Indigenous Approach to Healing Influential in Hep C Care

Ingrid Hein

September 16, 2019

MONTREAL — When working with indigenous people, it is important to take into account the emotional and spiritual aspects of wellness, said Elder Sharon Jinkerson-Brass, a member of the Key First Nation in Saskatchewan who works with the Indigenous Wellness Research Team in Vancouver, British Columbia, Canada.

The indigenous medicine wheel depicts four aspects of wellness: emotional, spiritual, mental, and physical, she explained.

Healing begins with an understanding that everyone and everything are interconnected. "We make sure that however people walk in the world, they are being honored and respected," she said.

This concept is particularly important for healthcare providers to take into account when dealing with hepatitis C and drug use in indigenous people, Jinkerson-Brass said here at the International Conference on Hepatitis Care in Substance Users 2019.

Often, people who inject drugs, especially indigenous people, face tremendous stigma, are refused services, and not treated with respect — even in a research context, she explained.

Western communication is often "cold," even when asking very personal questions, she said. "Were you raped? When were you raped? Do you have a place to stay? Here are your test results. They are positive. Here's your $50 for participating in the study."

"Sending these women out with a couple of bucks is wrong; we are facing an opioid epidemic," she added.

During discussion circles with indigenous people in Vancouver's Lower East Side neighborhood, participants become vulnerable when telling their stories. "We brush them down, give them water, talk with them. They actually experience healing, thank us, smile," she said. "It gives us hope."

They are honored for their essence, their spirit. "We love them up," said Jinkerson-Brass. They are not judged for what they do or where they are in life.

Trauma-Informed Care

Hepatitis C virus infection has been described as "Canada's most burdensome infectious illness" (PLoS One. 2018;13:e0191184).

Approximately 250,000 Canadians are infected with hepatitis C, but infection rates in indigenous communities are five times higher than those in the rest of the Canadian population, according to the recent Blueprint to Inform Hepatitis C Elimination Efforts in Canada.

And although direct-acting antiretrovirals are effective at eliminating the virus, they are not effective enough, on their own, to turn the hepatitis C story around in this population.

Hepatitis C and drug use in the indigenous population were put into historical and cultural context at the conference by Alexandra King, MD, Cameco Chair in Indigenous Health at the University of Saskatchewan in Saskatoon.

Historical and ongoing trauma "take us to a variety of different sequelae that cause emotional deregulation and lead to drug use, which in turn leads to hepatitis C," she pointed out.

"We can trace a pathway from colonization to hepatitis C. We look at colonialism as a risk factor, but we should also look at colonialism as part of the intervention," she noted.

For this reason, trauma-informed care is extremely important, King said.

Indigenous Heritage Is Not a Risk Factor

It is important to stop stigmatizing and to dispel the idea that being indigenous makes you part of a high-risk population for hepatitis C. "We don't group other populations with circumstances or behavior," said Sadeem Fayed, a graduate student at Simon Fraser University in Burnaby, British Columbia, who works with King.

High-risk groups for hepatitis C include people who inject drugs, men who have sex with men, and people with experience in the federal or provincial prison system. "Indigenous is not a grouping factor," she said, adding that indigenous people are members of all these groups.

Fayed went on to describe the concept of "two-eyed seeing."

The idea is to see with one eye the strengths of indigenous ways of knowing, and to see with the other eye the strengths of Western ways of knowing.

"The first step is balance, leveling the research field, developing an indigenous eye. The second step is partnership," she explained.

The Blueprint to Inform Hepatitis C Elimination Efforts in Canada recommends that approaches to address hepatitis C be "Indigenous-led, multidisciplinary (including shared care models that bring together Indigenous and Western approaches to health), and rooted in addressing Indigenous determinants of health (e.g., racism, social exclusion)."

Fayed said she agrees. When looking at health in these communities, it is important to "look at severe and complex intergenerational trauma" and incorporate indigenous healing systems.

A Healing Collaboration

Understanding the indigenous approach to healing proved to be vital for the Centre hospitalier de l'Université de Montréal (CHUM) addiction clinic. For years, indigenous people who presented for treatment at the clinic often left early and rarely returned.

"They were not receptive to accessing our services and, when they did, they came at later stages of illness and left against medical advice, often angry or frustrated with the healthcare system," said Stéphanie Marsan, MD, director of the addiction medicine specialty program at CHUM.

"Our team was frustrated that we were not able to better connect with them," she told Medscape Medical News.

But the relationship between the CHUM team and indigenous people with addiction issues changed in 2015, with the help of Curtis Nelson, executive director of the Onen’tó:kon Healing Lodge, an inpatient treatment center that provides a trauma-focused and culture-based program for indigenous people in Kanesatake, a Mohawk settlement just outside Montreal.

Nelson proposed a collaboration and "we jumped at the chance to work together," Marsan explained.

After a series of meetings and cultural sensitivity training for the CHUM team, it was agreed that indigenous people would be evaluated and undergo detoxification at CHUM and, once they were stable, would be transferred to the Onen’tó:kon Healing Lodge and enrolled in a 6-week wellness program.

The CHUM team had not understood the indigenous perspective on healing, the effects of colonization on indigenous people, or their values, beliefs, and cultures, Marsan acknowledged. As a result, "many of our clients fell through the cracks."

When indigenous people came to the CHUM clinic and engaged in beading projects in the waiting room or wanted to perform smudging ceremonies, her team worried about injury from needles or fires breaking out and prohibited the activities.

After a review of interviewing methods, the team saw how they could be perceived as insensitive, and understood why indigenous people immediately headed for the exit.

"The Western way is to ask a lot of questions," Marsan explained. The CHUM team asks "one question after another: When did you start using? How much are you using? When did you start using regularly? When did it become a problem? Show me your arms."

This abrasive approach to gathering information failed to build trust with the indigenous people seeking help.

With the new approach, team members ask clients to tell their stories. "We know we need to take time to listen," Marsan said. And although it takes longer, "we get a lot more information."

The collaboration between CHUM and Onen’tó:kon worked, and results were markedly better in the first year.

Marsan and her colleagues assessed 13 indigenous opioid users who started opiate agonist treatment at the hospital and who underwent detox treatment for an average of 2.6 days. Average retention in treatment was longer for the nine people who completed the 6-week program at the healing lodge than for the four people who did not (293 vs 52 days).

And to date, those nine "are doing great," Marsan reported.

Before the collaboration, one or two indigenous people were referred to CHUM each year. "Now, we're getting close to five a month," she said. Last fall, services at the CHUM clinic were expanded to include mental health evaluations and hepatitis C treatment.

"We're even looking into establishing a wellness area at the hospital, where an indigenous healer can come to perform smudging without setting off fire alarms," she added. Smudging, a cleansing ceremonial smoke bath, is performed in many indigenous cultures to purify the body, aura, and energy.

This will be challenging, Marsan explained, but "could give our patients a place where they can feel safe."

Jinkerson-Brass, King, and Fayed have disclosed no relevant financial relationships. Marsan reports receiving funding from Indivior. King reports receiving research support from Gilead and speaker honoraria from AbbVie, Merck, ViiV, BMS, and Indivior.

International Conference on Hepatitis Care in Substance Users (INHSU) 2019. Presneted September 11, 2019.

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