Working in Aboriginal Communities: What Kind of Health are we Promoting?
In this paper, I will explore the paradoxes and dilemmas embedded in intercultural health care practice. It is the intent of this work to reflect on theories and practices of Western-trained health care providers, consider the implications of our practice in an intercultural environment, and accept the invitation to the visitors on Aboriginal territory by Umeek to find guidance in scholarship from the world views as handed down over generations in First Nations creation stories (Atleo, 2004) to explore an Aboriginal understanding of health and health promotion.
Othmar F. Arnold, unpublished manuscript, University of Victoria BC, 2004
Individual beings are designed to help one another in order to fulfill the requirements of wholeness, balance and harmony, interconnection, and interrelationality. Therefore, to practice vanity as a lifestyle can be destructive. (Atleo, 2004, p. 35)
In the traditional Cree language of the Whapmagoostui, there is no word that translates directly into health (Adelson, 2000). In many Aboriginal worldviews, health is a desired state of the universe (Atleo, 1997). In our North-American context, it seems that health as an abstract and isolated concept that can be discussed and analyzed in a pure scholarly manner, a standard that needs to be achieved, is a phenomenon imported by the European colonizers of the continent. In the European tradition, physical and mental health are researched and discussed at least since the ancient Greek times. Since health is mostly defined as a state of physical and mental wellbeing, and therefore linked to the absence of disease and illness, it is associated with the biomedical sciences (Anderson & Reimer Kirkham, 1999). However, only within the last century was the medical profession successful in appropriating the definition of health and therefore dominating the health care system.
Health promotion is the foremost priority for health professionals trained in a Western science-based curriculum when considering work in Aboriginal communities. According to Labonte (1994), health promotion has a wide range of meaning for health professionals and bureaucrats. It is not a particular theory or program despite its landmark definition in the Ottawa Charter (WHO, 1986). In Canada, it is understood that it is the government’s mandate to provide for the health care needs of the Aboriginal population, as set out in the Indian Act of 1876 under the assumption that Aboriginal populations need the protection of the colonial powers from their own ignorance (Tobias, 1983). The Indian Act also prohibited many of the traditional healing ceremonies, thus destroying an intact Aboriginal health care system (Royal Commission on Aboriginal Peoples, 1996). The current government’s mandate is stated in the mission statement for the First Nations and Inuit Health Branch (FNIHB): To provide services or access to services, to promote health to a level comparable to that of other Canadians, and to build partnerships with Aboriginal nations to improve the health system (Health Canada, 2003b). The effects of that mandate are still seen by Aboriginal peoples as a continuation of the colonial process and often contrary to Aboriginal healing (Atleo, 1997). Consequently, a key question arises: how can the differences between health promotion from Aboriginal and biomedical cultural perspectives, based on enormous differences in paradigms, be acknowledged and possibly integrated into an inclusive health care system and nursing practice?
As a non-Aboriginal nursing student, living and expected to practice as a nurse in a First Nations community in Canada’s north, I have encountered several paradoxes and dilemmas based on differences in worldviews between the population being served and health care professionals: (1) the definition of health is dominated by the biomedical school of thought; (2) health promotion is based on remarkably progressive theory; but in practice it stops short of being much more than patient education for disease prevention; (3) culture is a variable that should be assessed to provide good nursing care.
In this paper, I will explore these paradoxes and dilemmas embedded in intercultural health care practice. It is the intent of this work to reflect on theories and practices of Western-trained health care providers, consider the implications of our practice in an intercultural environment, and accept the invitation to the visitors on Aboriginal territory by Umeek to find guidance in scholarship from the world views as handed down over generations in First Nations creation stories (Atleo, 2004) to explore an Aboriginal understanding of health and health promotion.
Health and Health Promotion from a Western Perspective
Health is a term with Germanic roots that is used in the English language since before the 12th century (Merriam-Webster’s, 2004). The meaning of the original word is traced back to safe, sound, and whole (Rootman & Raeburn, 1994). Today’s dictionary gives two main entries: (1) the condition of being sound in body, mind, or spirit; especially: freedom from physical disease or pain; (2) flourishing condition: well-being (Merriam-Webster’s). The term is used by professionals and lay people frequently and with ease; however, there are several assumptions embedded in the use of the term, as illustrated by the above definitions of the concept, that will create potentially conflicting meanings.
Philosophical underpinnings. In mainstream Western thought, a human being is an individual: independent, free-willed, self-determined, who can make one’s own decisions and bears responsibility for the consequences. This worldview is grounded in the thoughts expressed in John Stuart Mill’s essay On Liberty, which brings forward the theory about the human being as the captain of one’s own vessel shipping towards individual fulfillment and happiness: “In the part which merely concerns himself, his independence is, of right, absolute. Over himself, over his own body and mind, the individual is sovereign” (Mills, 1859/1991, p. 14). Mill’s writings were originally concerned about the influence of the state authorities and the restrictions oppressive governments impose on its citizens to maintain state control over individuals. Over time, the writings were remembered as the basis for an individualistic view of society, and the elevation of the individual human being as the absolute standard in political thought.
This political standard transcended and merged with the scientific view. Medical sciences are concerned with the human body and the mind. The body and the mind, as well as the spirit, are viewed as separate entities working together to create a whole. For analytical purposes, they can be isolated, assessed, quantified, and described as systems. With the advancement of technology, scientists are able to discover smaller and smaller parts within the body and elaborate on their individual functioning as part of the overall organism with a complex hierarchical structure (Saladin, 2001). Each part of the anatomy functions according to a clearly defined physiologic process; the central concept is homeostasis, the tendency to maintain internal stability within defined parameters. The body’s anatomy and physiology complement each other to create a “unity of form and function” (Saladin, p. 2). The human body exists within a world that forms environments, natural and social one’s, and it is up to the individual to interact with the environments of his or her choosing. These environments can have positive (nurturing) or negative (noxious, risk factors) influences on the human being.
Historical considerations. Hippocrates already postulated natural, physical causes for the malfunctioning of the body. He opposed the idea of attributing disease to the activity of gods. Aristotle presented the parts theory of the body; his writings were influential on scientists for two millennia (Saladin, 2001). Since the Renaissance, modern science, with the medical sciences at the forefront, refined the ancient knowledge mainly through the introduction of a reductionist approach: In this mode of investigation, the researcher formulates a hypothesis, focuses on a few dependent and independent variables, and experiments with the independent variable. Based on the findings of the experiment, the research supports or rejects the hypothesis. If the hypothesis is supported, we know “how things work” (MacDonald, 1998, p.5). In combination with technological advances, such as the microscope, science was able to create a convincing body of knowledge that not only explains how the human body and mind works, but also about the states of malfunctioning caused by disease and injury. The same scientific approach provided the basics for treatment modalities of how to return the body to its ‘natural’ state, the ideal combination of form and function (MacDonald).
Medical concepts of health. The medical view of health is very much defined from this scientific, reductionistic background. Rootman and Raeburn (1994) cite the following entry from a medical dictionary: “The normal physical state, i.e. the state of being whole and free from physical and mental disease or pain, so that the parts of the body carry on their proper function” (Critchley, as cited in Rootman & Raeburn, p. 57). It summarizes the concept of health as the absence of disease.
This definition based on the absence of disease forms the framework for diagnostics in the medical system. This perception of health is the foundation for the International Classification of Diseases (ICD) coding system, which serves the medical community as the standard for definition and classification of disease and illness, and provides internationally accepted norms for medical diagnosis and a classification of procedures and treatments (National Centre for Health Statistics, 2004). In mental health, a similar framework, the Diagnostic and Statistical Manual of Mental Disorders (DSM) is used (American Psychiatric Association, 2004). Both are constructed on the premises that there is a science-based, universal norm of health that can serve as a value free foundation for diagnosis of disease and illness, as well as health care delivery.
Expanding from an insular view of the human body, environmental, social, and cultural factors are considered and included. Based on the assumption that the individual has the ability to choose the interactions with the environment, the medical framework expands from the idea of homeostasis of the organism to the idea of a lifestyle standard set by the dominant society. Disease is not only seen as improper functioning of the human body, it is further linked to deviance from proper lifestyle. Socioeconomic factors, aboriginality, language skills, employment etc. are all measured from an ethnocentric, Western point of view. Diversity is framed as risk (homosexuality, skin colour/visibility as compared to whiteness,) or deviance (cultural expression not congruent with whitestream standards) (Mullaly, 2002). MacPherson (as cited in Rootman & Raeburn, 1994) summarizes the expanded view in the following definition:
The state of health implies much more than freedom from disease, and good health may be defined as the attainment and maintenance of the highest state of mental and bodily vigour of which any individual is capable. (p.57)
Notable is the shift from the physical dominance and a relatively static, passive view of the concept of health, as discussed above, to a rational approach which establishes an active locus of control within the individual’s mental capacity. This view is congruent with the ideas of human sovereignty presented by Mill. However, it does not abandon the focus of disease and deviance from a norm as the sources of ill-health.
Besides the medical views of the concept of health, Rootman and Raeburn (1994) identify the WHO definition of health, as well as lay, non-medical academic, and holistic concepts. The authors also mention the distinct, multidimensional view of the concept of health that the nursing profession holds.
Lay concepts of health. The lay concepts of health are strongly associated with ethnically influenced definitions of health, or what is more commonly framed as cultural views. This framing conveniently assumes that culture is something unique that applies to ethnically defined populations, but has no association with mainstream society and the medical sciences (Stephenson, 1999). It is interesting to note that the Western popular definition of health is closely related to the above discussed medical views. However, Rootman and Raeburn (1994) note some class specific differences: Middle-class people seem to orient themselves more on the lifestyle-based definition, emphasizing physical and psychological well-being as expressed in strength and energy. From there, they derive the power to resist or fight disease. On the other hand, working class people seem to express more a functional view of health: How much do disease, illness, and injury interfere with getting the necessary tasks done? This is a pragmatic interpretation of health, oriented in the absence of disease.
The lay concepts in Western societies are also reflective of the prominence of individualistic thought: People with a strong individualistic orientation define health more as the product of a self-determined lifestyle. People with a more collectivistic attitude see health as a state often negatively influenced by external factors such as the environment and micro organisms (Rootman & Raeburn, 1994). Common to the range of popular definitions of health in Western society is the notion that health as an individual, precious state (something that is owned or somebody has a right to) is subjected to the constant threats inherent in the world around the person. The determinants of health are a theoretical approach to understand and eventually to be able to harness the sources of risk to an individual’s health.
For the affluent in present day mainstream society, health becomes almost commodified. In combination with the idea of self-determination, the availability of services, the constant development of advanced diagnostics and treatments, health and beauty, a concept which is closely related to health in this context, can be protected and acquired. After the absence of disease, beauty – as expressed in physical appearance – becomes the second most important indicator for health. Not only are the people left with the impression that with the help of proper screening methods many diseases and deficiencies can be detected and avoided. People can choose their lifestyles and therefore assume responsibility for the determinants of health (based on a narrow, individualistic definition of the determinants). Through the media, the industry conveys the message that if a person does not like the look or shape of one’s body, or if one’s body does not match the culturally created standard of normality, that this can be changed, too, in order to gain optimal physical and psychological well-being (Liaschenko, 2002). MacDonald (1998) describes the attitude of individual responsibility for health through informed choice as healthism. The author implies that this attitude is the culmination of individualistic and consumerist thought, making one’s own body as the sole focus of values and decisions, thus making the wider society seem to become irrelevant in the context of health. It becomes a corruption of the idea of health promotion. Rootman and Raeburn (1994) summarize healthism as a popular middle-class phenomenon based on a holistic concept. Knowledge from a variety of sources, nutrition, Eastern and Western health sciences, folklore, etc. is combined to seek individual body-mind perfection with an insatiable engagement in health-promoting activities and behaviours. By excluding consideration for social conditions and the emphasis on individual responsibility, healthism creates a climate for social control through blaming the victim. The influence of healthism on the concept of health promotion will be discussed in further detail below.
Social sciences concepts of health. Non-medical, academic views of health are found in the social and environmental sciences. Rootman and Raeburn (1994) mention particularly the disciplines of psychology and sociology. Psychology’s approach to health is individual oriented and expands on the biomedical model. Psychology contributed the concept of the bio-psycho-social health, adding the person with social ties to the biomedical model that focuses on the physical body and the mental function. Psychology considers the social context of a person as influencing health, while sociology emphasis a broader social environment. However, Rootman and Raeburn note that much of the sociological research is also focused on illness and disease, examining the impact on the interpersonal level. Another key focus is the health institutions and their relationships to the wider society. However, parallel to the development of the ideas of health promotion since the 1970’s, theories emerged that see health as an independent continuum from the concepts of illness and disease; health is also studied as extending beyond the realm of the individual person.
Environmental concepts of health. A third non-medical academic field that is strongly involved in the health debate is environmental sciences. Their definition of health is tied to the concept that the human being does not exist isolated from the physical environment and that changes in the environment have an influence on human health and well-being. Health is often seen as the human’s ability to adapt to environmental influences and changes. On the other hand, disease and illness can also be caused by such. The ecologic movement emphasizes the interplay between the organism and the biosphere as its key argument for environmental protection as an important factor in health promotion and disease prevention. However, often other concerns such as safety and security are also discussed in connection with non-physical environmental concerns (Schubert, 2003). Environmental theories had a strong influence on the discussion about the determinants of health (Hayes, Foster, & Foster, 1994). This theoretical approach has strongly influenced the conceptualization of health and the definition of health promotion in the Ottawa charter (WHO, 1986). In combination with the above discussed individualistic thinking patterns and the concept of healthism, the physical environment is seen as a constant threat to human health and well-being. These thought patterns are mirrored in the social and political realm, where the world around a human being is increasingly conceptualized as a constant threat to individual freedom and choice, creating a climate for strong civic and corporate power and control. Therefore, the determinants of health as proposed by environmental sciences with a deep concern for a positive concept of collective health capacities have been appropriated over time in the mainstream thinking to support a negative concept individual health concerns in constant need of defense and protection.
The WHO definitions. The World Health Organization’s definition of health was formulated in the years after the Second World War in an attempt to create a universally accepted basis for curing the ills of the world. Health was defined as “a state of complete physical, mental, and social well-being, not merely the absence of disease and infirmity” (WHO, 2004/1948). This definition is embedded in the preamble of the WHO constitution which creates a wider context for it:
The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition. The health of all peoples is fundamental to the attainment of peace and security and is dependent upon the fullest co-operation of individuals and States. The achievement of any State in the promotion and protection of health is of value to all. Unequal development in different countries in the promotion of health and control of disease, especially communicable disease, is a common danger. Unequal development in different countries in the promotion of health and control of disease, especially communicable disease, is a common danger. The extension to all peoples of the benefits of medical, psychological and related knowledge is essential to the fullest attainment of health. Informed opinion and active co-operation on the part of the public are of the utmost importance in the improvement of the health of the people. Governments have a responsibility for the health of their peoples which can be fulfilled only by the provision of adequate health and social measures. (WHO, 2004/1948, ¶1)
Although it is regarded as a universal definition of health, it has also been criticized widely. Rootman and Raeburn (1994) mention some of these criticisms. For some, the definition is seen as to broad, too inclusive, and without boundaries. This argument is not only used to support concerns about economic consequences, but also for the fear that all aspects of life will be medicalized. The other main point of criticism is the definition’s appearance of being universal. Critics see the WHO definition as a product of social and political circumstances after the Second World War and dominated by Western scientific thought. The WHO definition is influenced by the medical definitions, as well as academic definitions from other disciplines. Cribb and Duncan (2002) see it as a definition somewhere between the narrow focus on absence of disease and the open-ended well-being. It is a foundation to meet people’s basic needs and thereby providing the conditions for personal autonomy. The initial WHO definition – and later versions such as in the one in the Ottawa charter – maintains the focus of health at the individual level, leaving enough room for cultural differences by not specifying the parameters for a fulfilling life.
It is unquestionable that the WHO definition has strongly influenced the development of health care policy worldwide. The concept of health promotion is one of the legacies that evolved from the original WHO definition of health. However, by becoming recognized as universal, it also marginalized any health belief system that is not built on a conceptualization of the individual as the locus on health. Spector (1996) provides an overview of diverse health belief systems around the world that do not correspond easily with the universal WHO definition. In the second part of this paper, I will describe one of these concepts, based on a Nuu-chah-nulth world view, and will discuss difficulties that may arise from the intercultural context.
Health promotion as a term has widely been used as an umbrella for activities such as disease prevention, health maintenance, and health education. But it is also argued that health promotion is not a particular program or a defined set of activities within a health care system, but rather a frame of mind that is grounded in philosophical approaches that view health as a broad and holistic concept, that intersects disciplines, and that incorporates the collective and individual realms (MacDonald, 1998).
Historical considerations. Long before the term health promotion appeared in policy papers and eventually gained widespread acceptance and use in the English language, the principles of health promotion were part of many diverse cultural practices around the globe for millennia (Young, 2002). Early modern health promotion practices were grounded in intuitive knowledge and missionary drive. For Florence Nightingale, health promotion was deeply rooted in her personal beliefs about the benefits of cleanliness. She combined this belief with social ideals that recognized her privileges in mid-19th century society. She recognized that the poor health and living conditions of the lower classes needed improvement and saw it as a duty of the upper classes to intervene. As a woman who had some social relevance and therefore access to the powerful, she was able to influence health care reform in the second half of the 19th century by publicizing her ideas about health promotion practice. Her often simple, but effective solutions were not supported by scientific research at the times; Nightingale even refused to acknowledge the emergence of the germ theory as a possible scientific proof for her actions (Pfettscher, 2002). She did not have to depend on science because her deeply religious beliefs were based on alternate sources of knowledge that gave her assurance of the righteousness of her theories, and the success of the outcomes provided support for her theories.
The germ theory and other major breakthroughs in the medical sciences in the late 19th and early 20th century, combined with the association of the medical sciences with the patriarchy in the dominant society, made it possible to marginalize the humanistic attitude that Nightingale brought in as the founding mother of modern nursing, and health promotion was secularized and eventually taken over by the medical system and completely rationalized. At the same time, the responsibility for health promotion shifted away from a social responsibility with concern for the disadvantaged, to the model of individual responsibility based on the health belief model (Young, 2002). With this shift in Western thinking, the individual human being emancipated from a being embedded in society and environment, to a being that is self-sufficient, in control, and connects to society and environment at will. Instead of being a fish in the pond, we became a part in a machine.
Along with the expansion of medical knowledge and development of technology came a change in the personal and scientific understanding of health. As discussed earlier, with the increasing focus on a definition of health as the absence of disease, health care expanded its service and research priorities toward medical diagnosis and treatment (Young, 2002). In folk medical beliefs, even within our modern society, the understanding of health care defied the dominance of the illness care model. The idea that health is linked to wellness, and disease being something else, has never completely subsided (Brady, 2001). This explains the persistence of many traditional healing techniques and modalities against the weight of scientific proof of their uselessness, their demonization on the grounds of possible dangers, or their association with superstition and irrationality.
In the 1970’s, the emerging scientific knowledge about links between the determinants of health and individual health, on a scale that was larger than the focus on illness and disease by the medical field, started to influence public policy (Hayes, Foster, & Foster, 1994). Today, we accept Lalonde’s report A New Perspective on the Health of Canadians (1974) as the first public policy paper that brought the modern understanding of health promotion into public awareness. It marked a transition from the regulatory philosophy by the government to protect the health of the population, to an approach that was to be built on individual values and beliefs and social marketing techniques (Badgley, 1994). Lalonde created a functionalist view of health which recognized lifestyle as an important determinant of health. Control over health was also shifted from the strict expert approach to a wider base within the people themselves. This resulted in a conceptual shift for the Canadian government to prioritize the prevention of disease instead of allocating its resources for treatment of illness. Subsequently, it also allows government to assume less responsibility, because the individual is in control of the private decisions affecting lifestyle (MacDonald, 1998).
The WHO definitions. In 1978, there was an initiative to establish Primary Health Care as global policy. The Declaration of Alma Ata (WHO, 1978) defined a service delivery model that provides promotive, preventive, and curative services. It was an important step towards the concept of ‘Health for All by the year 2000’ (MacDonald, 1998). The consensus on a delivery strategy was followed by a discussion on the challenges in health on a global scale. Epp identified in a document called Achieving Health for All: A Framework for Health Promotion unequal opportunities as the key challenge, shifting the main focus away from individual, lifestyle related control and adding a component of social responsibility for circumstances that are beyond an individual’s influence (MacDonald). Epp’s framework was then presented at the first International Conference on Health Promotion, whose resolution became known as the Ottawa Charter. Today, the WHO’s definition as presented in the Ottawa Charter still sets the standard that seems to be universally acceptable:
Health is, therefore, seen as a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities…. Good health is a major resource for social, economic and personal development and an important dimension of quality of life. Political, economic, social, cultural, environmental, behavioural and biological factors can all favour health or be harmful to it. (WHO, 1986)
However, this definition seems to mostly influence the conceptual approach of health promotion on a global scale and to inform policy in international development work. On the other hand, the empirical approach in mainstream society proceeds with the commoditization of health to the point where lifestyle, for the one’s who can afford – and it is the part of the normative standard to belong there – is based purely on personal choice; disease, illness, and even injuries are related back to individual lifestyle choices and judged as good or bad, depending on the deviance from the narrowly defined, medical standard of health. This norm is conceptualized and controlled with the medical profession and Western science in general as the gatekeepers. The norm is specified in terms of functioning of the body, but also in terms of appearance and ability. Only the perfect body is good enough, for everything else there is a credit card.
Cribb and Duncan (2002) relate the gatekeeper position of the medical profession to an ethical discussion about epistemology. Knowledge derived from social or human science is inherently contestable, because it is never able to appear as hard fact as quantitative data from the natural sciences and epidemiology. For the social marketing strategies in health care introduced with the Lalonde report, scientific proof sells ideas better than the complex, relative, and ever-changing knowledge derived from meaning. Intervention-based approaches, compared to long-term change in social processes, produce results that can be easily evaluated, which appeals the governments as the main funding agencies. MacDonald (1998) also discusses the question of power and authority of the medical profession as a strong influence on the empirical approach. The conceptual approach of health promotion as presented in the Ottawa Charter has a potential to break up the “medical monopoly” (MacDonald, p.51) on health that developed and consolidated since the Age of Enlightenment and scientific breakthrough in the Western world.
Health promotion as political activity further illustrates the dilemma between the conceptual and empirical approaches. The dominant side would argue that health promotion consists of various mechanisms of control: Legislation, influencing opinion through marketing, behaviour counseling, and consequences derived from personal responsibility. The individual’s behaviour puts oneself at risk for certain diseases, and therefore constitutes a risk and/or a liability for oneself and society. This establishes a duty for the health promotion practitioner, on ethical grounds and supported by public policy, to intervene to educate the client and improve the individual’s health (Cribb & Duncan, 2002). The authors also discuss that this controlling health promotion activity is often labeled as empowerment.
On the other hand, empowerment in the sense of the empirical approach is more emancipation to achieve social justice as the foundation for health promotion. The earlier definition of health in the WHO constitution emphasizes more the civic responsibility without excluding collective interests. In the Ottawa Charter, health promotion is defined as:
the process of enabling people to increase control over, and to improve, their health. To reach a state of complete physical, mental and social well-being, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment. (WHO, 1986)
From this definition, the locus of power to control health could be easily argued as being with the individual and whatever collective structure the individual is embedded in. The charter also explicitly states that health promotion is a shared responsibility, with health professionals and governments on the same level as individuals and community groups. The envisioned mode of delivery for health services is oriented by the principles of Primary Health Care as established in the Declaration of Alma Ata (WHO, 1978). From this shared responsibility point of view, empowerment would also mean the transfer of authorative, allocative, and ideological power to the margin. This does not only include access to resources, but most notably the recognition of the individual and collective capacity to create knowledge and make decisions concerning their health (Vanderplaat, 2002).
This grassroots-oriented approach contrasts the current, dominant approach, which extends the idea of control mechanisms for individual health behaviours to the societal level, where the uniform, globalized, post-industrial consumerist society seems to be the goal of any development or aspiration. However, based on the concept of healthism, there is a schism between the individual and society; therefore health promotion applies only to the individual human being and has very little societal impact or implications. Health promotion becomes clinically separated from any larger context, which makes it manageable within the positivist framework of the health care system. The health care system is, similarly to the definition of health, controlled by the medical profession as gatekeepers and using economic considerations as the roadmap. The mainstream, capitalist-consumerist society is portrayed as inevitable, a natural process, and therefore not questionable. It is the individual’s responsibility to assure an optimal functioning as a productive member of society. This ideology even establishes an individual’s responsibility to consume as one’s personal contribution to societal well-being and future development.
Health promotion in practice and research has not reached its ultimate form with the proclamation of the Ottawa Charter. The discussion about the conceptual and empirical approaches illustrates the ongoing evolution of the idea and several, often conflicting, concepts. DiClemente, Crosby, and Kegler (2002) describe a trajectory of theory development from the previously dominant emphasis on the individual-level theories to an increased focus on policy- and social-level theories. Many of the latter still embody the former. Harm reduction is one of the examples the authors use to illustrate the expansion of focus. Only a few of the emerging health promotion theories lend themselves to support broad social change toward social justice as associated with the definition of health promotion in the Ottawa Charter. None of them originate in a non-Western paradigm or challenge the political, societal, and economic assumptions of Western mainstream society explicitly. Therefore, it remains questionable if the evolution of the concept of health promotion in North America actually serves the wider interests of an intercultural and global community.
In the next part of the paper, the concepts of health and health promotion are illustrated in the more specific context of the current Canadian policy debate. This will serve as the transition to a discussion of health and health promotion as mirrored from one First Nations worldview.
Canadian Context for Health and Health Promotion
Canada is a signatory to the Ottawa Charter and has therefore theoretically adopted the definitions of health and health promotion as its guiding principles for policy development. A recently released government report, Healthy Canadians: A Federal Report on Comparable Health Indicators 2002, documents the current views on health and health promotion used by the federal, provincial, and territorial governments. It illustrates a clear contrast between the conceptual and empirical approaches in the Canadian health care system. The document is based on the agreement between the First Ministers of all the jurisdictions in Canada that have a legal responsibility for health and health care services. The framework of 14 categories with a total of 67 indicators used to support an action plan for renewal of the Canadian health care system establishes “a benchmark for further measurement” (Healthy Canadians, 2002, p.5). The indicators are grouped in the following areas: (1) health status, (2) health outcomes, and (3) quality of service.
Health status is indicated by life expectancy, infant mortality, low birth weight, and self reported health. Health outcomes are measured by changes of life expectancy, improved quality of life, and reduced burden of disease, illness, and injury. The quality of service indicators are based on waiting times, patient satisfaction, hospital re-admission rates, access to around the clock health services, home and community services, public health surveillance, and health promotion.
Looking closer at the individual indicators, it becomes evident how closely they are linked to disease-based epidemiological data. For instance, an increase of quality of life for Canadians is indicated by the increasing rate of hip and knee replacements. Access to health care is measured as the percentage of the population who states that they have a family doctor, with additional indicators to express the degree of difficulty in obtaining services. Health promotion, the main focus of the Ottawa Charter with a wide ranging scope including the social determinants of health, is simply indicated by smoking habits, physical activity levels, body mass index, and herd immunity for influenza among the elderly (Healthy Canadians, 2002).
The analysis of the indicators for health, as agreed upon by the governments responsible for health care delivery in Canada, supports the notion that official policy pays lips service to holistic views and is based on the definition of health as the absence of disease. It also supports the notion that the medical profession is the gatekeeper for health and health care. Indicators of health are refined in economic terms, and used to construct personal responsibility for lifestyle choices. Looking at the categories of indicators for health promotion in the Healthy Canadians report, it becomes apparent that three of the four are based on known risk factors for cardiac problems and cancers. The mortality rates associated with these select medical conditions are used to measure the overall health outcomes. Statistics related to the same cluster of medical diagnoses are used to indicate the satisfaction of Canadians with health services: Wait times for cardiac surgery and radiation treatment, and re-admissions for acute myocardial infarction (Healthy Canadians, 2002). This is a very limited and one-sided appropriation of Canada’s health agenda.
This view of health is in stark contrast to the one in the Ottawa Charter, which defines health as a resource for everyday life based on peace, shelter, education, food, income, eco-system, access to resources, social justice, and equity. The assumptions of the most recent government agreement are also based on individual responsibility for health, denying any collective responsibility for the individual’s experience of health other that providing diagnostic, treatment, and education services.
This limited view is not shared by all Canadians. In the 1997, the National Forum on Health submitted their final report: Canada Health Action: Building on the Legacy. In the report, it is acknowledged that Canadians are concerned about more than medical diagnosis and treatment:
We are particularly concerned about the impact of poverty, unemployment, and cuts in social supports on the health of individuals, groups and communities…There are success stories in Canada that demonstrate how individuals, communities and regions can overcome adversity and improve health through a variety of non-medical interventions. However, government does set economic and social policies that have important consequences for the health of individuals and populations. A better balance must be struck between short-term economic imperatives and the long-term health and well-being of Canadians. (National Forum of Health, 1997)
The contrast between the two government documents shows that the conceptual approach of health promotion does not always correspond with the empirical approach. Health promotion in Canada has a long theoretical tradition, but a limited prominence within the current health care system. The majority of health care dollars is dedicated to hospital-based illness diagnosis and treatment (Commission on the Future of Health Care in Canada, 2002). On the other hand, the 1974 Lalonde report is described as a critical turning point in the evolution of health care services and delivery theory. It promoted the shift from the biomedical approach with its ‘fix-it’ mentality towards a health promotion strategy based on the Health Belief model (Young, 2002). The Health Belief model assumes that health can be promoted by educating the client about the benefits of ‘good behaviour’ and the risks of ‘bad behaviour’. The goal of the behaviour modification strategy is to lessen the financial burden of health care from the increasing cost of diagnostic and treatment services and increase the overall health status of the population. However, instead of increasing the people’s control over their health, the model was used to promote a strong emphasis on youthfulness and productivity in a consumerist society, a normative standard of health that is medically oriented and socially accepted. The main responsibility for achieving health is delegated to the individual who is left with the impression of being able to choose one’s own lifestyle and to control one’s environment (Young).
Minkler (1999) states that health promotion based on the Health Belief model considers socioeconomic influences on the individual’s health. In its application over the years, the model is most influential for establishing the dominant view of individual responsibility for health through lifestyle choices because of its orientation on middle-class standards and values. Many of the health promotion programs in Canada are based on the same assumption, for example the Healthy Food Guide, the Healthy Activity Guide, anti-smoking campaigns, or the Canada Prenatal Nutrition Program and have a clear health education focus (Health Canada, 2004). The main focus of the current Health Canada strategy is weight control through individual lifestyle modification. However, Minkler points out that there is an overemphasis on personal control in health promotion and disease prevention, which leads to a tendency of blaming the victim, while social contexts, especially realities of systemic discrimination and disadvantage, are largely and conveniently neglected in the consideration. Further marginalization occurs for less-privileged populations who cannot afford to take control over circumstances beyond their means and influence (Mullaly, 2002).
Health promotion is one of the pillars for the Primary Health Care model in Canada (Stewart, 2000). Theoretically, it follows the WHO definition of health that was proclaimed in the Ottawa Charter in 1986. The charter states clearly that health promotion goes beyond healthy lifestyles. Improvement of health requires a secure foundation of resources such as peace, education, stable eco-system, and social justice (WHO, 1986). Therefore, the emphasis is on social, economic, and environmental factors, without denying that lifestyle choices by individuals contribute to health and well-being. Health is not seen as a universal norm, but a process of striving towards achieving one’s individual potential, a view that relies on personal meaning rather than medical standards (Young, 2002).
Community Health Nursing, the commonly used model of health services delivery in First Nations communities, is conceptualized on the Primary Health Care model. Lemire Rodger and Gallagher (2000) acknowledge that the implementation of the model has made a difference in community nursing in Canada, but they also recognize that it falls short in the implementation of appropriate technology and the emancipation from the biomedical definition of health promotion. This creates ongoing dilemmas for health care providers, especially when working in First Nations communities, because of the prominence of the diversity in health beliefs and worldviews.
Health and Health Promotion from an Aboriginal Perspective
Differing definitions of health present the first dilemma for health care professionals working in Aboriginal communities. In a preceding part of this paper, I described the various definitions of health as they are discussed in scholarly literature in Western society. There is no single consensus on the definition of health, despite the fact that governments in their health policies are consistently referring to the WHO definitions as a foundation for the health care system. The following discourse will examine the concepts of health and health promotion using a First Nations perspective as a mirror to increase the understanding of the differences between Western and Aboriginal approaches.
Just like in any society and culture around the globe, in Aboriginal communities, there exists no generalized definition of health. For many First Nations people, today’s understanding of health is influenced by traditional knowledge, colonial history, Western science, the mass media, and the health care system as experienced in the Aboriginal communities (Atleo, 1997). However, in a government report, the Aboriginal health concept is described as a balance of harmony with the physical, social, economic and spiritual environments (British Columbia, 2002). Interestingly, this view of First Nations health resembles the World Health Organization’s definition (WHO, 2004/1948) as well as the wording used to develop health promotion theory (WHO, 1986), wherein health is a positive concept, defined as a personal and social resource for everyday life. It maintains the focus on the individual interacting with various environments. However, it also recognizes the importance of spirituality and the process of harmony.
Many scholarly views on Aboriginal health belief systems seem to identify commonalities and similarities that lead to generalizations, such as the concept of living in harmony with nature (Rootman & Raeburn, 1994; Spector, 1996). Adelson (2000) describes health from a First Nations’ understanding based on Cree experience as a complex, dynamic process that has to do with social relations, land, and cultural identity, which are all linked to quality of life. For this paper, I use the stories as told by Richard Atleo, whose Nuu-chah-nulth name is Umeek, as the mirror to reflect on the Western concept of health and health promotion theory in an Aboriginal context. Atleo (2004) does not mention health per se in the theory of Tsawalk. In his theory, based on the traditional Nuu-chah-nulth origin stories, health can not be isolated as a stand-alone concept from the unity of creation. Umeek’s worldview implies that health is the orderly whole, a continuum of harmony within the physical and metaphysical worlds: “the universe is unified, interconnected, and interrelated” (Atleo, p. xix).
Aboriginal health. Despite these highly sophisticated and complex worldviews and diverse health beliefs, Aboriginal health is mainly discussed in the literature and reported in government documents with regards to the incidence and prevalence of diseases (Health Canada, 2003c). Deficits in Aboriginal health are emphasized from a Western scientific point of view, supported with epidemiological data (Waldram, 1995), and form the rationale for program delivery (Health Canada, 2003a). Particularly the federal government emphasizes the data collection and presentation along racialized categories for Aboriginal peoples, justified with the “particular responsibilities in the area of health care delivery” (Healthy Canadians, 2002, p.1). These perceived responsibilities are a result of a century-old tradition of colonial politics with treaties and promises made to various Aboriginal groups to maintain them as allies in conflicts among colonial powers, or to manage Aboriginal populations to facilitate the colonial expansion across a continent (Waldram). For Henry et al. (2000), this continued, unilateral domination of the health agenda is a form of aversive racism.
In other scholarly sources and government reports, it is acknowledged that First Nations people are disadvantaged in accessing health services, due to remoteness, socioeconomic disadvantage (Commission on the Future of Health in Canada, 2002), or open, direct racism on behalf of the health care providers (Browne & Fiske, 2001). Socioeconomic inequities affecting health are often explained as a temporary side effect of economic changes for the benefit of the entire population, or as a lack of education on an individual level (Osberg, 1997). On the other hand, it is difficult to find information on the inherent strengths and capacities of First Nations populations for health and healing. One of the main difficulties in the arising dilemmas between Western and Aboriginal concepts of health is the difference in paradigms used in understanding and creating meaning. A further discussion needs to examine ontologies and epistemologies in an intercultural context.
What’s so different? To explore the differences between Western and Aboriginal understandings of health, I use a model proposed by Morley (1987) that identifies four categories of influence in traditional health belief systems. These are: (1) immediate, (2) non-supernatural, (3) ultimate, and (4) supernatural causes. I will illustrate these categories both with examples from a Western scientific point of view as well as with examples from the Nuu-chah-nulth worldview. The discussion and interpretation of the categories is based on my own grounding in Western scholarship.
The first category of immediate causes includes obvious, direct influences resulting in imbalance. It is possible to observe a direct cause and an immediate effect. In the health care field, this category includes direct, physical injury. In a fall, the mechanism of injury is the cause, while the broken limb is the effect. In the Nuu-chah-nulth stories, the cause and effect dyads are well represented. They provide for sometimes very dramatic effects:
The chief came forward and welcomed him and asked him to sit by the fire. Even while Aint-tin-mit was being seated, the fire was being built into a roaring inferno. Hotter and hotter it grew. When the fire finally became unbearably hot, Aint-tin-mit took some of his medicine powder and threw it into the fire. Ho! The flames died down. (Atleo, 2004, p.44)
The fire itself had a direct potential for serious injury and caused discomfort to the point where Aint-tin-mit needed to interfere to maintain his quality of life, a health promoting activity. Cause and effect are shown between adding of fuel to the fire and the increase of heat, but also between the medicine powder and the decrease of the flames. In the first example, our Western minds accept the link between cause and effect because we know about the correlation of fuel and heat and can provide scientific proof for it. The second example belongs, from a Western point of view, into the realm of good storytelling and imagination. The sprinkles of barnacle powder (Atleo) have no scientific merit as fire extinguishing agent. However, in the Nuu-chah-nulth worldview, cause and effect in this case are immediate and real. This understanding is based on the implicit knowledge of a supernatural cause that transformed the attributes of the barnacle powder.
Linked to the immediate causes is the second category of non-supernatural causes, which explains why a particular situation occurred. It is also based on observable cause-and-effect relationships as well as reasoning. For example, the germ theory falls under this category: we can establish with the help of technology a correlation between the presence of a pathogen and the resulting signs and symptoms of a disease. In a non-medical context, the construction of a road with the resulting absence of certain game animals due to the disruption of their established migration patterns is also considered a non-supernatural cause. In Umeek’s account of Nuu-chah-nulth origin stories, we find instances of teasing which we know can cause a temporary imbalance based on an observable cause-and-effect relationship:
First he must see the two snail women. One was blind and the other almost blind. He went to their house and found them cooking. He decided to tease them good-naturedly. Very carefully and quietly, he took some food from the plate of one of the women. When she discovered the missing food, she turned to her friend and scolded her, “What are you doing?”
“Eh!” the other said in surprise.
“Why are you stealing my food?” the other replied indignantly. As the two old snail women quarreled, Aint-tin-mit interrupted them with a chuckle. “Hold on there,” he said. “Here is your food. I was only teasing. I’m sorry if I upset you.” (Atleo, 2004, p. 43)
The teasing was not apparent for the main characters in the story; the listener of the story was able to know what was going on. Hiding food from a blind person is creating insecurity which may result in conflict. The key is not in the direct action of cause and effect, but in the reasoning as of why a certain effect is created. The same act in a different context might not establish a comparable cause-and-effect relationship. The non-supernatural causes are an expression of intersectionality of various concepts and ways of knowing.
The third category, the one of the ultimate causes, explains health states and diseases that are based on non-observable interactions between the human being and the environment and the understanding of properties beyond the physical realm of animate and inanimate objects. Smudge from burning a particular plant or herb, as an example, is attributed cleansing qualities and is used in conjunction of events where emotional, psychic, and spiritual purification is desired (Spector, 1996). People living near industrial sites or high-voltage power lines, complaining of unexplained signs of symptoms that have no observable or scientifically proven cause, will claim the exposure to immeasurable or legally-sanctioned safe levels of contamination of soil and water, air pollution, noise, or electromagnetic fields as sources for their illnesses. In the field of complementary and alternative medicine, ultimate causes are used to make claims for healing properties that can not be proven using Western scientific research methods.
In Umeek’s worldview, birthright and legal membership in the family, community, or nation are important factors in maintaining balance and harmony. Aulth-ma-quus, the pitch woman, is described as not having membership in the community and is an example of the antithesis of the design of creation: She has
neither birthright nor legal membership…. She is an enemy of life and balance and harmony, an enemy of family and wholeness, and an enemy of interrelatedness. She is an inverse of a quus (human) living in community.
Atleo draws a parallel to contemporary, individualistic society: “she is alienated, surrounded by people yet alone, and has a closer relationship with technology than with family” (p.34). Aulth-ma-quus’ evil spirit is not defined by the lack of membership; but the relationships she forms to human beings prevent her from acquiring rights and creative participation in the community. On the other hand, Aint-tin-mit, son of mucus, is described as being born into the particular community he was meant to help. This awarded him membership, rights, and responsibilities.
Pitch and mucus are both part of the physical world. The two characters represented by pitch and mucus in Umeek’s story have both spiritual forces and claim a place in the world of the Nuu-chah-nulth. Their importance in health (balance and harmony) or disease (destruction) is associated with their characteristics such as kindness, generosity, selfishness, egotism. These characteristics have no normative standards, but are determined by individual experiences in the context of communal experience (Atleo). Membership is both an individual experience (personal belonging) and a communal experience (contributor to wholeness and “beneficial reciprocity”; Atleo, p. 35). Therefore, ultimate causes do not need ‘hard scientific’ (quantitative) proof; they exist based on experience; they may be inconsistent and contradictory, and may defy any logic. With the theory of Tsawalk, Atleo proposes a scholarship whose authority is based on Nuu-chah-nulth perspectives and practices which provides methodology that does not exclude any variables of reality.
In the final category, the supernatural causes are explanations that Western scholars categorize as spirit and demon intrusion, and are generally considered scientifically irrelevant and associated with religious practices (Spector, 1996). A strong element of supernatural causes is their characteristic to explain fortune and misfortune. In the Nuu-chah-nulth origin stories we find many instances of transformations of people and objects. In Umeek’s world view, there are no exclusionary boundaries between the physical and the spiritual world. The design of creation is based on strong relationships between the two worlds; therefore, it is only natural that spiritual powers are associated with persons and objects in the physical world. The creative interaction between the two worlds requires strict observation of protocols, rituals, and spiritual contracts, an aspect that is closely linked to membership and initiation (Atleo). In the prologue to Tsawalk, Umeek shares a whaling story from his great-grandfather that illustrates the union between the spiritual and physical world as well as the whaler’s luck:
All of a sudden something went wrong,…Everyone in the whaling canoe remained true to the protocols – cleansed, purified, and in harmony. Prayer songs intensified. Still, the great whale refused to turn toward the beach, heading straight off shore. Keesta and the paddlers had kept true to their agreements, and now there seemed nothing left to do except to cut the atlu, the rope attached to the whale.
Keesta took his knife, and as he moved to cut the rope, Ah-up-wha-eek (Wren) landed on the whale and spoke to Keesta: “Tell the whale to go back where it was harpooned.” Keesta spoke to the whale, and immediately the great whale turned according to the word of Wren… (Atleo, p. x)
In the excitement over the successful hunt, family members ashore have prematurely broken away from the ritual necessary for the whale hunt, to prepare for the return of the hunting party. Only a spiritual power, in form of a little bird with the ability to communicate with humans, was able to intervene and restore the harmony required to finish the hunt and provide for the community.
The four categories in Morley’s (1987) model seem to parallel distinct fields of inquiry in the Western world: The immediate category resembles the epistemology of the natural sciences, the non-supernatural category the one of the social sciences. The ultimate category is mirrored in the way the human sciences understand the foundations of knowledge, and finally the supernatural category would constitute the spiritual sciences. While in the Western world each field has the tendency to make an exclusive claim to be the best or the right one, Aboriginal inquiry, as represented by Atleo’s Tsawalk (2004), has the capacity to integrate the four categories into one paradigm that embraces the universe as a whole.
An understanding of health promotion from a First Nations perspective can be constructed based on Morley’s categories. Avoidance of known immediate and non-supernatural causes can be compared to primary prevention and health promotion according to the Health Belief model approach (Young, 2002). An individual or community has to realize that they are susceptible to a process that has consequences; they also have to believe that there is a course of action that can reduce or avoid the consequences. Both processes are based on the conceptualization of cause and effect. Furthermore, that course of action needs to be more beneficial than the perceived risk (Young, 2002), which adds an element of value or hierarchical thinking.
Health promotion, the maintenance of harmony and balance, is partially linked to behavioural action. Traditionally, health education to learn about risks and teach the appropriate behaviours is deeply embedded in Aboriginal storytelling. Often, disharmony and imbalance in life are results of the abandonment or non-acceptance of the proper teachings as handed down over generations from the origin stories: “everyone has a role, and each place and purpose in life demands appropriate teachings for fulfillment” (Atleo, p.31). Health education continues to have a place in health care delivery in First Nations. However, it needs to be questioned whether Western knowledge of health, and health information, which is often derived from scientific studies where variables are reduced, controlled, and applied in an isolated, experimental setting, is meaningful to Aboriginal populations. As discussed above, the Western scientific modes of inquiry are not congruent with a world view such as the one presented in Tsawalk.
For Adelson (2000), the health promotion approach based on the Health Belief model and health education is too limited and too focused on the notion that health is always linked to disease, illness, or non-health. She argues that health is a constituted social reality, which excludes the construction of a dualistic world view built on mutually excluding opposites. This corresponds in part with the WHO definition of health as a state of physical, emotional, and social well-being, as outlined by Labonte (1993). Adelson’s definition also incorporates a strong phenomenological approach, whereas health is an understood meaning of a lived experience (2000). Morley’s third category of ultimate causes helps us look at health beyond disease and illness as a social construct, based on an individual meaning or collective understanding of lived experiences. One of Adelson’s informants phrased the concept’s essence in one sentence: “If the land is not healthy then how can we be?” (2000, p.1). In the informant’s understanding, the land does not simply refer to the natural environment of the Cree, but includes the social and political realities, reflecting on the historical context, the present, and the nation’s outlook to self-government. This view is also summarized in the theory of Tsawalk, in which Atleo (2004) claims that respect for all life forms is the central aspect of social study. Health promotion, therefore, needs to be consideration and action that supports or enhances quality of life derived from social reality, based on the proposition that respectful protocols promote balance and harmony.
The fourth category, supernatural causes, is beyond the capacities of inquiry in Western science; and like the spiritual field, supernatural events are left to philosophical and religious interpretation. Supernatural influences are used to explain fortune and misfortune. They do not follow a cause-and-effect pattern, and have esoteric qualities, which means that they are only accessible to the specifically initiated. Many ceremonial and healing traditions, such as the syewen, or winter dance in the Coast Salish Longhouse, can only be understood by lay people (non-initiated, or without membership in the cultural community) with great difficulty and by using an expanded vocabulary and world view (Denis, 1997). Atleo (2004) creates an account of a tloo-qua-nah ceremony, described by anthropologists as the wolf ritual of the Nuh-chah-nulth. Umeek translates the meaning of tloo-qua-nah as “we remember reality” (Atleo, p.80). It is a worldly representation and celebration of the unity between the physical and spiritual realms of the universe, using diverse modes of expression, all guided through the observance of a series of protocols. Many ceremonies within a First Nations community belong to this category of holistic and spiritual health promotion that also includes all elements of the first three categories as outlined above.
One of the struggles in Nuu-chah-nulth health promotion, and it seems to speak for many Aboriginal groups, is the difficulty to remember the original design of the physical and spiritual worlds. Aboriginal people
become more and more fully engaged with such taxing earthly issues as maintaining the well-being of the community, balancing individual and group rights, overcoming diseases, and simply hoping that survival is possible when difficulties appear insurmountable. (Atleo, p.45)
This statement sounds like criticism even of the most progressive health promotion theory in the repertoire of the Western-trained health professional. It speaks to our inability, unwillingness, or failure to consider and integrate the spiritual world into professional practice.
Morley’s categorization provides a useful tool for Western-trained practitioners to begin to expand their own worldview; but it is less than adequate in addressing the complexities and ambiguities of Aboriginal health beliefs. For example, by listening to or reading First Nations stories, we begin to understand how the four categories suggested by Morley can be presented not as discrete units, but all-at-once, as multidimensional, and paradoxical. In addition to Morley’s model, Smylie (2001) presents an Aboriginal framework using the medicine wheel as a circular paradigm with a three-dimensional overlay to illustrate the cyclical, holistic perspective of health in the life cycle. Atleo (2004) on the other hand, provides in Tsawalk a theory based on Nuu-chah-nulth origin stories that can guide the development of a framework based on First Nations ontology. The theory of Tsawalk offers an alternative view from which methodology for contemporary problem solving can be achieved. Tsawalk also offers an outline of an expanded scholarship from a First Nations point of view, through the practice of oosumich, interpreted as “initiating a positive interaction with the spiritual realm” (Atleo, p.17), which is seen as a research method and healing practice at the same time.
Considerations of Culture
Patient or Human Being?
The diversity in paradigms as discussed above in the context of health and health promotion is the foundation for a second dilemma for the health care provider: the understanding of a person and one’s culture. In the Western tradition, a patient is a body with a mind and a soul, which is not healthy in one or more aspects (Anderson & Reimer Kirkham, 1999). The health care system is either accessed in order to correct a deviation from the norm (treatment of disease and illness), or to attain optimal, sometimes enhanced functioning and wellness (prevention and promotion). The defective parts are identified and isolated for treatment. This view of the individual, independent, somehow neutral or value free physical body that is not connected to the rest of the world unless the person’s mind chooses to, leads to philosophical discussion in biomedical ethics about the beginning of personhood.
Many philosophers pondered the ethical questions around the beginning of life and the development of personhood in the quest to understand at what point in time it would be appropriate to intervene medically (abortion) or to settle economical (trade of embryonic tissue) as well as other questions related to emerging reproductive technologies (Pence, 1998). Tooley (1998) states that personhood is a “purely moral concept, free of all descriptive content (whereas ‘human’ is purely factual)” (p. 205). From there the question arises: when does a human being acquire personhood? At conception; when the ability to perceive pain develops; at birth; or with the emerging maturity of self-consciousness? The limitations of Western thought become apparent in the context of pregnancy. The mother is recognized as one person, but the status of one or more fetuses is highly disputed; the philosophers assign certain rights to the one, but not the other(s). Based on the individualistic thinking pattern, it is not possible to conceptualize a person embedded within a larger organism: whether this is a fetus in the womb, or any human being in the world or universe.
For the same reason, culture is seen as a set of beliefs and values that influences the person’s behaviour: it is a distinct entity that can be put on hold and changed at will. Culture is not part of the complex hierarchical structure of human anatomy and physiology; it is a set of values in the personal and social realm that can be seen as risk to human health (Mullaly, 2002). Cultural beliefs have a marginal place in a biomedical approach to health care. It is seen as interfering with efficient health care delivery (Stephenson, 1999).
In contrast, the First Nations understanding of a human being is an open system that does not work in a mechanistic way. A human is a being within the universe, and the two are in constant, reciprocal interaction. The theory of Tsawalk assumes that they are one (Atleo, 2004). Culture is the expression of embeddedness in the universe. The larger system can be articulated as immediate reality through words, tunes, movements, colors, and places, as it is often done during ceremonies. Therefore, cultural practices are not seen as separate aspects from a person, but they are essential to health and well-being (Toelken, 2001).
Bridging the Cultural Gap
Although biomedical and First Nations worldviews are obviously located in different paradigms, Morley’s model, based on principles of Western inquiry, appears useful for understanding the differences. A biomedical approach in health care for First Nations can be appropriate for concerns located in the immediate and the non-supernatural category. However, the ultimate category, which includes the consideration of social justice issues, and the supernatural can only be addressed by an expanded, progressive application of health promotion in the spirit of the Ottawa Charter. In today’s practice, the social determinants of health are only marginally recognized, incorporated, and acted upon in health promotion activities. More holistic initiatives for Aboriginal health that include the consideration of supernatural causes and Aboriginal modes of inquiry remain absent or grossly underrepresented.
Denis (1997) suggests a health promotion strategy that addresses health in the ultimate and supernatural category is what is most needed from an Aboriginal perspective. As long as the demons of century-old oppression are not tamed, a successful healing of the human being will not occur. Alcohol and drug prevention and treatment programs need to go hand in hand with restoring cultural identity and self-government initiatives in order to achieve long-term positive outcomes for individuals and the communities. In Atleo’s words, there is a “gap between the concept of holistic health and machinations of bureaucracy” (1997, p. 70) which prevents a culturally sensitive way of healing for Aboriginal populations. Therefore, culturally sensitive health services in Aboriginal communities require the ability to operate within two different paradigms. Biomedical knowledge needs to be integrated as part of a holistic approach: This highly specialized body of knowledge holds its own merit in support of other elements within a larger world. Without such awareness, it will be impossible to see the human being beyond the patient; and the ineffectiveness of the prescribed cures will continue, much to the frustration of the well-meaning service providers.
In New Zealand, Maori nurse leaders have developed an educational strategy for health care providers with the goal of being able to provide culturally safe care in intercultural environments, particularly in Aboriginal communities in a colonial context (Ramsden, 2002). The concept of cultural safety allows for the formal recognition of unequal power relations between health care providers and clients and its consequences. It acknowledges the social, political and economic factors that influence and shape individual and collective attitudes (Polaschek, 1998). Through exposing post-colonial ideologies, cultural safety works to see the limitations of the taken for granted assumptions of dominant cultural values that underlie health policies, research, and interactions. Awareness is drawn to the discrepancies in health delivery and ultimately health status between diverse groups based on the cultural, social, and political processes of health care systems (Smye & Browne, 2002). Anderson et al. (2003) examined the transferability of the cultural safety framework to use in a Canadian context. In their findings they postulate that an adoption of the principles of the cultural safety concept into Western scholarship will change the way health care providers will interact and open up a path to healing in any intercultural environment.
Health Promoter or Healer: The Role of the Health Professional
The discussion about various paradigms in health services raises a third dilemma: What role does a health professional play in our society and in Aboriginal communities in particular? Are nurses best understood as ‘angels of mercy’ taking care of one of the most disenfranchised and vulnerable populations in Canada? Or, are health promoters more accurately envisaged as activists promoting social justice in accordance with the WHO definition of health promotion? Or, does health care continue to be like a fire department responding to emergencies?
From a postcolonial perspective, the paternalistic practice needs to be replaced with a facilitating role towards more balance and harmony between the individual, the community, and the universe, between the patient and society (Browne, Smye, & Varcoe, 2004). Nursing theories that are located in the simultaneity paradigm provide the potential for a transition from the nurse as the caring professional in the medical field to a healer in one’s own right. Parse’s (1998) Human Becoming theory is one example that is based on human science and provides the theoretical base for a holistic nurse-client relationship that can be sensitive to Aboriginal health beliefs. Parse’s assumption of the human being is defined through ongoing mutual processes between the human being and the universe in the light of the meaning that is co-created from such multidimensional interactions.
For as long as the Canadian health care system relies on the principle of federal responsibility for health services delivery to the Aboriginal population, the adoption of the Human Becoming theory as the foundation for practice could help bridging the intercultural gap. Parse’s theory makes it easier for Western-trained professionals to provide health services that are meaningful to Aboriginal populations, without abandoning either benefits of medical sciences or traditional healing practices because of epistemological and ontological incompatibilities. The Human Becoming theory promotes a more cooperative approach in the nurse-client relationship. Such cooperation is crucial, because dealing with the ‘demons of oppression’ will yet be a priority of health promotion in Aboriginal communities for years to come.
An approach to health promotion grounded in Parse’s nursing science allows the non-aboriginal health care provider to comply with the call from First Nations people that they are Best Left as Indians (Coates, 1991). Instead of monopolizing the situation with well-intended program delivery, health care providers can become allies for liberation and social justice for Aboriginal becoming, and human becoming in general, complemented with Western evidence-based programming. A health care provider’s own awareness of and liberation from the dominance of the Western science paradigm will be a first step towards acknowledging the co-existence of various paradigms. The acceptance of ambiguities, paradoxes, and dilemmas is the foundation towards a mutually-rewarding intercultural nursing practice.
The majority of the current approaches to acknowledge and correct the disparities in Aboriginal health, as well as the recognition of the diversity in worldviews that account for the difficulties in ‘fixing the problems’ are located within the categories of immediate and non-supernatural causes. For instance, the federal government adopted a policy of devolution of health services from the federal bureaucracy to the First Nations and Inuit authorities. Existing health resources are transferred to be controlled by Aboriginal governments operating under self-government rules (Health Canada, 2003b). Political restraints, such as restricted financial resources and legal discussions over sovereignty, imposed by the federal, colonial government, continue to dictate the agenda of Aboriginal health services (Denis, 1997). In the end, a few dream catcher symbols printed on a healthy heart pamphlet repeating the behaviour modification message based on individualistic lifestyle choices as a person’s risk factors does not constitute a significant shift of paradigms or recognition of Aboriginal knowledge and scholarship. Translating the health education messages based on medical facts about diabetes into Aboriginal languages, or into to an easy to understand English, does not make the information more meaningful to an Aboriginal person who is struggling with loss of cultural identity and poverty. The only effect such a adaptation of the health education materials has is the further stereotyping of Aboriginal people as being incapable of learning and understanding English or French or as being under-educated (Arnold & Graves, 2004).
Even the adoption of theory based approaches such as Parse’s Human Becoming School of Thought (1998) or Ramsden’s Cultural Safety (2002) within the existing health care system does not go beyond a cause and effect mentality. In the human becoming school of thought, the nurse or health care provider maintains the status of expert; however, the health care provider’s position in this nursing science framework is clearly distinct from role assigned in the medical model. Parse’s theory emancipates the nurse from the status of the doctor’s handmaiden to a health professional in her or his own right. Nursing science is seen as a distinct discipline of equal importance working in partnership with the medical profession. The phenomenon of concern in the human becoming theory is the human-universe-health process, which builds the foundation for a nurse-client interaction that less separated than a therapeutic relationship according to current nursing standards (RNABC, 2000). A human being is postulated as an open energy field in a continuous mutual process with the environment. The nurse and the client are co-creating human becoming, which is structuring meaning and transcending possibles (Parse, 1998). In community practice, the nurse-community process is focused on the intentions of the community and guided by community priorities. Nurses are with community to initiate and unfold change (Parse, 2003). The emphasis of the health care provider’s role in intercultural health promotion is no longer paternalistic, but participatory and as an ally, comparable to other liberation and emancipatory approaches (DiClemente, Crosby, & Kegler, 2002).
Ramsden’s approach in the cultural safety framework is an education initiative at the provider level (2002). Instead of modifying the health education information used by health promoters, Ramsden designed a framework that influences the training and education of the providers themselves. Cultural safety is achieved through a change in the provider’s attitude informing practice and through integrating political processes such as transfer of decision making power regarding the health system to the margin.
One dimension or aspect that I am missing in the various concepts and frameworks and their application in health promotion practice is the question of membership. As discussed earlier, in the Nuu-chah-nulth world view, membership is an important factor in maintaining balance and harmony in the universe (Atleo, 2004). Membership constitutes not only rights and responsibilities, both concepts of the non-supernatural category of causes, but it has properties beyond the physical realm and the cause-and-effect relationship of the rights and responsibilities. The sense of belonging as a personal and communal experience, creating an understanding of wholeness based on the perception of mutual benefit through characteristics such as kindness and generosity, is a central theme in Nuu-chah-nulth creation stories (Atleo). These ultimate qualities – based on Morley’s model – of membership need to be addressed further in discussing the role of the health care provider in an intercultural setting.
From my own observations I assume that a large percentage of health care providers in and for Aboriginal communities in Canada are not members of the community they are serving. Membership in this context is not understood as Aboriginal based on the definition found in the Canadian constitution (Sec. 35(2); Constitution Act, 1982), Indian status as defined in the Indian Act (1985), or Aboriginal ancestry, which is based on scientific (genetic) or legal (marriage and adoption) categorization. Membership is also not understood by geographical location; health care providers can be resident, transient, commuting, visiting, or distant. And not every community has a distinct geographical location. Shields and Lindsey (1998) also discuss political and relational elements that are necessary to capture an expanded vision of community; they describe being in community as more than involvement in relationships:
The experience of being in known surroundings; places where they feel safe and have a sense of history and memories, as well as hopes and dreams for the future; people in their life; patterns of how their lives overlap with others… (p. 26)
Membership is also described as one of the elements of community and defined as the “feeling of belonging and sharing” (Shields & Lindsey, p. 27). These hard to describe characteristics of membership, beyond the element of relationship, are all related to a way of being. This view is also expressed and illustrated in Umeek’s stories and Atleo’s (2004) analysis.
Based on my understanding of the role of the health care provider in the current health care system, as an employee or contractor delivering programs to promote health, prevent, or diagnose and treat disease as conceptualized according to government or institutional policy, it is hard to imagine a membership with qualities of the ultimate level. Through applying theories in practice, such as Parse’s Human Becoming and Ramsden’s Cultural Safety, the intercultural relationships between professionals and Aboriginal communities can be greatly improved. This one step will significantly change the kind of health we are promoting as professionals, with much less conflict based on diversity in paradigms and an improved chance for healing. However, the question of how a Western-trained health care provider may acquire membership in an Aboriginal community to become “quus (human) living in community” (Atleo, p. 34) and contribute to balance and harmony of the orderly whole in the physical and spiritual realm, must be examined in a further study.
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