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14 Everything Is Connected:

Everything Is Connected: Integrating First Nations Perspectives and Connection to Land into Population Health Reporting

Lindsay Beck, Damele Behn-Smith, Maya Gislason, Dawn Hoogeveen, Harmony Johnson, Krista Stelkia, Evan Adams,

Perry Kendall, and Bonnie Henry

So the first question; how does connection to land, water and territory influence health and wellness, mental, physical, spiritual and emotional, that question doesn’t make any sense to me personally. That’s who I am. I am the land. I am the water. I am the territory. Part of, parts of me and the whole of me. There’s no disconnect between me and whatever territory, no matter where I am on Earth. (Marie Oldfield, Knowledge Keeper, Vancouver Coastal, Kitasoo/Xai’xais First Nation)

INTRODUCTION

For First Nations in Canada, land reflects a connection to ancestors, a resource for living, a link to culture and teachings, and a gift for future generations. First

Nations is a term used to describe aboriginal people in Canada who are ethnically neither Metis nor Inuit. In this chapter, we provide an overview of the groundbreaking British Columbia (BC) First Nations health governance structure and describe how it enables a collaborative, two-eyed seeing approach (Iwama et al„ 2009) to population health reporting that aims to privilege and elevate the importance of ecological health and connection to land. (The term "land” as used throughout this chapter includes land, water, and the animals and plants as well as other beings that live on this Earth.) Indigenous knowledge systems and w'ays of being in the world, which emphasize interdependence and reciprocal stewardship with all of our relations in the natural world, can offer solutions for advancing health promotion, equity, and sustainable development now and for future generations (Ratima et ah, 2019). This case study explores early lessons from our efforts to integrate First Nations perspectives, notably connection to land, w'ithin a population health-reporting framework.

CONNECTIONS BETWEEN LAND AND HEALTH FOR FIRST NATIONS

In January 2020, the BC First Nations Health Authority (FNHA) and the Provincial Health Officer (PHO) released a First Nations Population Health and Wellness Agenda (PHWA) that foregrounds a framework of interconnected indicators that collectively illuminate elements that nourish health and well-being. This includes the relationship between land and health. We quote the report here to ground our case and demonstrate the journey the FNHA has been on to champion First Nations philosophies and w'orldviews and decolonize Western health care systems in the province of BC:

Land, water, and territory permeate all aspects of First Nations wellness, as they are sources of healing, and of mental, physical, spiritual, and emotional health and wellness. Land and water nourish culture, form the basis of First Nations languages, systems of governance, and identities. Lands hold stories that guide people how to live a good, healthy life. First Nations people draw sustenance, healing, and medicines from the land. Animals that co-exist on the land and in the water provide teachings, food, clothing, and regalia. Access to healthy lands is required to exercise inherent rights as First Nations - they are stewards of the land and have sacred responsibilities to the land. Given that First Nations health and wellness is borne from a connection to the land, it is seen as a key determinant of health or “root of wellness.” Without jurisdiction, access, and continuity of relationship with the land. First Nations peoples cannot fully exercise self-determination. (First Nations Health Authority and the Office of the Provincial Health Officer, 2020).

INTEGRATING "CONNECTION TO LAND" INTO BC FIRST NATIONS POPULATION HEALTH REPORTING

Created by and for BC First Nations, the province-wide FNHA is the first of its kind in Canada. FNHA pursues a vision of "healthy, self-determining and vibrant BC First Nations children, families and communities” through effective health system partnership and integration, as well as management and funding of First Nations health programmes. An important marker of FNHA success is the advancement of First Nations governance and self-determination and the hardwiring of First Nations perspectives and values into the broader health system, such as the importance of connection to land and the integrity of First Nations territories (First Nations Health Authority, 2019).

To support efforts to change the health system through First Nations governance and self-determination, the FNHA created a First Nations leadership position responsible for monitoring and reporting on First Nations people’s health in BC and tracking progress against health and wellness indicators. As a result, the FNHA implemented the only Chief Medical Officer (CMO) in Canada that works from the governance authority of First Nations (First Nations Data Governance Initiative, 2019). In many coastal BC First Nations cultures, the traditional role of the Watchmon is to watch over, protect, and guide their people through difficulties and challenges. Because of its importance, the Watchmon is depicted in carvings and atop poles in many communities. Inspired by these teachings, FNHA’s CMO holds an important role as a Watchmon who monitors and acts as a guardian of the health and wellness of First Nations people province-wide. The CMO does so by drawing upon the richness of First Nations knowledge and teachings, alongside the best of mainstream population and public health approaches. The key roles of the CMO as Watchmon are as follows:

  • See and hear, by gathering information and data from various sources to capture the story of health and wellness of First Nations and Indigenous people in BC
  • Report, by sharing the story of health and wellness of First Nations and Indigenous people in BC to support improvements in health and wellness
  • Guide, by providing two-eyed seeing leadership to facilitate a strategic response to what was seen, heard, and reported

Prior to the establishment of the FNHA. BC’s PHO held the sole responsibility for reporting on the health of Indigenous peoples living in BC. In 2014, following the establishment of FNHA’s Office of the CMO. the two organizations took on a shared responsibility for First Nations population health reporting. Through their commitment to the First Nations perspective of health and wellness (Figure 14.1), strength-based, wellness-focused, and two-eyed seeing approaches in their reporting processes, First Nations population health reporting was now able to create space for, and attend to. First Nations worldviews. For the first time in BC’s provincial health reporting history, First Nations were driving their own data and telling their own story in a way that reflected their governance, philosophies, strengths, and resilience.

The FNHA's CMO and the BC PHO developed a First Nations Population Health and Wellness Agenda, which established a suite of health and wellness indicators reflective of First Nations understandings that “everything is connected”

The First Nations Population Health and Wellness agenda. (Reprinted with permission from the FNHA.)

FIGURE 14.1 The First Nations Population Health and Wellness agenda. (Reprinted with permission from the FNHA.)

and which supports a paradigm shift from a sickness-based to a wellness-based philosophy. By bringing together Indigenous knowledge and ways of knowing, and Western knowledge and ways of knowing, the PHWA provides an “eagle eye view” of the health and wellness of First Nations people living across BC. The development of the PHWA was an act of self-determination - as First Nations were controlling their health narrative in a way that reflects their strengths and resilience, and what is important to them.

A key aspect of the PHWA is a focus on the foundational roots of First Nations wellness, in particular the importance of connection to land in achieving FNHA’s vision. However, the partners were challenged to hold space and find ways to honour this root of wellness within their population health reporting process, especially in the face of highly entrenched Western views of the environment and land. In general, our extensive review found that existing ecologic and health status reports typically:

  • 1. Characterize the environment as a source of harm or hazard (e.g. pollutants or boil water advisories);
  • 2. Rely on Western values of disturbance, commodification, and productivity (e.g. natural resources (Raibmon. 2018), hectares of productive old growth forest); or
  • 3. Use measurements that are highly disconnected from the ecosystems that support them (e.g. numbers of caribou or salmon in a given area).

These three factors capture a fraction of the picture but none reflect First Nations perspectives which tend to view the environment as all-encompassing and a source of health and healing with connection to identity and ancestors. As described by the Potawatomi botanist Robin Wall Kimmerer (2013),

In the settler mind, land was property, real estate, capital, or natural resources. But to our people, it was everything: identity, the connection to our ancestors, the home of our nonhuman kinfolk, our pharmacy, our library, the source of all that sustained us. It was a gift, not a commodity.

Integrating First Nations perspectives into a public health agenda means foregrounding water, land, and human and non-human life as interconnected kin.

Studies linking ecological change to human health outcomes are rare in the literature and insufficient to determine an ecological monitoring approach that is valid, understandable, and repeatable (Stephen and Wittrock, 2017). Our search of the literature found no Western evidence-based way to select the appropriate scale, frequency, or ecological variables to construct an ecological indicator; there is much complexity, debate, and inconsistency in how ecological indicators are selected, assessed, and measured (Stephen and Wittrock, 2017). The predominant biophysical focus of ecological approaches fails to consider socio-cultural elements such as the importance of spirituality and the impact of colonialism (Czyzewski, 2011) on ecological health and connection to land.

Following this initial exploration of "Western eye” ecological health indicators, the partners turned to their “First Nations eye” to re-ground. They recognized the need to situate themselves as learners and seek teachings from First Nations Elders, knowledge keepers, and youth on the connections between land and health. The land itself was seen as a profound teacher. While there is a small growing body of literature exploring connection to land, water, and territory for First Nations peoples in Canada, there is still very little empirical literature exploring this within a BC context (Yazzie and Baldy, 2018). To examine this integral connection and to support the development of the PHWA, the We Walk Together project was formed.

SEEKING KNOWLEDGE TO HONOUR CONNECTION TO LAND IN HEALTH REPORTING

The We Walk Together study was initiated in partnership between the FNHA, Office of the ВС PHO, and academic partners. Its purpose was to explore the connection between land, water, and territory as an Indigenous determinant of health for BC First Nations. Gatherings were held or planned across diverse areas of the province. The gatherings were land-based and relied heavily on the sharing circle and land-based methodologies to enable First Nations Elders, Knowledge Keepers, and youth to share teachings and co-create their conceptions of the connections between land, health, and wellness.

Preliminary findings revealed a diversity of perspectives and worldviews among BC First Nations peoples, which are varied and specific to peoples and place. However, several overarching commonalities emerged, including a common belief of interrelatedness of all existence and a relationship between the spiritual and physical worlds. The lessons learned from the gatherings demonstrated that connection to the land is an integral component of health and well-being for individuals, families, and communities. This integral connection was described by participants as involving complex, personal relationships with land and all living and non-living things. The intersections between health and connection to land, along with cultural identity, spirituality, ancestral knowledge, and Indigenous ways of living were profound. The preliminary findings tell that connection to land, water, and territory for First Nations in BC is complex and interconnected and can only be captured using Indigenous ways of knowing and being frameworks.

FORWARD DIRECTIONS

It became clearer that the task of describing the complexity of land and human health connections at multiple scales and through various systems does not fit neatly into the logic of wellness indicators. Several key conceptual, methodological, and epistemological issues emerged in relation to the notions of reductionist indicators and wholistic First Nations understandings of land and environment. Careful consideration of these issues led to reflecting on the relevance of indicators, which are artefacts of settler colonial systems and practices. It left us with the following questions:

  • • How does our understanding and design of indicators need to transform to produce one that aligns with worldviews that value sustainability and the health of all our relations?
  • • How is it possible to work from First Nations understandings of “everything is connected,’’ “all my relations,” and “togetherness” and translate it into a Western scientific framework that works by dichotomizing concepts.

decontextualizing, and studying aspects of larger issues using in-depth Western expertise developed through siloed disciplinary approaches?

• Despite the challenges, is there a role for an ecological indicator that signals and alerts the Watchmon to trends that can be used to catalyze systems change?

Attempting to integrate a connection to land indicator within the PHWA, despite the tensions and challenges, has gone far beyond the previously imagined benefits of sharing data. It has reinforced the continued need to elevate First Nations philosophies to their rightful place in understanding the world (Ratima at al., 2019). This means meaningful representation of First Nations understandings in governance and decision-making processes at multiple levels, including local planning as well as system-wide cross-sectoral work that address the determinants of health. The emphasis on "interdependence and reciprocal stewardship with all of our relations in the natural world” (Ratima et ah, 2019) offers solutions not only for advancing health promotion but also for stewardship, the development of public health, health service agendas and interventions in politics, economics, and social life. We hope to have demonstrated how the FNHA is contributing to a critical intervention in a historically Western public health lens. “Hardwiring” of integrated land, health, and wellness perspectives will nourish the roots of wellness not only for First Nations but also for all British Columbians.

AUTHORS' SELF-IDENTIFICATION

  • • Lindsay Beck. MSc, fifth-generation Canadian settler, American, Norwegian, and English ancestry. Born and raised in the territories of the Yellowknives Dene and North Slave Metis in Yellowknife, NWT.
  • • Daniele Behn-Smith, MD. Eh Cho Dene (Big Animal People) of the Fort Nelson First Nations in British Columbia, with Metis roots in the Red River Valley.
  • • Maya Gislason, PhD, seventh-generation Canadian settler, Icelandic and Scottish ancestry. Born and lives in British Columbia on unceded Coast Salish territory.
  • • Dawn Hoogeveen, PhD. third-generation Canadian settler of Dutch and British ancestry, raised on Anishinaabe territory on Williams Treaty lands near Peterborough, Ontario.
  • • Harmony Johnson. MHA, Coast Salish, born and raised in Tla’amin Nation, BC.
  • • Krista Stelkia. PhD candidate, Sylix/Tlingit from Osoyoos Indian Band, BC.
  • • Evan Adams, MD, MPH, born and raised in Tla’amin Nation, BC.
  • • Perry Kendall, MD, Canadian settler born in England.
  • • Bonnie Henry, MD, MPH, FRCPC. fifth-generation Canadian Settler, Scottish highland and Welsh ancestry. Born and raised in Mi’kmaq territory, PEI and NB.

REFERENCES

Czyzewski, Karina. “Colonialism as a Broader Social Determinant of Health.” International Indigenous Policy Journal, 2. no. 1 (2011).

First Nations Health Authority. “Summary Service Plan: An Operational Plan for the Fiscal Year 2019/2020.” FNHA (2019): 64.

First Nations Data Governance Initiative. “Data Governance Discussion Paper: Rolling Draft." First Nations Health Authority, First Nations Information Governance Centre, West Vancouver, BC. 2019.

First Nations Health Authority and the Office of the Provincial Health Officer of British Columbia. “The First Nations Population Health and Wellness Agenda Summary of Findings.” FNHA (2020): 18.

Iwama, Marilyn. Murdena Marshall. Albert Marshall, and Cheryl Bartlett. “Two-Eyed Seeing and the Language of Healing in Community-Based Research.” Canadian Journal of Native Education, 32, no. 2 (2009): 3-23.

Kimmerer. Robin Wall. “Braiding Sweetgrass: Indigenous Wisdom." Scientific Knowledge and the Teachings of Plants (Minneapolis: Milkweed Editions. 2013), 320.

Raibmon, Paige. “Provincializing Europe in Canadian History; Or. How to Talk About Relations Between Indigenous Peoples and Europeans." Active History, 2018. http:// activehistory.ca/2018/10/provincializing-europe/

Ratima. Mihi. Debbie Martin, Heather Castleden. and Treena Delormier. “Indigenous Voices and Knowledge Systems: Promoting Planetary Health, Health Equity, and Sustainable Development Now and for Future Generations.” Global Health Promotion 26. no.3 (2019): 3-5.

Stephen, Craig and Julie Wittrock. “First Nations Population Health & Wellness Agenda: Options for Finding a Path Forward to Incorporate Ecological Health Indicators.” Report to the First Nations Health Authority (2017).

Yazzie. Melanie, and Cutcha Risling Baldy. “Introduction: Indigenous Peoples and the Politics of Water.” Decolonization: Indigeneity, Education & Society, 1, no. 1 (2018): 1-18.

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