Module 1: Culture and Indigenous Determinants of Health

1. Module 1: Culture and Indigenous Determinants of Health

2. Welcome to Culture and Indigenous as Determinants of Health. This course takes 45 minutes to complete. There is a quiz at the end of each chapter and a link to handouts and resources at the end of the learning module. There is a quiz at the end of each chapter and a link to handouts and resources at the end of the learning module. Select the arrow keys at the bottom of your screen to move forward and move back, or to stop and start the module.

3. Course Learnings By the time you complete this learning module, you will be able to identify: Recognize the connections between culture and health Understand the impact of colonial and post –colonial events on the health of FNIM Identify the main factors of health between First Nations, Inuit and Métis people Culture and Indigenous Determinants of Health

4. Accurately portraying a history of cross-cultural relationships is never straightforward. Consider how much greater the differences in interpretation can be when it comes to perspectives rooted in fundamentally different cultural traditions. Take a moment to think about your perspective on the health of First Nations, Inuit and Métis (FNIM) in Canada and what has shaped your view

5. All patients experiencing health concerns, particularly those facing potentially life threatening diseases such as cancer may experience challenges like: • uncertainty • fear • economic • changes in family and marriage • treatment difficulties. FNIM people may experience these challenges as well, but there are additional stressors that are unique to FNIM people and communities Let’s get started. Move forward to begin Chapter 1.

6. Chapter 1: Overview: Recognize the Connections between Culture and Health

7. Culture refers to the cumulative deposit of knowledge, experience, beliefs, values, attitudes, meanings, hierarchies, religion, notions of time, roles, spatial relations, concepts of the universe, and material objects and possessions acquired by a group of people in the course of generations through individual and group striving. Culture is the sum of total of the learned behavior of a group of people that are generally considered to be the tradition of that people and are transmitted from generation to generation. Source: https:// www.tamu.edu/faculty/choudhury/culture.html

8. Broader Determinants of Health “It takes a healthy village to raise a healthy child”

9. There are a great number of inputs to both an individual’s health and the systems (environments, families, communities, nations, etc.) to which they belong. Some of the factors that have been recognized as having a direct impact on an individual’s health This list is far from exhaustive, but it gives a glimpse into the complexities that arise when considering the question of why particular individuals or groups of individuals like First Nations, Métis and Inuit are less likely to be healthy than others in society.

11. Economic self-sufficiency and equality predict community health and well- being. Inadequate housing, food, medicine, water, and employment all impact social capital and community cohesion. We will review some of the determinants in a little more detail throughout the course chapters. The World Health Organization, 2008: “Social justice is a matter of life and death. It affects the way people live, their consequent chance of illness, and their risk of premature death. Within countries there are dramatic differences in health that are closely linked with degrees of social disadvantage. Differences of this magnitude, within and between countries, simply should never happen.”

12. Socio-Economic Status as a Health Determinant “Life expectancy is shorter and most diseases are more common further down the social ladder in each society. The longer people live in stressful economic and social circumstances, the greater the physiological wear and tear they suffer, and the less likely they are to enjoy a healthy old age”. (WHO 2003)

13. Socio-economic status (SES) is regarded as the most important social determinant of disease. People from the lower socio- economic class have less opportunity and training to influence the events that impinge on their lives. Studies over the last three decades suggest: control of destiny, “the ability to deal with the forces that affects their lives,” is the key component of SES. Socio-Economic Status Control of destiny” was found to be lower in the lower status groups.

14. Control of destiny has been supported by neuroendocrinological studies, which have shown that lack of control over life circumstances creates a load of stress on the body, which may eventually result in the development of a variety of diseases and conditions, especially: • insulin dependent diabetes • cardiovascular diseases • alcoholism • suicide

15. A significant number of FNIM people live in poverty and fourth world conditions: • The median income per FNIM household is $46,865, significantly lower than Ontario’s median household income of $73,290. • The FNIM unemployment rate in Ontario is 12.3% compared to the provincial rate of unemployment of 7.2%. (HRSDC, Spring 2013)

16. Source: Statistics Canada, 2006 and Aboriginal Affairs http://www.aboriginalaffairs.gov.on.ca, 2006 Communities with self-government including higher levels of health and education control had an 85% reduction in relative risk of suicide and health improved by 29%.

17. Housing and Health Housing is best understood as impacting health through the physical environment, as the built environment has been demonstrated to impact both • physical and mental health, • and well–being. Source: Public Health Agency of Canada

18. FNIM people are more likely to live in poverty, go hungry, suffer from poor nutrition and obesity, and live in overcrowded, substandard housing.

19. Poor housing quality in First Nations reserve lands has been previously associated with respiratory morbidity. Chronic airways disease is common in FNIM people in Canada. Asthma is a frequently reported chronic condition in FNIM children, with prevalence estimates ranging from6% to 12%. Source: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3603758/

20. Participants in The Health Council of Canada’s 2011 study discussed factors that have cascading effects on personal health and family relationships. They included: • Poor living conditions • Overcrowding • Lack of housing • lack of affordable or easily available nutritious food

21. Education as a Health Determinant The higher the level of education, the more likely it is that a person is employed. FNIM people in Ontario: • 38% have no certificate, diploma or degree. • 61.8% have high school graduation or less.

22. The effects of the combination of poverty and social disadvantage in FNIM people can be seen in many diseases. For example, First Nations people have a significantly higher prevalence of carotid atherosclerosis and cardiovascular disease and associated risk factors (smoking, glucose intolerance, and obesity). The higher prevalence of disease may be a connected to the significant proportion of FNIM people live in poverty, which is then associated with high rates of cardiovascular disease and associated risk factors. Improvement of socio-economic status (SES) might be a key to reduce cardiovascular diseases.

23. Respect and Empathy for Culture as a Health Determinant Strengthening ethno-cultural identity, community integration and political empowerment can contribute to improving mental health among Aboriginal peoples. (Kirmayer, 2003)

25. According to a 2011, Health Council of Canada study: Non-Aboriginal Canadians don’t necessarily understand the importance of honouring Aboriginal practices and integrating them with modern health care or other services. One front-line provider described a common misunderstanding: “People don’t see how Aboriginal needs for cultural understanding are different from the needs of the immigrant families in my program.”

26. FNIM people and immigrant populations should not be compared. There is a long and painful history of efforts by past governments to deliberately eliminate Aboriginal culture; one of the greatest reminders of this is the infamous statement that the intent of residential schools was to “kill the Indian in the child.” Chapter 2 covers more on Residential Schools. The Aboriginal Healing Foundation stated that rediscovering pride in one’s culture and identity is good medicine. One example is a 1998 study looking at youth suicide within Aboriginal communities in British Colombia found cultural continuity to be a protective factor against suicide (Chandler & Lalonde). Some communities suffer from youth suicide rates 500-800 times the national average

27. Differences between FNIM and Western Definitions of Health In the section of the chapter, we will briefly touch on the “western” or modern medicine and provide some additional insight into the FNIM definitions of health and healing practices.

29. Aboriginal medicine contains innumerable folk remedies, many of which have formed the basis for pharmaceutical treatments that we use routinely in Western medicine Traditional approaches to healing are holistic and consider mind, body and spirit. Medicine is distinguished from healing, which goes beyond mere treatment of sickness. As Donald Warne points out, it is somewhat ironic that modern physicians say they provide health care when they really treat diseases Source: Warne D: Traditional perspectives on child and family health. Paediatric Child Health 2005;10:542

30. The healing relationship is based on a series of virtues: • respect • humility • compassion • honesty • truth, • sharing • hospitality • divine love Traditional Aboriginal care recognizes many more routes to healing than does Western medicine. Seven routes are commonly mentioned: • Talking • Crying • Laughing • Dancing • Sweating • Yawning • Yelling (giving vent to your feelings, rather than yelling at someone).

31. The Aboriginal Path of Well-being Traditional medicine and Aboriginal health and wellness are rooted in a holistic approach. Active choice: one’s ownership for health decisions Joint and personal responsibility: health and well-being is the duty of the individual, family and community Holistic approach: balance the mind, body, and spirit with community and environment Health in balance: giving equal importance to all aspects of health Understand root causes: past and present aspects that impact health Wellness: both emotional and spiritual

32. Aboriginal Healing Practices The following are some common Aboriginal healing practices

33. Medicine Wheel The medicine wheel symbolizes the interconnection of all life, the various cycles of nature, and how life represents a circular journey. The number 4 is sacred to First Nations and Métis people in Canada and can represent many things including:

34. The Number 4 Represents • 4 seasons • 4 directions: north, south, east, west • 4 parts of a person: physical, mental, emotional and spiritual • 4 kingdoms: animal, mineral, plant and human • 4 sacred medicines: sweetgrass, tobacco, cedar and sage)

35. Medicine Wheel You may see the medicine wheel presented in several different ways. For a traditional healer, an imbalance (e.g., the loss of traditional values, perhaps resulting from experiences in residential schools) may affect health decisions (e.g. leading to alcohol dependence to deal with painful memories).

36. The Four Sacred Medicines Sweetgrass (the North), Cedar (the South), Tobacco (the East), Sage (the West)

37. The Four Sacred Medicines: Sweetgrass (the North)

38. The Four Sacred Medicines: Cedar (the South)

39. The Four Sacred Medicines: Tobacco (the East)

40. The Four Sacred Medicines: Tobacco (the East)

41. The Four Sacred Medicines: Sage (the West)

42. Smudging A 'smudge' is smoke used for ritual cleansing is a ceremony traditionally practiced by some FNIM cultures to purify or cleanse negative energy, feelings or thoughts from a place or a person. Sacred medicines such as cedar, sage, sweetgrass or tobacco are burned in an abalone shell. The shell represents water, the first of four elements of life. The medicines represent gifts from mother earth and the burning represents fire, the next two elements. The person puts their hands in the smoke and carries it to their body, especially to areas that need spiritual healing (mind, heart, body). The smoke represents air, the final element. Perhaps the smell of the burning medicines stimulates the brain to produce beta-endorphins and promote healing processes.

43. Healing Circles • Healing circles are gatherings held to heal physical, emotional and spiritual wounds. • A symbolic object, often an eagle feather, may be given to a person who wishes to speak. • it is passed around the circle in sequence to others who wish to speak. • Traditional Healers, Shamans may conduct the ceremony.

44. A sweat lodge is a ceremonial sauna used for healing and cleansing. A healer pours water on the stones to produce steam and participants may spend an hour sweating in the lodge. It is made of a wooden framework covered by blankets or skins, about 1.5 metres high and large enough for eight people to sit in a circle on the ground. Sweat Lodge (Purification Lodge) Hot stones are placed in a shallow hole in the centre of the lodge.

45. The lodge combines the four elements of fire, water, air and earth. Toxins can be released if grasses that have been exposed to pesticides are placed on the rocks, Ceremonies include: • offerings, • prayers, and • reverence. Sweat Lodge (Purification Lodge) At times, excessive exposure to the heat of the lodge may have health effects.

46. Sun Dance (Rain Dance, Thirst Dance, Medicine Dance) The sun dance is a ritual that celebrates the harmony between man and nature, and spiritual dedication. Originally practiced at the summer solstice, the sun dance represents continuity between life, death, and regeneration. The symbolism often involved the buffalo. Four days before the ceremony, dancers prepare by purifying themselves, at times in a sweat lodge, by meditating and collecting ceremonial items of dress to use in the sun dance.

47. Sun Dance (Rain Dance, Thirst Dance, Medicine Dance) The sun dance itself takes another four days, and generally involves drumming, singing, and dancing, but also fasting and, in some cases, self-inflicted pain. This symbolized rebirth and often involved piercing the skin and attaching cords that the person had to tear out. This element led governments to suppress the sun dance around 1880, but it has been re-introduced.

48. Pipe Ceremony • The pipe is used individually and in groups for prayer and ceremonial purposes. • Participants gather in a circle. A braid of sweetgrass is burned to purify the area and those present, to make a sacred place for the spirits to visit. • Tobacco or kinnickkinnick, a traditional mixture of bearberry and wild herbs or red willow shavings, is smoked so that prayers can be made to the Great Spirit or requests made of the spirits. • The pipe may also be smoked to open other meetings or ceremonies. When not in use, the bowl and stem are separated and carried by one individual, the pipe holder.

49. Potlach A ceremonial feast among northwest Pacific coast First Nations people is held to celebrate major family events such as a marriage or birth. The host distributes gifts according to the status of each guest; reinforcing the perceived hierarchical relations between groups. At times the gift-giving became competitive, the host giving away personal possessions in anticipation that others would reciprocate in their turn. Missionaries encouraged the government to outlaw the potlach around 1885; it is now common. Source: Review of Aboriginal Health Systems in Canada (pdf article from J Aboriginal Health, 2004)

50. Many studies have shown that culturally sensitive programs like the ones mentioned in this learning module are needed to enhance health. Move forward to begin the quiz for this chapter Source: Review of Aboriginal Health Systems in Canada (pdf article from J Aboriginal Health, 2004)