinical Practice Initiatives [email protected] Lead for Aboriginal Health Services, Vancouver Coastal Health (VCH). Tonya is the facilitator of the Aboriginal Health Practice Council and works with First Nations and Indigenous Health leadership both provincially and internationally in the building of policies to protect, bring together and extend Indigenous health practices, policies and protocols. [email protected]