Bridging cultures for better healthcare: how the Ktunaxa Nation is leading health systems transformation
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Bridging cultures for better healthcare: how the Ktunaxa Nation is leading health systems transformation
The legacy of colonialism continues to dominate the design and implementation of Canadian systems and institutions, including healthcare. The healthcare system’s colonial norms mean it often does not deliver on the needs of First Nations peoples, nor integrate their insights and knowledge on health and well-being. This has negative consequences for everyone, whereby no one is benefiting from best practice to improve health outcomes across populations. A unique partnership between the Ktunaxa Nation, regional health authority Interior Health, University of Victoria (UVic), and the University of British Columbia Okanagan (UBC-O) is aiming to change this through the xaȼqanaɬ ʔitkiniɬ research project, which translates as ‘many ways of working on the same thing’ in the Ktunaxa language.
Glossary
First Nations — the original inhabitants of what is now known as Canada. There are over 630 recognised First Nations and more than 70 distinct First Nations languages across the country. As self-determining people, First Nations hold inherent rights, which are the rights they have always had since before colonisation. Additionally, some have treaty rights, which are agreements made with the Canadian Government that affirm their rights to land, resources and self-governance
Ktunaxa — (pronounced as ‘ktoo-nah-ha’) an Indigenous people who traditionally occupied and continue to inhabit parts of what is now known as southeastern British Columbia in Canada and some northern US states
xaȼqanaɬ ʔitkiniɬ — a Ktunaxa phrase meaning ‘many ways of working on the same thing’
qapsin kiʔin ʔakaɬxuniyam? — a Ktunaxa phrase meaning ‘what would a healthy community look like?’
Equity — an idea, benchmark and experience. As an idea, equity means that everyone should have what they need to reach their full potential. As a benchmark, it means we aspire to create societies where no one is unfairly disadvantaged from reaching their full potential due to preventable causes, like their race, income, where they live or their self-expression. As an experience, we know that the lack of equity, or not having our needs met, is felt in people’s bodies and manifests through differential and unfair health outcomes, among other things
Two spirit — a cultural identity used by some Indigenous people to describe a person who embodies both masculine and feminine qualities or a variety of gender expressions and sexual orientations
Watch these videos to learn about the pronunciation of Ktunaxa phrases:
What makes a healthy community?
The Ktunaxa Nation has existed alongside the Kootenay and Columbia rivers and the Arrow Lakes of British Columbia for over ten millennia. The Ktunaxa language is unique, unlinked to any other. For thousands of years, Ktunaxa people were seasonal migrants, following vegetation and hunting cycles, before they were displaced and dispossessed of their land by European colonisers in the late 1800s. Like all First Nations people, the Ktunaxa Nation faced colonial oppression at the hands of colonists, and the effects of systemic discrimination and intergenerational trauma continue to this day.
Many are now attempting to address Canada’s colonial legacy, and its ongoing impacts, by addressing systemic inequities, acknowledging historical wrongs, and co-creating pathways for reparation and relationship building. This journey is neither simple nor linear and involves building mutual understanding and the sharing of knowledge and perspectives, through respectful and community-led communication. In British Columbia, the xaȼqanaɬ ʔitkiniɬ project puts Ktunaxa communities at the forefront, creating connections between Ktunaxa and non-Ktunaxa peoples to find healthcare solutions based on Indigenous knowledge that can benefit everyone.
The xaȼqanaɬ ʔitkiniɬ research project
The xaȼqanaɬ ʔitkiniɬ project brings non-Indigenous and Indigenous knowledge-holders together to co-design solutions that promote equitable health outcomes across the Ktunaxa Nation. The project is co-led by Dr Christopher Horsethief, the Ktunaxa Nation Project Lead, Dr Sana Shahram, UBC-O Project Lead, and Dr Bernie Pauly, UVic Project Lead. They work alongside Dr Alex Kent (UBC-O), Shaunee Keyes (UBC-O), Jen Driscoll (Interior Health), Kris Murray (Interior Health), and Smokii Sumac (Ktunaxa Nation). The project is overseen by Ktunaxa Elders and Knowledge Holders in the xaȼqanaɬ ʔitkiniɬ Advisory Group.
One key goal for the project is to engage in community dialogues in response to the question, qapsin kiʔin ʔakaɬxuniyam? – ‘What would a healthy community look like?’. A second key goal is for Interior Health to learn from and integrate Ktunaxa understandings of wellness into its systems and processes. This will enable it to provide health services that honour Ktunaxa culture, language and worldviews for all people who live within Ktunaxa Nation territory. Interior Health is a regional health authority in British Columbia, where health authorities have responsibilities for the planning, funding, delivery and evaluation of health services and programmes within their geographical region, under the guidance of the provincial Ministry of Health.
Community engagement
Crucial to the project’s success was finding mutually respectful and enriching ways to engage with communities. The xaȼqanaɬ ʔitkiniɬ project steps away from established research methods typically used by institutions with colonial roots, instead working to find ways to build more meaningful, anti-colonial relationships with participants. This involves participating in community gatherings, with shared meals and facilitated discussions, rather than relying on surveys, questionnaires, patient records, or other information-gathering techniques typical to academic and medical institutions. Sana contrasts this to the typical research approach. “Academics can often make things more complicated than they need to be, without necessarily recognising the expertise of the people actually living in these systems,” she says. “Yet, they’re the ones living and breathing the values we claim and, often, in transformative ways.”
“Community engagement has been the most important part of our research,” says Christopher. “Following advice from the Advisory Group, we organised dinners in every community and invited people to join us.” Food is a powerful unifier; Christopher recalls that while many community members arrived with intentions of eating but not staying, all besides a couple of teenagers decided to stay and participate.
The theme of community leadership, both through elders and other community members, runs strongly throughout the project. “Once we’re with a community, we do very little talking. We do a whole lot of listening,” says Sana. “You don’t learn about people’s worldviews by handing them a questionnaire. You have to speak to them to get to know them and what’s important to them and their community.”
“Our project has worked from a standpoint of how we should operate, rather than how we can operate within institutional guidelines,” says Alex. “Institutions like universities and ethics boards often put up a lot of roadblocks to ensure alignment with guidelines and ‘best practices’, which can act as barriers to effective connection.” Christopher is the Chair of the Ktunaxa Nation Council’s Ethics Committee and enabled the Ktunaxa Nation to lead on processes around research, control and data governance. While not always consistent with university policies on data, the insights generated through taking this alternative approach open doors for future community-led projects.
Community through connection
A key ongoing lesson for Canada’s healthcare institutions is appreciating that colonial and Indigenous perceptions of health and wellness often differ. Since 2018, the project has hosted gatherings in a number of Ktunaxa communities to discuss what a healthy community looks like. The team’s experiences engaging with Ktunaxa elders and other community members has helped build mutual understanding of these differences and how to accommodate them in just and meaningful ways.
The most common theme for wellness that emerged from these gatherings focused on connection, and how disconnection can lead to negative consequences for community health. “Colonisation disconnects people from their community, their families and, in many ways, from themselves,” says Christopher. “The most successful parts of our research have involved reversing that: reconnecting people to one another, to experiences, language, culture, land, and bitterroot.”
“The notion of connections between individuals and within communities is a core component of health,” says Alex. “That extends beyond interpersonal connection. Within the Ktunaxa Nation, we heard frequently about the importance of connection to land, nature and other species.” Alex recalls experiencing this connection first-hand, through participation in land-based activities such as harvesting bitterroot, a plant valued by the Ktunaxa Nation for its nutritional content and ceremonial significance. “Feeling connected through an activity that has been performed by the Ktunaxa Nation for generations is really symbolic of wellness for me,” she says.
By not only hearing about the importance of connection, but also experiencing it, the team was able to appreciate participants’ insights more deeply. “Coming together, sharing space and a meal with each other, getting to know and understand each other – for me, that defines a healthy community,” says Jen. Smokii reflects on the success of one community wellness gathering: “A young person who wouldn’t normally speak said it felt safe to contribute. This demonstrated to me the importance of healing through connection.”
Healthy approaches to challenges
Reference
https://doi.org/10.33424/FUTURUM533
Ktunaxa bitterroot harvest
Ktunaxa artist Darcy Luke created a selection of artwork to represent the community wellness themes of the xaȼqanaɬ ʔitkiniɬ project:
Connection and Belonging
Language
The significance of such connections manifests itself when it comes to addressing collective challenges. “The elders we spoke with said that the most important aspect of a healthy community is the ability to solve problems without conflict,” says Christopher. “We should be able to talk about any problem in a meaningful way, through the ways we have used and developed over 13,000 years.” Sana agrees, noting the collective approach to problem-solving. “With the elders, you see the embodiment of caring for one another,” she says. “While they are navigating all sorts of personal challenges, they are still showing up in the space to solve communal problems, together, because they see caring for one another as an obligation and an honour, not a chore.”
Colonial healthcare systems tend to focus on treating symptoms of illnesses once they have begun developing, rather than creating environments that promote health. This contrasts to what the team learnt during their discussions with Ktunaxa communities. “Solutions are never purely in response to a crisis,” Sana says. There are increasing calls for healthcare institutions to adopt a similarly holistic approach, and examples such as these are instructive in how to do so.
Sana also noted the use of humour as a key means of healthily approaching difficult subjects. “Often, these community gatherings involve talking about very heavy topics, given the level of trauma that has been imposed by colonial governments over centuries,” she says. “Yet, people are able to navigate these hard conversations by laughing together and finding a way to stay connected, even in these hardships.”
Moving forward from colonial impacts
Colonialism gravely damaged, and still damages, the connections that define community health. “Colonisation is the process of disconnection,” says Kris. “If you take away everything that makes a population healthy, like culture, language, land and medicines, people will become ill.” This is also true of health services, whose practices are typically based on research performed by and for non-Indigenous peoples. “Institutional racism and systemic racism are present through policies and hostile healthcare environments,” explains Alex. “They don’t represent Indigenous cultures, and historically – and even today – have segregated Indigenous patients or treated them as second-class citizens.”
These traits may not be immediately apparent, or even recognised by the people who work within these systems. “Our institutions and health systems have become so focused on efficiency that we’ve lost sight of effectiveness,” says Sana. “We’re efficient at reporting on metrics that give the impression we’re accomplishing things – but this can be ineffective in the grand scheme of things.” Efficiency can often lead to the pitfall of inflexibility, which tends to be most damaging for people who are excluded from decision-making, as the ‘solutions’ are rarely designed to meet their needs.
Historical injustices
Christopher reflects on Canada’s recent coming-to-terms on the topic of Indian residential schools, where many Indigenous children were forcibly assimilated into colonial culture and isolated from their own. Thousands of children died, exposed to infectious diseases not common within their own communities. Those that survived graduated without familiarity of their own communities, but also subject to racism and discrimination in wider Canadian society and were purposefully equipped with limited skills and training compared to other school programming at the time. This practice took place throughout the majority of the twentieth century.
This is far from the only cause of intergenerational trauma among Indigenous people in Canada. The ‘Sixties Scoop’, for instance, saw around 20,000 Indigenous children removed from their homes by child welfare authorities from the 1960s to 1980s, to later be fostered or adopted by white families. This was driven, in part, by horrific policies that allowed state officials to receive funding for removing these children, in a practice where the state effectively sold Indigenous children for profit. These days, the institutions responsible for these injustices are beginning to appreciate the scale of harm caused. “The exposition of these collective traumas has led many institutions, such as Interior Health, to take a deeper look at their own past and structures,” says Christopher. “That really helped to prime the conversation and let our community members see that there was a safer place to talk about these things.”
But even if the institutions are ready to talk, the damage done to the process of passing on knowledge and keeping community connections alive means that a lot of relationship-building needs to happen first. “The persecution of our communities has created a sense that traditional knowledge has to become secret to protect it,” Christopher says. “If we had begun the project by going in with the traditional research approach of immediately asking questions, without taking the lead from community members, we would have probably just been told, ‘No’.”
Taking the lead from Indigenous people
The xaȼqanaɬ ʔitkiniɬ team considered carefully how to build relationships, and have since led, or been invited to lead, a wide variety of community activities. One especially important activity involved the gathering of bitterroot. “The elders decided to invite the team out to our bitterroot feast, which is not open to the general public,” says Christopher. “It’s a very private thing, and an important mode of teaching.” Smokii recalls how the non-Ktunaxa researchers were initially unsure if they would be welcomed. “The lead had to come from the community,” he says. “There’s a lot of nuance and implicit communication in our ceremonies, so the relationship could have been severed without the community lead. Our researchers are representing the research world as a whole.”
Such relationship building exercises help create trust and connection between researchers and community members, and set the stage for sharing knowledge. “Researchers don’t always recognise community elders as subject matter experts, as they don’t hold academic qualifications,” explains Christopher. “Yet, our elders are the true source of this information.” Sana adds, “It’s been rewarding and humbling to recognise that, despite our titles and qualifications, we’re rarely the experts in these spaces.” The project is aiming to demonstrate this role of Indigenous communities as leaders in the knowledge space – that inclusion of their input should not just be a concession within the current system. “Legacies of colonialism live on in attitudes to Indigenous inclusion,” says Kris. “It’s often an afterthought – an addition of an Indigenous language to a sign, or an Indigenous perspective in a project. But they’re additions; they’re not Indigenous-led.”
The team believes that the Ktunaxa Nation’s insights into health are not only relevant to Ktunaxa community members, but wider society too. “There’s a deeply held presumption that while institutional health systems can serve the needs of everybody, Indigenous health knowledge is only relevant for Indigenous people,” says Sana. “Perhaps we should let Indigenous knowledge guide the development of services for everybody.” Concepts like social determinants of health and holistic approaches to healthcare are quite novel for institutional healthcare services, yet have been integrated into Indigenous knowledge for generations. “The project is trying to flip the dynamic so that the health system can learn from Indigenous knowledge,” explains Sana. “Colonial processes and systems are actually bad for all of us – we are all interconnected, so what harms one part of society, harms us all.”
Now, the team members are reflecting on how they can catalyse change within their respective institutions. “Our organisations typically run meetings using ‘Robert’s rules’, a standard guide for facilitating discussions and decision-making,” says Sana. “Yet, these rules conflict with the ways many Indigenous Nations work, and also with communal problem-solving.” Jen agrees with the need to encompass a broader array of perspectives, including within Interior Health. “It’s important to be willing to take a step back and realise that there are different worldviews out there,” she says. “We need to open our hearts, be receptive to differences, and learn from each other.” This integration of different approaches has the potential to lead to major benefits for everyone. “The current system makes it so challenging to learn from other ways of knowing and solving problems,” says Sana. “This robs us of an incredible wealth of knowledge, learning and wisdom.”
A space for everyone
Christopher notes how early experiences can influence people’s perspectives on the role of Indigenous knowledge and inclusion. “The first time I saw an Indigenous professor was when I was at university,” he says. “What would have happened if I had met him when I was younger? How would it have influenced my view of members as recognised subject matter experts?” Smokii explores this idea further. “I’m two spirit – I’m transgender,” he says. “I wonder how my perception would have differed if I’d seen another two spirit person when I was younger.” With these thoughts in mind, the team felt it essential to include young people in the project.
“Seeing young people take the reins on facilitating community conversations is a really beautiful thing,” says Christopher. Getting the younger generation involved in these conversations is essential for formative experiences to ensure that these connections persist. “The late Herman Alpine taught us to ‘give me your hand’ as a way to greet each other,” says Smokii. “As we give our hands to young people, we’re pulling them into the circle, and they have to reach back.” As well as enabling youths to be present, the team is ensuring they are a part of conversations. “Representing all generations allows us to heal ourselves,” says Smokii. “Every person has their role; they don’t have to try to be something else to show leadership. We want to see our young people grow.”
The team also organised discussions around specific harm reduction and mental health strategies, such as self-care and self-love, and their relations to identity. “These discussions require people to feel comfortable, and this is often better achieved when surrounded by family and other community members, rather than one-to-one clinical settings,” says Christopher. “Making yourself vulnerable and sharing a space requires engagement and connection.” Smokii co-led the harm reduction working group of the project and also supported conversations around diverse genders and sexualities. “Most healthcare settings involve busy schedules where people arrive, talk about the issue at hand, then leave,” he says. “In this project, however, we start with building those relationships. Before we even have meetings, we make sure we’ve eaten and spent quality time together.”
Reflections for the future
Alex recalls the harm reduction regional gathering as a highlight. “We brought together folks working in harm reduction to engage in dialogue about ways to learn from Ktunaxa understandings of community well-being and harm reduction,” she says. “People were honoured to be invited and really enthusiastic about moving this forward. That speaks to the quality of the relationships we’ve built and the authenticity of this work.” Smokii also points to the regional gathering as an important moment. “At the end, one doctor said that their idea of harm reduction was changing as a result of the conversation,” he says.
Sana reflects on the eight years that the project has run to date. “We’ve really grown together as a group – we started as a research team, and now we’re a buddy team!” she says. “You can tell how much this team cares about each other.” These connections extend to the community gatherings too, where the establishment of running jokes and light-hearted small talk signifies the level of trust that has built up.
“We’ve done so much listening and learning, and now have some really clear next steps in terms of rethinking and reimagining healthcare interventions,” says Sana. “I’m excited to show our partners that there is value in working in a different way, and that there is potential to achieve better results through better process.” The xaȼqanaɬ ʔitkiniɬ team hopes that the project’s insights will demonstrate best practice in community-led work, with results that can benefit not just the communities themselves but also the wider regional and even global community. “It’s created a beautiful space of connection that extends beyond the project,” says Kris. “I’m looking forward to bringing more people along for this journey of unlearning and learning together.”
Meet the xaȼqanaɬ ʔitkiniɬ team
Dr Christopher Horsethief, MA, PhD
Ktunaxa Nation Project Lead
Consultant, Ktunaxa Nation Council
Christopher is a member of the ʔakisqnuk First Nation. He is a Crazy Dog, the right hand of the Chief of the Yaqan Nuʔkiy Band and the Chair of the Ktunaxa Nation Council Research Ethics Committee.
Dr Sana Shahram, MPH, PhD
Nominated Principal Investigator and UBC Lead
Assistant Professor, University of British Columbia – Okanagan
Sana is the child of Iranian immigrants currently residing on Syilx (Okanagan Nation) territories (colonially known as Kelowna). She researches how we can transform systems to promote equitable health outcomes.
Dr Bernie Pauly, RN, PhD
UVic Lead and Harm Reduction Working Group Co-Lead
Professor, University of Victoria
Bernie is a third-generation settler of German ancestry, living and working on the unceded territories of the Songhees, Esquimalt and W̱SÁNEĆ peoples. Her research promotes health and wellness through community led research.
Hon. Sophie Pierre, LLD (Honourary)
Elder Advisor
Hereditary Chief and Former Elected Chief, ʔaq’am
Sophie is a member of ʔaq’am (St. Mary’s Band), and served on Council for 30 years, 26 as elected chief. She is a Knowledge Holder and language speaker for the Ktunaxa Nation and multiple research studies.
Dr Alex Kent, MPH, PhD
Postdoctoral Fellow and Project Coordinator
Research Scientist, University of British Columbia- Okanagan
Alex is a fifth-generation settler of British and Dutch ancestry, currently residing on Syilx territories (colonially known as Kelowna). She brings research expertise in cultural safety, anti-oppression, anti-colonial methodologies, patient-oriented research, and knowledge translation.
Smokii Sumac, MA
Two spirit LGBTIA+ Inclusion Lead and Harm Reduction Working Group Co-Lead
Cultural Lead, T̓ikxawiȼikimik ● Foundry East Kootenay
Smokii is a two spirit poet and emerging playwright, and he currently works as Cultural Lead for T̓ikxawiȼikimik ● Foundry East Kootenay – for all things to be connected – where he supports youth and staff in integrating Ktunaxa and Indigenous knowledges into youth-focused healthcare.
Ms Shaunee Keyes, MACP
Youth Internship Coordinator and Intergenerational Working Group Co-Lead
Clinical Counsellor and Graduate Research Assistant, University of British Columbia- Okanagan
Shaunee is mixed settler, Cree, and Metis from what is now called Manitoba. She has lived most of her life in ʔamakis Ktunaxa and is honoured to be a part of Ktunaxa community. Shaunee seeks to support community wellness through helping to reduce the intergenerational and systemic impacts.
Ms Jen Driscoll, MACP
Interior Health Collaborator and Harm Reduction Working Group Co-Lead
Regional Harm Reduction Coordinator, Interior Health
Jen is a second-generation White settler with Scandinavian ancestry. She currently lives as an uninvited guest on Ktunaxa Nation territory in Kukamaʔnam, colonially known as Kimberley. Jen has 15 years’ experience as a frontline mental health nurse in the field of harm reduction and substance use.
Ms Kris Murray, MSc
Interior Health Collaborator
Corporate Director, Aboriginal Health & Wellness, Interior Health
Kris is Métis, with roots in the Red River Settlement area of what is now Manitoba. She lives as an uninvited guest in Ktunaxa territory and is a member of the Rocky Mountain Métis Association and Citizen of Métis Nation BC. She has experience in decolonising public policy, health systems transformation and creating safe spaces for healthcare.
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