The Two Great Healing Traditions: Issues, Opportunities, and Recommendations for an Integrated First Nations Healthcare System in Canada

ABSTRACT The First Nations in Manitoba, Canada, are calling for active recognition and incorporation of holistic traditional healing and medicine ways and approaches by the mainstream healthcare system that has hitherto tended to ignore all but biomedical approaches. This request for recognition requires elaboration on areas of opportunity for collaboration that could positively influence both Indigenous and allopathic medicine. We discuss pathways to an integrated healthcare system as community-based primary healthcare transformation. A community-based participatory research approach was used to engage eight Manitoba First Nations communities. One hundred and eighty-three (183) in-depth, semi-structured key informant interviews were completed in all communities. Grounded theory guided data analysis using NVivo 10 software. We learned that increased recognition and incorporation of traditional healing and medical methods would enhance a newly envisioned funded health system. Elders and healers will be meaningfully involved in the delivery of community-based primary health care. Funding for traditional healing and medicines are necessary components of primary health care. An overall respect for Indigenous health knowledge would aid transformation in community-based primary health care. Recognition of and respect for traditional healing, healers, medicines, therapies, and approaches is also recommended as part of addressing the legacy and intergenerational impact of assimilative policies including Indian residential schools as the Truth and Reconciliation Commission of Canada has stated in its Calls to Action.


Introduction
The Canadian healthcare system is informed by and operates a cultural standpoint that many Indigenous peoples consider "colonial" and delivering culturally unsafe models of care in their communities. 1,2 The federal and provincial healthcare systems seem to alternatively be unaware of or ignore traditional health knowledge and healing ways upon which some Indigenous peoples rely to achieve and maintain their health and wellbeing. 3,4 Within this arrangement, First Nations (FN) peoples and communities have consistently called for balanced, holistic and integrated approaches to support their pursuit of wellbeing. [5][6][7][8] We have come to understand from FN that holistic health care means that nothing beneficial to health is left out of health planning and implementation, including a recognition of approaches that FN want and choose for themselves. 8 Integration, on the other hand, is a sociological concept applicable in the healthcare context, which was best been articulated by Burkart Holzner in 1967. He stated it to be characterized by "whole-part relationships . . . related to each other in such a way that they form an integral entity . . . united to form a whole. The parts may not share any attributes of the whole . . ., in this case, the parts are interdependent in terms of a relationship." 9(p51-2) Healthcare systems integration is based on principles that take context and patient population into account, including the provision of comprehensive services, geographic coverage, organizational culture, and health governance structure among others. 10 Thus, the call for recognition and integration of FN traditional health knowledge and healing ways is really a call to transform current systems into those that work for Indigenous health and wellbeing.
It is well established that Indigenous populations in Canada bear a higher burden of disease than the general population. 5,[11][12][13] Concerted and coordinated efforts are therefore necessary to close existing health gaps and ensure equitable access to healthcare services for all Canadians, and particularly for Indigenous peoples, a term that includes Inuit, Metis, and First Nations. [14][15][16][17][18] Many FN communities in Manitoba maintain that any effort to improve communitybased primary health care (CBPHC) should necessarily include support for a healthcare system that adequately recognizes the significant role that Indigenous traditional healing and medical methods play alongside mainstream biomedical models in the health and wellbeing of FN communities. 8 Indeed, the Canadian Truth and Reconciliation Commission Calls to Action recommend the recognition of the value of "Aboriginal healing practices" and their use in the treatment of Indigenous patients, 17 in order to effect change within the Canadian healthcare system. This paper discusses FN perspectives on developing a holistic healthcare system that recognizes, adequately supports, and respects traditional medicines and healing ways as part of a borderless healthcare system.

Background
Historically, the provincial and federal governments of Canada implemented challenging and confusing policies and processes, informed by a colonial mindset. [19][20][21][22] The government of Canada formed its health system around the preferences of European-descent citizens and then forced some reduced version of that system on FN members, while at the same time outlawing Indigenous practices and taking a segregationist approach to health care 23,24 Colonization of Indigenous lands and people began from the first European contact in 1534. 4 Eventually, federal legislation in the form of the Indian Act, made Indigenous ways of life, including traditional healing practices and ceremonies illegal. 25,26 Residential schools set up in the 1970s by church and political powers, were intended to assimilate and strip Indigenous peoples of culture and languages. It was also to firmly establish European control over Indigenous people and lands through religious manipulation and dispossession. 4,27 In cases where colonization imposes powers and structures intended to control the lives of people, efforts by the colonized to self-develop initiatives are marginalized by the colonizing government structures. 28 In the FN context, "healthcare" is generally pruned back to some level of community participation in the organization and delivery of basic health and social services in communities. 4,[29][30][31][32] Thus, Indigenous traditional healing and medicine ways were forced underground and confined to secrecy in many cases. 3,26,33 Only in recent decades has traditional healing and medicine ways regained acceptance even within FN communities. Therefore, FN have been calling for improved CBPHC to be embedded in ongoing socio-political and cultural revitalization and self-determination, [28][29][30]34,35 including the adoption, support for and adequate financing of Indigenous healthcare approaches.

Methodology
This article is based on findings from one of five substudies within a larger program of research entitled "Innovation Supporting Transformation in Community-based Primary Healthcare in First Nations and Rural and Remote communities in Manitoba (iPHIT)." The purpose is to discuss key issues, opportunities and some recommendations advanced by FN communities in Manitoba concerning the possibility for an integrated healthcare system in which traditional healing approaches are a recognized and supported part. Our findings and conclusions are based on data from eight FN in Manitoba and do not claim to reflect the perspectives of all FNs. FNs who participated in this study elected to do so and represent varied and unique experiences, cultures, and histories deserving individual recognition.
A qualitative study design that used communitybased participatory research (CBPR) methods to engage FN Elders, knowledge keepers, community members, and healthcare workers. CBPR is a tried approach in research with Indigenous peoples. 36,37 It allows the expanded application of Indigenous ways of knowing which is also desirable when the goal is to encourage ongoing knowledge translation. 38 Our particular use of CBPR is described in previous publications. 39,40 A grounded theory approach 41 was also used to examine respondents' experiences with traditional healing, healers and medicines in eight FN communities selected to represent four of the five Indigenous groups and languages spoken in Manitoba (Dakota, Dene, Cree and Ojibway). The communities also represent various geographical locations, isolated fly-in-only communities, semi-isolated communities with winter road access, and non-isolated with all-year road access. The First Nations Health and Social Secretariat of Manitoba (FNHSSM), a research and policy organization representing FN in Manitoba, provided coordination, financial management, and general oversight throughout the study. In addition to ethics approvals obtained from the University of Manitoba Human Research Ethics Board and the Health Information and Research Governance Committee at the FNHSSM, Indigenous team members took the lead in selecting and inviting communities to participate in the study. Each community communicated the decision to participate in writing, by way of a band council resolution (BCR), which is an official document conveying the community leadership's consent. Each community also selected research assistants from the communities to conduct interviews and participate in data analysis. Participating communities decided when and how the study would be carried out on the ground and ensured that free, prior, and informed consent was obtained from all respondents (Table 1). 39,42 Data collection and inductive data analysis were conducted concurrently. Data were constantly analyzed when received and compared to inform ongoing interviews. 41 This was done through weekly teleconferences with local research assistants. One hundred and eighty-three in-depth semi-structured, key informant interviews were conducted with purposively sampled respondents who have experience in the healthcare systems within and outside the communities. a All interviews were in English but sometimes respondents answered in their respective Indigenous languages in the course of the interview. In those instances, the local research assistants translated back into English those particular phrases and sentences. Interviews were audio-recorded and transcribed verbatim then uploaded to NVIvo 10™ for coding and thematic analysis. Themes were constructed from the experiences shared by respondents. Analysis was also aided along by clarifications of concepts during data validation sessions in each community following interviews, lived experiences of Indigenous research team members and researchers' familiarity with the literature on traditional healing and medicines. 43,44 Theoretical saturation was attained when all substantive concepts and ideas were well understood and could be supported from available data.

Findings
Respondents in this study have communicated multiple means to transform CBPHC. Salient among the themes is promoting holistic and spirituality within an integrated healthcare system. To do this, it will be necessary to de-stigmatize traditional healing and medicine ways, rebuild trust with FN for health improvement, recognize and support traditional medicines, traditional healers, traditional teachings and practices. The role of FN Elders in protecting and extending traditional healing and medicine ways must also be highlighted as is the need for committed funding to support traditional healthcare components of CBPHC. Quotes have been selected to represent majority views under each theme. We selected quotes that were distributed across all communities and most respondents. We do not consider one theme to be more important than another, but each represents the voice and perspective of respondents. Finding are summarized in two categories as shown in Table 2.

Holistic, Spiritual and Integrative Healthcare
Respondents say that the current healthcare systems must determine ways to work together, with neither superseding the other. A key component is the active recognition of the holistic and spiritual nature of FN health orientation. A quote, echoed by several others, is indicative of this aspiration; [Healthcare] means that we are meeting the needs of the community and the people in the community, individuals, families and community, in a holistic way. So, we are meeting not just their physical health, [but also] their emotional health, their spiritual health, that we are addressing all that . . . the spiritual aspect is so important and so strong, because there is such a history of colonization, the residential schools, all that soul sickness. We need to address all that. So how do we do that, right? I believe that we have to look at the strengths of the community . . . that underground kind of sleeping traditional stuff . . . If we do not bring that back, the rest is useless. The answer is not in western medicine; we are not going to heal with western medicine (A001).
This quote also highlights that First Nations health needs and perspectives are varied and broader than what biomedicine presently provides. Respondents were clear that primary health care must go beyond physiological requirements and include spiritual and traditional healing. Some respondents however, expressed fear they may have lost their traditional healing knowledge: There is no interest [in traditional medicine] because all our Elders are gone, the ones that knew about medicine. It was not passed on to the younger generation plus all our roots of medicine or gifts are wiped out because of the roads, the clearing of the land. The floods are washing it away. (CFG302).
Recognition and respect-Many other respondents say traditional medicines still exist and are requesting a system that does not ignore or disrespect the traditional healing and medicine ways that have supported FN people and communities.
So, I think if we were to go back to our old ways, but bring it into a newer context, then that would help our community out a lot. And not just our own community but I'm sure everyone else's because then it would kind of show where we came from and where we will be going and it will ground us a lot more and especially our [young] parents and the youth. They would know oh, that is what that means or oh that is what they used to do and stuff. I think it is important that we keep the traditional aspect in there when you are looking at health (H004).
Address historical trauma-Part of healing individuals and addressing historical impacts of colonization, then, requires holistic approaches that bring traditional medicine and healing ways to interact with and offer alternatives to the western conventional healthcare system.

De-stigmatization of Traditional Healing and Medicine Ways
Respondents pointed to a continued feeling of fear or shame associated with the use and practice of traditional health practices, due to decades of Euro-Canadians denigrating and outlawing such practices, jailing practitioners, and confiscating or burning medicine bundles. Prolonged stigmatization caused shame and uncertainly even among FN people themselves. The following quotes express the depth of fear.
We have to bring back traditional things, traditional ways, and traditional ceremonies. And it has to become something that is not shameful, something that is not 'devil worshipping'. That stigma has to stop. People going on the radio and saying you are 'devil worshipping' if you believe in this, it has got to stop. You do not have to believe it, but there has to be a respect for it. There cannot be a 'you are wrong, and this is wrong, and you are bad'. That has got to stop because that is the only way (A001).
It is almost like a taboo, and that is what I said. It seems like a lot of our people in our community [when they] see traditional medicines and roots and herbs and these things they associate them right away with Spiritism or spirituality which is a lot of the time not the case (C005).
This observation speaks to the harm of sustained colonization, stigmatization demonization of traditional health practices. Although FN community members can choose such practices, the residual effects of decades of disapproval are still in effect, stigmatizing and causing fear and shame for practitioners.

Building Trust with First Nations for Better Collaboration in Healthcare Improvement
Respondents pointed to what is deemed to be a fearbased system in present healthcare delivery that prevents authentic and open engagements with FN peoples which is the only way to promote mutual understanding. One respondent explains this fear-based system: They [health system] will not approach us because of the history of our two peoples. Mistrust and recent incidents like violence in their hospitals. Still our community members are going to the hospital and there is mistrust there, and they are scared of us. They want to help us, but they do not know how to approach us, and that is the difficulty here. Canada supplies a lot of health services, yet we do not know how to approach them and they do not know how to approach us. And it has been like that because of the history we had with the outside influences here [through] residential schools. It has been passed from generation to generation not to trust. . ., and that still sticks with us today, those types of things (E011).
Respondents stated that stakeholders on both sides will need to work at building trust as a platform for health care transformation if progress will be made toward an integrated and collaborative system.

Traditional Medicines
Some respondents shared examples of how western conventional medicine and their prescribed medications have negatively affected their lives. As a result, some developed distrust of the mainstream system owing to these bad experiences, such as not having consistent access to or not being able to afford prescribed medications when needed. Respondents generally expressed confidence in the availability and use of traditional medicines which include, among other things, teas, ointments, oils, and potions made from roots, barks, leaves and herbs. Some respondents implied that they may prefer traditional medicines to treat or prevent illnesses. Well, I would think somebody has to take the initiative to start recording these things and really making that their area of interest. And maybe that is something where the health centre has to take a leading role in that or something to that effect because, somebody has to record them, somebody has to capture it. And I think the incentive would be that health services and medical health are always cutting back on things that were available before but not available now (D003).
Yes, I think before we lose all our Elders, we should get what knowledge we can off them to where we can start using our natural traditional medicines. It is time that we go back to that kind of living. One of these days we are not going to be able to afford our medicine. Prescription drugs already, we have to pay (E010).
Preserving traditional healing and medicine knowledge may ensure that future generations understand and continue to use those options.

Traditional Healers
Respondents believe that traditional healers can cure ailments even when conventional medicine fails.
I know several people, when the mainstream health practitioners fail; they go to the traditional people especially for help with cancer. My mum saw a traditional healer for when she started to get that shaking in her head . . . she was starting to shake and then she went to a healer and that woman cured her. So yeah, my mum did not make it a secret. I know there is other people that go, and they go outside our community to traditional healers (C008).
Traditional Healers are also said to conduct a range of therapies and practices to help people be healthy.

Traditional Teachings and Practices
Respondents reported that in some cases, knowledge and use of traditional healing and medicine ways requires understanding of associated protocols and ceremonies.
The protocol is that these are traditional medicines, you do not just go into the bush and cut out what you need, but there has to be somebody to show you what to do, and the main thing is how to work with these medicines . . . Some of these things we have to relearn, relearn these ceremonies (GFG004-11).
You cannot just go pick a medicine and then use it. You have to pray (H004).
Experience in appropriate harvesting and administering traditional medicines, teachings and practices is important. One of the Knowledge Keepers who guided this project explained that in Dakota ways, picking the plants safely and sustainably to ensure that the healers will continue to have access to the plant medicines, is a separate function from the processing and the application of these medicines. Both must be learned and preserved.

The Role of Elders
Many respondents see Elders as holders and executors of traditional healing knowledge and medicine ways. They are expected to use the knowledge to support the wellbeing of their communities. The Elder then decides if he/she can address the need or refer the seeker to another Elder or traditional healer depending on the need. The tobacco is used for ceremony, as an offering to the Creator, who guides the Elder or traditional healer.

Funding
Respondents said that funding for traditional healing and medicine ways could significantly improve options and enhance access for people seeking traditional medical care as part of CBPHC.
We [community] used to send people down to our traditional healers, down in the United States . . . then the funding stopped. So I think our traditional, our access to our own culture and traditional medicines and knowledge, has been cut by Health Canada. Therefore, I think the support needed here is either the medicine men come up here and it costs money or in real critical cases, we should be able to send our patients down there. In addition to using western medicine, we can use our culture, our traditional medicines to give that person some peace of mind (E011).
This quote echoes others who explained that programs supporting access to traditional health care existed in their communities, had served the healthcare needs but funding was either not available or inadequate to support the services on an ongoing basis.

Discussion
To improve the general state of health and CBPHC, FN communities are advocating for returning to and recognition of traditions healing and medicine ways that are holistic, address colonial distresses and close existing gaps. 26,[45][46][47][48][49] According to respondents in this study, the mainstream system may be wary of and hesitant to adopt collaborative healthcare system because historically, the mainstream has tended to devalue, harm and attempted to obliterate Indigenous systems and peoples through residential schools. 27 This has caused intergenerational trauma, fear of the healthcare system and shame about practicing Indigenous healing and medicine ways. [50][51][52] Many FN communities are resurfacing traditional practices that originally supported holistic wellbeing to combat persistent, complex and cumulative trauma. 53 FN band governments having authority within their local jurisdictions in all communities, in furtherance of a holistic and integrated health system, could actively support the effort of reconnecting with family ties, the use of known herbs and medicines, and immersion in culture and language and teachings based on the medicine wheel. 8,48,54 FN communities emphasize the critical importance of the current healthcare system fully understanding and actively supporting holistic care within a framework of social determinants without which it is difficult to provide safe and quality care to FN populations. Particularly as FN are culturally diverse and have values that may call healthcare practitioners to a higher cross-cultural engagement standards than they may be used to. 55,56 For example, in order to treat physiological conditions, FN say that a comprehensive understanding of spiritual, emotional, mental and physical factors is necessary within a holistic model that may also necessitate an ecological approach. The biomedical model currently addresses presenting and immediately influencing factors when caring for patients. FN calls for improved health and CBPHC services are embedded in an ongoing socio-political and cultural revitalization, responsiveness and self-determination especially as there may be competing worldviews between FN and mainstream systems. 19,29,[57][58][59] FN want to be supported in teaching and learning about traditional healing and medicine ways that have been challenged through colonization, dispossession, demonization's and a general lack of recognition. Federal and provincial governments could make funds available to FN communities for traditional health knowledge preservation, teaching and learning. This would signal a change in attitude from the Euro-Canadian state and demonstrate a willingness to build trust with FN peoples within an integrated healthcare system. Trust building is possible through building intentional partnerships for linking biomedical and traditional medicines, 60 shared decision-making approaches that consider culture, 61 and intercultural dialog which sets the stage for respectful and culturally safe engagement. 62 FN recommend collaborative engagements to promote cultural safety in health care. 63,64 Examples abound of such efforts that mirror recommendations of respondents in this study. In some places, traditional healers work together in the shared spaces with biomedical practitioners, and there may be dedicated spaces for traditional practices, such as smudging, sweat lodges, prayer rooms, and storage of traditional medicines. Recognizing and connecting traditional healing and medicine ways to the conventional primary healthcare system in this manner, could be key to transforming CBPHC for FN. Where this is not feasible for any reason, healthcare systems directors, managers and other decision makers could recruiting FN healthcare practitioners in Indigenous healthcare contexts precisely because they have shared cultural knowledge or backgrounds and may be the closest option to ensure culturally sensitive care. [65][66][67][68] Lack of funding is identified to be a barrier in accessing traditional healthcare options, especially when the traditional medicines or healers are not available in the community and patients have to travel to access the care elsewhere. Some patients may not be able to afford associated costs such as transportation, accommodation, meals and payments or gifts for the practitioners. The federal and provincial governments responsible for FN health depending on jurisdiction could provide adequate and continued funding could support access to traditional healthcare in such circumstances. Funding for the traditional healers in particular could help legitimize them, thus destigmatize their practices, and thereby help decolonize the healing sector of the FN cultural interface.
Other opportunities to support an integrated healthcare system are through policy interventions and deliberate planning to identify and implement FN recommendations in the existing CBPHC landscape. 69,70 Consultations with FN communities to understand what and how they want to proceed is a helpful starting point. One community in the study, for example, mentioned that they send patients to traditional healers in the United States, where colonial borders have created national separation lines. Yet the communities continue to seek help from their relatives across the borders for care. Such communities may wish to have arrangements for seamless exit and entry for care and remuneration for instance.
Communication and trust building with FN peoples and communities are key starting points for collaboration, fostered through mutually respectful engagement. [70][71][72] Fostering an accord with FN communities in this manner would be supportive of a self-determined, supportive and integrated healthcare system. 73,74 An integrated healthcare system comprising the two great healing traditions is being practiced to a small extent in some places in Moose Factory (FN) and Moosenee hospital in northeastern Ontario, Sioux Lookout Hospital and The hospital for Sick Children in Toronto, Ontario, Opaskwayak Cree Nation and St. Anthony's Hospital in the Pas, Northern Manitoba. It is important to advise flexibility in application and extensive consultations with Traditional Healers on how integration could serve both traditional and mainstream medical practitioners. Keeping in mind that depending on the details, not all traditional healers may wish to be integrated within the mainstream healthcare system, some may prefer to be respected and supported in what they do. 26 The models in these places are continually reaching for equalitarian and decolonized practice, to offer preferred options for Indigenous patients who choose traditional approaches to meet their need for holistic healthcare.

Conclusion
It makes practical sense to support the ongoing use of traditional healing and medicine ways where and when required by the patients, by funding the traditional health sector to function alongside allopathic medicine and funding access to the traditional health options for those who choose it. It is crucial to move ahead with respect for the two Great Healing Traditions of Canada, as recognized and advocated for by the Royal Commission on Aboriginal Peoples. The First Nations in this study have stated that increased access to and support of traditional healing and medicine ways, is a key part of holistic and effective community-based healthcare systems. We learned that this proposed integrated system is currently being used in many FN communities as a parallel system of healthcare and prevention but is not yet commonly recognized by the mainstream health system. FN say that an overall respect for and recognition of Indigenous healing and medicine ways by federal, provincial, and healthcare jurisdictions could transform community-based primary health care and improve overall health outcomes in FN communities. More so, strengthening the traditional healing sector could help heal the cultural illness that leads to individual illness. Therefore, support for an integrated and cooperative healthcare system is a positive step in pursuing decolonization and reconciliation. It would also address the Truth and Reconciliation Commission call for a holistic health system where in reality, many FN people are already making these choices to apply traditional healing for their wellbeing. Note a. One small community with about 800 people had 10 key informant interviews, 3 others with about 3000 people had 20, 2 with about 5000 people had 30 interviews and a large community having over 800 people had 53 interviews.

Disclosure of Potential Conflicts of Interest
No potential conflict of interest was reported by the authors.

Funding
This work was supported by the Canadian Institutes of Health Research (CIHR) under Grant number 297945.