Indigenous Health Leadership: Protocols, Policy, And Practice
Indigenous Health Leadership:Protocols, Policy, and PracticeTonya Gomes, MA, RCCAlannah Young Leon, PhD candidateLee Brown, PhD.AbstractIntroductionThis article describes the process of the Vancouver CoastalHealth’s Aboriginal Health Practice Council (AHPC) whoprovide policy direction to Vancouver Coastal Health(VCH). The AHPC operates within the unceded territoriesof the Xʷməθkʷəy̓əm, Skwxwú7mesh, and Tsleil-WaututhNations in what is now known as British Columbia,Canada. The council consists of Aboriginal Elders,knowledge keepers, community members, and VCH staffwho work collaboratively to develop and implement besthealth care practices for Aboriginal people. Working withinlocal Indigenous protocols to create policy for servicedelivery this council operates under the assumption thatto improve health outcomes it is incumbent for VCH tocreate appropriate methods of access to Aboriginal healthpractices. The council facilitates Aboriginal leadership inpolicy development informing health care practitionerson how they can support Aboriginal clients’ right toculturally appropriate Aboriginal health care services.The article describes the processes employed by theAboriginal Health Practice Council. These processes offera methodology for non-Indigenous organizations servingAboriginal peoples to implement Indigenous communitybased research principles, protocols, and practices centralin the provision of effective, culturally appropriate healthcare.Keywords: Aboriginal community health, Indigenousknowledge protocols, health policy, protection ofIndigenous knowledge, human rights health care practice,culturally relevant health education, cultural competency,cultural harm restorative practices, Indigenous preresearch protocols.We acknowledge that we live, work, and study asguests in the unceded territories of the Coast Salishpeoples. We believe it is our responsibility to demonstrate this acknowledgement through active ongoingengagements with local Indigenous communities bycreating respectful relationships. This includes ourresponsibility to follow local Indigenous protocolsin our health leadership practices. We extend ourrespect by working with the local Indigenous Eldersand knowledge holders to cultivate a reciprocal, responsible relationship that honours the spirit of theTreaties and reflects a truth and reconciliatory practice as a means to making right relationships.1Right relationship is the foundation for us tocreate access to culturally appropriate health systems. In this article we provide an account of theAboriginal health practice council’s work and sharethe story of working from Indigenous Knowledgeholders’ protocols to policy and practice; our journey thus far. We also acknowledge the work ofmany Indigenous scholars around the world whoare working with local Indigenous Elders and knowledge holders in order to cultivate a reciprocal, responsible relationship as a means to making rightrelationships and providing access to culturally appropriate health systems (Marsden, 2005; AhuririDriscoll et al, 2008; Kirkmeyer et al., 2009; Reading1We dedicate this work to beloved Xʷməθkʷəy̓əm (Musqueam FirstNation) Elder and educator Norman Rose Point, Papep (1933–2012),who generously provided her practical wisdom to the Health PracticeCouncil. We acknowledge her tireless work in creating space forrespectful reciprocal relationships in education health contexts. hervision truly encompassed the seven generations of which she oftenspoke. We also offer our deepest appreciation to the members of thepractice council; their leadership, courage, generosity, and love embodythe spirit of Indigenous teaching protocol principles. Hyska OSiem. The Government of Canada and the courts understand treaties between the Crown and Aboriginal people to be solemn agreementsthat set out promises, obligations, and benefits for both parties.Hunting, fishing, and gathering plants for food and medicinal purposes are examples of Aboriginal inherent rights. Aboriginal peoplesalso have the right to maintain their distinctive cultures and to livein accordance with their own customs and laws. Treaties are considered mutually beneficial arrangements that guarantee a co-existence between the treaty parties. http://www.treaties.gov.bc.ca/. Weacknowledge that not all nations are in formal treaty relationshipsand that modern day treaties have a differing circumstances but thatliving as a good relative is an imperative we intend to operationalize.Pimatisiwin: A Journal of Aboriginal and Indigenous Community Health 11(3) 2013565
Indigenous Health Leadership: Protocols, Policy, and Pimatisiwin: A Journal of Aboriginal and Indigenous Community Health 11(3) 2013et al., 2010; Smylie et al., 2009). Many of these researchers have shown that right relationship and research involves a complex decolonizing process thatinvolves reconciling settler and Native relations. AsLinda Smith (2005, p. 88), describes Indigenous research, the decolonization project involvesthe unmasking and deconstruction of imperialism and colonialism in its old and new formationsalongside a search for sovereignty, for reclamationof knowledge, language and culture and for the social transformation of colonial relations betweenthe native and settler.Jeff Corntassel’s (2012, p. 86), work on decolonization, cultural restoration, and resurgenceof Indigenous knowledges links the struggles ofIndigenous freedom to the everyday acts of allpeoples to restore sustainable relationships to landsand resources. This is particularly true of Idle NoMore where, for example, limited access to freshwaters will affect the health of all peoples.2For Native peoples surviving on the fault-line ofthe intersection of gender; race; and class violence,marginalized both in the dominant society and intheir communities, the meaning of deconstruction;sovereignty; and reconciliation can start with reparations of settler relationships (Young and Nadeau,2005). Health care providers in their position as settlers can actively educate or decolonize themselves asa contribution to building right relationships. Oneaspect of this decolonizing process is the creation,through leadership from Indigenous peoples, of processes for access to culturally appropriate health caresystems.Many others around the world have cultivated relationship and consultation with Indigenouspeoples, however, we have been unable to find another Indigenous clinical practice council withina health authority and we believe this work to bethe first of its kind to be documented in this region. While we are presenting decolonizing researchengagement processes for policy development forhealth care services for Aboriginal peoples, we understand that more research will be required to as2The Idle No More grassroots movement, started by four Aboriginalwomen in Canada, protests the creation of new and modified federal laws that harm Aboriginal rights and put the environment atrisk. For information on the laws see Land, Bradley & Zimmerman.Olthuis Kleer Towhshend LLP. Dec 2012. Toronto Ontario.sess the short and long term effects of the Indigenousprotocols on policy process.Decolonizing our health care processes involvesaddressing the effects of colonialism as evidenced inthe national and international indices that suggesta transformative change is required for health care.3Our leadership is committed to understand howwe are all implicated in the ongoing injustices committed towards Aboriginal peoples and to explicitly address cultural harm and redress as required inInternational Human Rights instruments.4 The practice council documents the process of how we areguided by a collective of local Indigenous health careleaders. We outline how we make space for the interface of decolonization and resurgence and we suggest that we cannot do this effectively without leadership from Indigenous knowledge and protocols.In resisting imposed structures of thinking, outdated systems and service delivery models and moving towards reconciling and recovering the sense ofconnection with the peoples of this land as our relatives, as treaty peoples, we began to build right relationship. This is the first phase of our informal (pre)research process. Community readiness and the appropriate facilitator of the process are all factors thatcontribute to the success of a decolonization process.The process of moving from local land based culturalprotocols to policy requires the engagement of localIndigenous protocols to inform the policy makingprocess. We suggest that Aboriginal health leadershipis demonstrated through collective cultural efficacyproviding resources to enable Aboriginal peoples,who are often marginalized in inner cities, to participate in their health care choices with improvedUnderstanding Health Indicators, a report developed by the FirstNations Health Center (2007b), gives examples of First Nationsmodels and cultural frameworks to expand and understand indicators for health and well-being that are culturally relevant and reflectFirst Nations knowledge at all stages.4 See www.un.org/esal/socdev/unpfii/en/drip.html ARTICLE 311. Indigenous peoples have the right to maintain, control, protect anddevelop their cultural heritage, traditional knowledge and traditional cultural expressions, as well as the manifestations of theirsciences, technologies and cultures, including human and geneticresources, seeds, medicines, knowledge of the properties of faunaand flora, oral traditions, literatures, designs, sports and traditionalgames and visual and performing arts. They also have the right tomaintain, control, protect and develop their intellectual propertyover such cultural heritage, traditional knowledge, and traditionalcultural expressions.2. In conjunction with indigenous peoples, States shall take effectivemeasures to recognize and protect the exercise of these rights.3patient outcomes. This happens when policies followlocal protocols. It is our hope that this process of protocols to policy will also contribute to the resurgenceof healthy leaders and community processes.In this article we will highlight the steps takenin our methodology to allow non-Indigenous organizations serving Aboriginal peoples to implementIndigenous community-based research principles,protocols, and practices central to the provision ofeffective, culturally appropriate health care. We contextualize the work in the political framework of thetime and outline the process of our work: protocols,principles of engagement, living the work, policy inpractice, and research. We end with some issues,challenges, and recommendations.ContextThe BC Tripartite First Nation Health Plan (FirstNations Leadership Council, 2007), agreed to by theBC First Nations Health Council, the BC provincialgovernment, and the Canadian federal governmentincludes principles of respect and recognition ofcultural health practices: “Cultural knowledge andtraditional health practices and medicines will be respected as integral to the well-being of First Nations”(p. 3). In this ten year trilateral agreement, all threeparties have committed to action in four priorityareas: governance; relationships and accountability; health promotion and disease; and injury prevention. This agreement created the framework forVancouver Coastal Health (VCH) to look to FirstNations and Aboriginal leadership in creating healthcare services.5 The question from the Indigenouscommunity on ethically engaging with First Nationsand Aboriginal communities in ways that would decolonize imposed health structures and support andrespect the resurgence of Indigenous knowledgesneeded to be addressed.Protocol Principles: First StepsIn 2008, in response to the Tripartite HealthPlan priorities, Aboriginal Health Services in the5Vancouver Coastal Health (VCH), one of the five health authoritieswithin British Columbia, provides health services to 15 First Nations(12 rural, two subrural) and the urban Aboriginal population ofVancouver aboriginal-communities/).Vancouver region of VCH approached Tonya Gomes,an Indigenous female facilitator from GuyanaSouth America and one of the authors of this article. Tonya, who was living and working with theurban Aboriginal community, was asked to formthe Aboriginal Health Practice Council. AboriginalHealth Services wanted to establish a process foraddressing Aboriginal peoples’ clinical services; andalthough VCH saw the initial task of the practicecouncil as developing clinical guidelines for healthcare service delivery to urban Aboriginal community members, Tonya articulated the need to haveAboriginal leadership guide the work. This requiredthe building of right relationships with the localland based and urban Aboriginal peoples.Before accepting the responsibility of creatingthe health practice council, Tonya followed placespecific cultural protocols and engaged in a seriesof consultations with local traditional knowledgeholders. She asked about the possibility of creatingan Aboriginal health practice council with representation from local Indigenous nations. She wanted to find out their thoughts about the work andif she was the appropriate person to facilitate it.Tonya followed local Indigenous protocol principlesof the Coast Salish peoples and presented culturally appropriate gifts to spiritual leaders in the local unceded nations: xʷməθkʷəy̓əm, Skwxwú7mesh,and Tsleil-Waututh. She asked their permission toground the council’s work in protocols, ceremonial principles, and frameworks and she participatedin cultural ceremonies with them to discuss theirthoughts and recommendations. The Indigenousknowledge holders recommended having appropriate cultural representation on the council to provideinput regarding health issues that affect the localnations and guidance on their protocols and ceremonies. The Indigenous knowledge holders also saidthat while they would see how the work evolved,it was Tonya’s responsibility to continue to engagein annual consultations, and that this would be thefoundation of a reciprocal relationship between allparties.As a way to maintain accountability and sustainable relationships with citizens of the local FirstNations and Aboriginal community knowledge
Indigenous Health Leadership: Protocols, Policy, and Pimatisiwin: A Journal of Aboriginal and Indigenous Community Health 11(3) 2013keepers Tonya committed to the ongoing ceremonial principles and processes required for centringthe practice council‘s work in Aboriginal healthleadership and for engaging Indigenous health caresystems. The foundation of the council’s work isinformed by this pre-engagement practice ethic inwhich we take direction from Indigenous knowledgekeepers and follow local protocol principles to beginany new work relating to the creation of service delivery policy to Aboriginal peoples. How we takedirection is outlined in the visioning section of thisarticle.From these beginning consultations, AboriginalHealth VCH, urban Aboriginal community membersand Elders from the local nations initially createda health practice council, based in local protocolsand principles, to develop clinical practice guidelines for health services to urban Aboriginal people.Indigenous Knowledge systems and mainstreammedical practices were to be addressed within theseframeworks. However, once the council agreed tobase their work on the recommendations from theTripartite agreement, it quickly became clear thatthe task of the council would be to create policiesfor VCH staff to make space for Indigenous healthknowledges within the health care system and to facilitate access to Indigenous health care.6 The tension became how to build right relationships withthe urban and local Aboriginal leadership based onlocal protocols and principles of decolonization andresurgence while concurrently creating policies andprocesses to guide VCH. The council was then structured to provide guidance from urban Aboriginalheath leadership and align with the United NationsDeclaration on the Rights of Indigenous Peoples(2007), to facilitate appropriate policymaking.Aboriginal Health Practice CouncilVCH Aboriginal Health extended invitations to theVancouver urban Aboriginal health leadership members and VCH employees to discuss a framework fordeveloping the Aboriginal Health Practice Council(AHPC) and the first meeting was held in October2008. One of the first tasks of the council was to6To improve health outcomes and access for Aboriginal people healthcare systems need to create appropriate access to Aboriginal healthsystems.establish relational protocols and terms of referenceto frame the work.Principles of EngagementIn the urban setting we were mindful that the majority of the council members are visitors to thisterritory and remain committed to the making ofgood relationships — in effect, they are guided bythe commitment of being a good relative. As thecouncil membership reflected the diversity of theurban Aboriginal population, we needed to have relational protocols on how to work together in waysthat aligned with cultural protocols and principles.We knew that to accurately engage in a decolonizingprocess and reflect Indigenous knowledge systems,we needed to develop principles of engagement byfollowing the protocol existent in ceremonial cultural practices. We agreed to begin with local landbased cultural protocol principles. Following therecommendations from the Indigenous knowledgekeepers to have representation from local Aboriginalhealth leadership we invited local Elders to co-chairthe council. Our practice principles and policy ensures that the Elder co-chairs are paid regular consultant fee for sharing their expertise.Discussing principles of engagement enabledthe council members to establish terms of referencefor their meetings. We established that the council would consist of a minimum of fifteen members, meet monthly from September to June, andbe co-chaired by an Aboriginal Elder from a localNation. Of these members, three quarters would beof Aboriginal ancestry, represent Aboriginal healthleadership, and the urban Aboriginal population.We drew our membership from three strategic areas:VCH staff; VCH Aboriginal Community Partnerships;and Aboriginal urban community members and organizations. The qualifications for membership included people with demonstrated commitment toAboriginal health and social issues.There are a total of fourteen guiding action itemsin the terms of reference and we list four points here.Each item is situated in the position of recognition,protection, and regeneration of Indigenous knowledges: developing, implementing, and evaluatingevidence and culturally based practice standards,guidelines, protocols, and policies; identifying opportunities for practice improvements and addressing these opportunities using Aboriginal frameworks; developing evidence based and/or culturallybased indicators that support integrated processesfor Aboriginal, Euro medical, and alternative healthpractices; and identifying education needs of VCHstaff specific to working with Aboriginal people.7Decolonizing our Practice:Principles of PracticeDecolonizing our practice reflects Indigenousprinciples and practices as central to Aboriginalhealth leadership in improving the health status ofAboriginal peoples and reconciling colonial imposition of structures that largely do not benefit thehealth of Aboriginal communities (Kelm, 1998).We knew that working within the intersectionsof Indigenous and mainstream medical health systems would make how we came together in relationship and how we negotiated the language in ourwork critical. For instance, the term “medicine” hasmultiple meanings throughout health systems. Weknew we would be weaving threads of understanding between multiple cultures while dealing withintellectual property rights of Indigenous knowledges (National Aboriginal Health Organi
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. Hunting, fishing, and gathering plants for food and medicinal pur-poses are examples of Aboriginal inherent rights. Aboriginal peoples
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