Access to traditional medicine in a western Canadian city.

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Access to traditional medicine in a Western Canadian city James B. Waldram

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Associate Professor in the Department of Native Studies , University of Saskatchewan , Saskatoon, SK, S7N 0W0, Canada Published online: 12 May 2010.

To cite this article: James B. Waldram (1990) Access to traditional medicine in a Western Canadian city, Medical Anthropology: Cross-Cultural Studies in Health and Illness, 12:3, 325-348, DOI: 10.1080/01459740.1990.9966029 To link to this article: http://dx.doi.org/10.1080/01459740.1990.9966029

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Access to Traditional Medicine in a Western Canadian City

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James B. Waldram This paper examines the question of access to traditional Indian medical systems in the western Canadian city of Saskatoon. The data demonstrate that many Natives desire such access, and do not see difficulties in having Indian healers available in Western-style biomedical clinics. A variety of language variables proved to be the best predictors of access questions, indicating that those with the greatest cultural adherence were most likely to want a more formal access. It is argued that a lack of access to traditional Indian medical services represents a legitimate health need. Considerations for the implementation of such a formal access to traditional Indian medicine are discussed.

INTRODUCTION

The last fifteen years have witnessed a veritable explosion in interest concerning traditional medical systems throughout the world. Sparked by the Alma-Ata declaration of the World Health Organization (1978), anthropologists, other social scientists and health policy analysts began to explore in a more concrete fashion the extent to which traditional medical systems are utilized and the manner in which these systems could possibly be integrated into national health systems which were based primarily on the Western scientific, or biomedical, model. Most of this research has been directed toward the Third World countries, especially those in Africa and Central America, where the availability of biomedical services was limited in urban areas, and tragically unavailable in many rural areas (e.g., Press 1969, 1971; Dunlop 1975; Green and Makhubu 1984; Nchinda 1976; Woods 1977; Asuni 1979; Bichmann 1979; Green 1980,1988; Finkler 1981,1985; Nyamwaya 1987). Research was also directed toward particular Asian countries with strong traditional medical systems, where these systems and biomedicine have come to coexist in a more-or-less formal relationship (Bhatia et al. 1975; Taylor 1976; Kleinman 1980; Kurup 1983; Pei 1983; Ladinsky et al. 1987). Considerably less research has examined the state of traditional medical systems in countries with very strong biomedical systems, such as the United States and Canada. Research among North American Indian peoples has suggested that their traditional medical systems, though somewhat modified as a result of colonialism and the inevitable interaction with biomedicine, remain fairly strong on the reserves JAMES B. WALDRAM is an Associate Professor in the Department of Native Studies at the University of Saskatchewan, Saskatoon, SK, S7N 0W0, Canada. His current research activities include an investigation into models of collaboration/cooperation between traditional North American Native and biomedical practitioners, and an examination of the role of culture in understanding the patterns of criminality and mental illness for Native Canadians. 325


326 /. B. Waldram

despite over a century of oppression and attempts at forced acculturation by Canadian and American governments (e.g., Adair 1963; Camazine 1980; Jones 1984; Gregory 1988,1989). However, the last two decades have seen considerable migration from these reserves into urban areas, as Indian peoples sought to improve their educational and economic fortunes. While it has often been assumed that such a migration was evidence of either acculturation or a desire to acculturate, we now know that many of these individuals sought only a form of integration, to benefit from all that North American society had to offer without necessarily abandoning their Indian heritage. It follows, then, that the traditional health and illness beliefs of migrants would not likewise be quickly abandoned, and that the traditional Indian medical systems would continue to have relevance even where individuals were literally surrounded by a myriad of biomedical facilities and services. It is significant that very little research has ever been undertaken to determine the extent to which urban Indian peoples have retained traditional health and illness beliefs, and more importantly whether or not access to traditional medical services in the city is of issue to them (Fuchs 1974, and Fuchs and Bashshur 1975 are notable exceptions). The purpose of this paper is to examine the question of access to traditional medical services for Native1 peoples in the western Canadian city of Saskatoon. EXAMINING ACCESS

Questions of access to medical services are crucial in understanding the utilization patterns of any given population, and it is necessary to adopt a broad view of what is meant by "access." For instance, Lasker (1981:159) includes not only the presence of a given service in her definition of "access," but also other factors such as the time delay in receiving treatment, costs of the service, and the quality of communication that exists between consumer and practitioner. We must also include in any definition of "access" the specific health and illness beliefs of the population under consideration, as well as other social or structural factors, such as overt racism directed toward consumers and the legal status of alternative treatment modalities. In examining the question of access to traditional medical services, some researchers have tended to concentrate their efforts on the practitioners of both traditional and biomedical systems, and the barriers that exist which prohibit the development of more formalized access services (e.g., Good 1977; Bichmann 1979; Green and Makhubu 1984: Nyamwaya 1987). The most significant barrier cited is the attitude of physicians and other practitioners of biomedicine toward any alternative form of treatment which they define to be without scientific merit. In North America in particular, the professionalization of biomedicine has had, in the past, a profound effect on alternative treatments, such as homeopathy, naturopathy, and chiropractic, forcing many of these alternatives underground or out of existence through the enactment of legislation (Green 1988:1129). In general, the conclusions that derive from these studies are that the barriers are simply too insurmountable to allow for such formal service delivery in countries where the biomedical system is dominant and powerful; the solution is to simply allow traditional medicine to operate as it does, informally, largely without regulation, and mostly beyond the


Access to Traditional Medicine 327 eyes and ears of biomedical practitioners. These researchers, and others, do admit that the traditional systems are indeed quite vibrant, and have not buckled under even in circumstances where biomedical services are readily available. Likewise, research shows that in circumstances where both biomedical and traditional medical systems are available, traditional peoples tend to use both. They develop a "hierarchy of resort" (Schwartz 1969) for the alternative treatments available, in a pattern described by some as "dual use," (Press 1969), others as "concurrent use" (Woods 1977), "complimentary use" (Asuni 1979; Nyamwaya 1987), and "simultaneous use" (Garrison 1977; Welsch 1983). The simple fact that many traditional peoples utilize both biomedical and traditional medical systems even where adequate biomedical services are available is often ignored in discussions of access. Given that utilization of both systems occurs, and that therefore the consumers find utility in such usage, what are the implications of severing or impairing access to either of these systems? More to the point for purposes of this paper: where Native peoples move away from the reserves which serve as the loci for their traditional medical systems, do they lose access to them? And if they do, does biomedicine fully replace them in their new locale? Further, do they continue to desire access to traditional medical services? Finally, is it possible to provide such access, either through alternative means such as Native organizations or else through government-sponsored efforts? In addition to informing us of the fact of "dual use" among traditional peoples, research has also demonstrated that such peoples rarely see any difficulties in such a utilization pattern, even where biomedicine and the traditional medical systems are inherently hostile to each other (as in North America). It can be argued that researchers who have tended to view these various medical systems as essentially separate and autonomous, with the consumer moving back and forth between them (cognizant of the fact that he is indeed changing systems), have been overly influenced by the apparently broad differences between the two systems and the attitudes of practitioners (Nyamwaya 1987:1285), and have failed to examine closely the perspective of the consumers. More convincing research, based heavily on the consumers themselves, has demonstrated that they frequently do not view these medical systems as separate, but rather see them as sectors or components of a single system. As Welsch (1983:34) noted in his study of the Ningerum of New Guinea, people choose between alternative treatments, and not alternative systems. Indeed, the health consumers by-and-large care not if there are antagonisms between the two systems, if they are aware of them at all. Asuni (1979:37) notes that, "The question of cooperation of traditional and modern healing practice does not pose a great problem to the consumer... He will use both facilities with or without the knowledge or approval of either." Similarly, as Romanucci-Ross (1983:13) has described, consumers are not concerned about the "explanatory principles" of various treatment modalities, but rather are concerned about symptoms and cures. While the practitioners of biomedicine and traditional medicine may feel that there are too many differences between them to allow for any form of cooperation and collaboration, consumers tend to consult with them as if they were simply alternatives in the same medical system. Hence, biomedical and traditional treatment modalities are viewed as being both necessary and essential; if access to one were to be severely curtailed, then a health care "need" would exist.

328 J. B. Waldram


ACCESS TO TRADITIONAL MEDICINE IN THE URBAN CONTEXT

When traditional peoples move into urban areas, they do not become completely divorced from their rural-based culture; they bring it along with them. There are no instant cultural transformations upon migration. When a sufficient number of culturally homogeneous migrants come to live in an urban area, access to traditional medical services may become an issue of concern to them as a whole. Likewise, under such circumstances traditional healers, or in many cases what we may call "neo-traditional" healers, emerge. The key difference between the two types revolves around the extent to which the healers have altered their traditional practices, and in the long run the extent to which the traditional healing systems evolve, in response to the changing cultural demands of the clients. Hence, we see the development of neo-traditional medical systems incorporating a variety of biomedical treatments and illness etiologies, as well as clinical practices somewhat distant from the personalistic services usually rendered by healers in the rural setting. In his investigation of the "dual use" of traditional medical systems and biomedicine in Bogota, Columbia, Press (1969,1971) has described the relatively brief and impersonal nature of the encounter between healer and consumer, which he contrasts with the more personal, family-oriented practices in rural areas. Similarly, he has described how the personal styles and specialities of the healers have diversified to meet the broader demands of a more heterogeneous population (Press 1978:75). Finkler (1985), in her excellent study of spirtualist healers in Mexico, has also reported the largely impersonalistic approach of the temple curers, where little compassion or support is provided to the patient. Finkler's (1985) work also demonstrates the manner in which the delivery of traditional or alternative medical services can be formalized, and even institutionalized. Her descriptions of the temples where healing occurs define a delivery process which is, in its own way, very formal and bureaucratic. Certainly they are not "underground" alternative health facilities, for they operate in the open with a broadly-based clientele. Such a situation likewise holds for Puerto Rican residents in various cities in the American Northeast, where Garrison (1977) and Harwood (1977) have described very formal treatment facilities. In these cases, the availability of traditional or alternative medical systems is obvious to the passer-by, and may even be advertised in newspapers, magazines, or in store-front windows. The traditional healing systems of Indians in Canada and the United States have not moved into the urban areas in such a formalistic fashion. In one of the few studies to examine the utilization of traditional medicine in an American city, Fuchs and Bashshur (1975) described how many Indian residents of San Francisco returned to their home reservation for treatment. The situation is not very different in Canada. Most traditional medical practices, it is believed, are available primarily on the reserves. Insofar as traditional medical systems have found their way into the urban environment in any formalized manner, similar to the American experience they tend to be the result of isolated initiatives by individual biomedical practitioners in conjunction with Indian people. The occasional availability of traditional medicine in urban hospitals, especially in northern and western Canada, generally represents the extent of such practices. In Winnipeg, for instance, Indian medical


Access to Traditional Medicine 329 interpreters working in one hospital act as mediaries between the traditional and the biomedical systems, including arranging for Indian healers to consult with patients in the hospital (O'Neil 1988). For Canada we have not seen the development by the Indian people themselves of more formalized traditional health services in the urban context. Nonetheless, the evidence that does exist (much of it informal) suggests that many Indian urban dwellers still have a strong attachment to their traditional health systems, despite their utilization of the biomedical system. The problem for them is that, while there are often Indian healers in the city, they may be hard to locate until the migrant effectively taps into the Indian network. In order to obtain a more formal access to Indian medicine, they invariably must be hospitalized to attain it! Under such circumstances, the Indian consumer suffering from less serious illness has few options available: he may return home to the reserve or travel to some other Indian community to seek out a healer, or he may attempt to locate one in the city. Whether or not a healer is of the same Indian culture as the patient becomes problematic.

ACCESS TO TRADITIONAL MEDICAL SERVICES IN SASKATOON The city of Saskatoon is a small prairie city of 170,000 people in central Saskatchewan, Canada. The Native population of the province, approximately 140,000, represents between ten and fifteen percent of the total provincial population, and it has been estimated that they constitute between seven and eleven percent of the city's population (Clatworthy and Hull 1983; Star-Phoenix 7 October 1986). The province as a whole, immense and extremely rural, is characterized by many isolated and semi-isolated Native communities and Indian reserves. Since the 1960s there has been a fairly extensive migration of Native people into Canadian cities (Denton 1972; McCaskill 1979; Clatworthy and Hull 1983). Unfortunately, the poverty characteristic of the reserves which many migrants seek to escape confronts them once again in the city. A 1982 study in Saskatoon demonstrated the extent to which many Native residents remained poor despite the range of employment opportunities which the city is believed to provide (Clatworthy and Hull 1983). Many of the city's poor people, both Native and non-Native, can be found in the west section of the downtown area of Saskatoon, an area characterized by hotel beverage rooms, discount stores and pawn shops. In 1987 and 1988, the author undertook a study to examine the health care utilization patterns of urban Native and non-Native residents in this west core area. The overall results of this study have been reported elsewhere (Waldram and Layman 1989), but it is worth emphasizing here that these data in general demonstrated that Native urbanites utilized biomedical services as extensively, and in some cases more extensively, than non-Native urbanites who were similarly disadvantaged. While many Natives demonstrated a strong tendency to utilize "walk-in" facilities for medical care, and in particular one hospital emergency department and the Westside Clinic, they nevertheless tended to establish a strong relationship with a particular physician in these facilities. The overall study concluded that the strong similarities between poor Natives and non-Natives in their utilization of health care facilities in Saskatoon was due to their similar low socio-economic situation. For


330 J. B. Waldram those unfamiliar with the health care system in Saskatchewan, it should be stressed that no individual is required to pay for most health services. Indeed, Saskatchewan is widely considered the birthplace of universal medical care (medicare) in North America. One aspect of this study concerned the extent to which the Native residents utilized traditional medical services and whether or not access to these services was an issue. Not surprisingly, there exists no comprehensive listing of the Native residents in the core area of Saskatoon, and hence purely random sampling procedures could not be employed. Interviews took place in two adjacent facilities in the west core area: the Westside Clinic, a community clinic staffed by physicians, nurses, health and clinic aids, and the Friendship Inn, a social service agency providing meals and companionship for poverty-stricken urban residents. The interview schedule was adjusted only slightly for the two locales. An availability sample was employed with potential respondents being requested to participate. In general, all individuals over the age of 16 were approached; however, there were occasions when both interviewers were busy and potential respondents were unable to wait. The interview schedule was comprised of 123 closed- and/or open-ended questions plus three supplementary schedules. In total, interviews were completed with 142 Natives and 84 non-Natives. Only the data for the Natives is relevant to this paper. There were only a handful of refusals. The two facilities were excellent locales for making contact with a substantial population of disadvantaged Native and non-Native urbanites. In fact, both had been established in the west core area specifically to provide a variety of health and recreational services to the city's poverty-stricken residents. Both operated in a very relaxed manner, attempting with great success to provide a comfortable atmosphere for potential clients. While a variety of Native staff were present at the Friendship Inn, the inn did not undertake to provide any medical services. In contrast, at the time of research there were no Natives employed at the Westside Clinic, and none of the non-Native staff was proficient in an Indian language. This was a constant irritation for the medical staff, and ten years of proposal submissions to the government detailing the need for Native personnel had been unsuccessful. Hence, the clinic was unable to offer culturally appropriate medical services. However, it became apparent during the course of the interviews that the clinic did provide culturally sensitive care. The two physicians had experience in Third World settings, and brought an action-oriented perspective to their work. Many respondents noted that the staff at the clinic treated them like human beings, with respect, in contrast to the racist disrespect often sensed at other facilities. The Westside staff undertook to learn about their patients, their social and economic conditions, and whatever else they felt was necessary knowledge to provide effective treatment. The patients responded with strong loyalty to the clinic. Native peoples from at least six different cultural traditions were represented in the sample: Northern or Woods Cree, Plains Cree, Dene, Dakota, Saulteaux (Plains Ojibwa), and Metis. The recent trend toward a "pan-Indian" blending of Indian healing traditions in Canada has been noted (O'Neil 1988), with patients from one tradition seeking out or receiving treatment from a healer representing another tradition. The latter is not an entirely new phenomenon, however, since the Indian peoples in western Canada have long acknowledged the existence of certain heal-


Access to Traditional Medicine 331 ing and medicinal specialities within distinct cultural groups, occasionally crossing cultural lines to obtain such services. It is likely that the dual use of traditional medical systems and biomedicine is really a more recent variant of an older practice of dual (or multiple) use of somewhat different Indian healing systems, either intraculturally or cross-culturally. It is to be expected that cultural groupings as diverse as those represented in this study would exhibit a variety of nosological systems, illness etiologies, and treatment strategies that vary both within broad cultural lines as well as between cultures. Healing systems, as well as other aspects of Native culture, are known to vary to some extent from community to community for a single cultural group, often parallelling variability in language dialects. Significant intra-cultural variability may also exist within individual communities. There may be those healers considered as "traditionalists," as well as peyotists, Christian faith healers, and eclectics, or those utilizing a variety of techniques of diagnosis and treatment. Some patients may use only one of these competing systems, or may use any number of them serially or simultaneously. There are also, of course, those individuals who utilize only biomedical services, or these services in conjunction with one or more of the others. Furthermore, individuals may seek out the services of a healer from another culturally similar community, and perhaps even from a culturally different one. Unfortunately, there have never been any studies on the health care seeking behaviour of particular Native communities in Saskatchewan, and my observations presented here derive from informal discussions with Native peoples throughout the province. Also lacking are good published sources of traditional health care beliefs and practices for the Indians of Saskatchewan. Of the groups represented in this study, the most information is known about the Northern and Plains Cree. Keeping in mind the fact of intra-cultural variability, the recent study by Young et al. (1989) presents the best, and most recent, account of Northern Cree healing. Based on research with one Alberta Indian healer, this study describes the strong individualistic flavour of Northern Cree healing. The healer in their study was a herbalist who also had the ability to conduct sweat lodge ceremonies and was training to learn the shaking tent ceremony. The relationship of the healer to the Creator, the source of the ability to cure, was an essential component of the medical system. This particular healer was also a shaman (although it is not always the case that herbalists are shamans) who had the ability to treat cases of "bad medicine," or illness and misfortune caused by malevolent shamans. Hence, his medical domain was both the organic and the spiritual. Aiding him in his work was sweetgrass, burnt as an offering to the Creator and to spiritually cleanse himself, and his patients, to allow for healing. Cree people, as well as the other Indian groups represented in this study, traditionally used sweetgrass, sage, or fungus in this manner. These natural substances could also be burned by individuals seeking protection from evil forces, for good luck and health, and hence in proper context, they acted as a form of preventive medicine. Mandelbaum (1979) provides an extensive discussion of Plains Cree shamanism in his 1930s research in Saskatchewan. He describes the technique of sucking illness from the patient's body, often utilizing a bone or horn, and notes that shamans had the ability to send illness as well as heal it (often referred to as "object intrusion" in


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the literature). He also describes the existence of "evil medicine," known also today as "bad medicine," including "love medicine," which could be directed towards the source of a client's affections but which often had disastrous results. Most healing was done individually by each shaman, although occasionally larger activities, such as the sun dance, occurred which had a healing component. The sweat lodge was also used by the Plains Cree. Of particular interest is Mandelbaum's reports of the sharing of medical or spiritual knowledge between cultures on the plains. For instance, he notes that "love potions were a Saulteaux specialty" probably borrowed by the Cree (1979:164). His informants also indicated that, although the "fame of Cree medicines was widespread," many of them did indeed come from the Saulteaux. In general, the Plains Cree were wary of the "bad medicine" of the Northern Cree and Saulteaux. Tarasoff (1980) has provided some discussion of the utilization of biomedicine in relationship to traditional medicine for the Plains Cree. According to him, "people will seek help from a medicine man or woman only after the medical doctor has failed to cure some illness such as persistent pain in the stomach or as serious as the contagious tuberculosis. In any case, the transition is considered to be a sacred one involving prayers, the smoking of the pipe, a gift exchange, and perhaps the singing of a ritual song with the accompaniment of a medicine drum" (Tarasoff 1980:17). It is likely that the situation of serial utilization of biomedicine and Indian medicine is more complex than he reports, with patients consulting the healers first in some cases, or both healers and physicians in others. Tarasoff (1980:17) also notes the existence of "deep rooted" belief in "bad medicine", even among those Cree who are "acculturated" and members of Christian churches. Less has been written of the healing traditions of the Dene, Saulteaux or Canadian Dakota. The Saulteaux are often considered by academics to have essentially the same traditions as the Plains Cree, due to a long period of coexistence. However, Mandelbaum (1979) did indicate that the Saulteaux, or Plains Ojibwa, introduced elements of the mite-wiwin to the Plains Cree. This highly structured Ojibwa healing complex likely migrated from the Lake Superior area in the 19th century, and there are reports of mite-wiwin ceremonies still being conducted across the western plains and subarctic. Smith (1973) described one element of the Dene healing tradition in his monograph on the Dene of Fort Resolution, Northwest Territories. He noted that the supernatural abilities of a Dene person (Chipewyan in this case) derived from his inkonze, or his ability to "know something a little" (Smith 1973:8). Dreams were an important source of inkonze, and through dreams knowledge about root and herbal medicines could be imparted to certain individuals, who would become healers. Smith notes that many of the Dene herbs were borrowed from the Cree, "who are noted for their outstanding root medicines" (1973:10). In seeking treatment it was essential that the patient seek out the healer (and not vice versa), and that he pay something for the services. Payment could be in the form of meat, furs, a dog, etc. The Dene recognized both organic and supernatural illness etiologies. There are virtually no written reports of the medical traditions of the Metis. These individuals are descendents of mixed Indian-non-Indian marriages dating as far back as the time of first contact in western Canada. A hybrid culture formed, with elements of both Indian and European (primarily French) coming together in a


Access to Traditional Medicine 333 somewhat unique formation. It is likely that Metis medicine is similarly a hybrid of Indian and European elements. There are Metis traditional healers in Saskatchewan, but the extent to which their medicine differs from neighbouring Indian groups cannot be ascertained. To generalize, it is apparent that there are some common features of current Indian medicine in Saskatchewan that bear directly on this research. First, each cultural tradition exhibits a variety of different healers, often with specialties and degrees of qualification. Legitimate healers are very cognizant of their limitations, both in the context of Indian medicine and biomedicine, and are known to make referrals when a particular problem is beyond their expertise. Second, treatments may vary from individual, herbal oriented treatments, to sweat lodge ceremonies, to extensive ceremonial or spiritual activities lasting many days. Self-treatment, involving the use of herbal remedies and sweetgrass, is common. Third, illness may be viewed as the product of either or both the organic and the supernatural. Fourth, Indian groups in the province are aware of the similarities and differences between their healing traditions, and while in some cases an individual may cross cultural boundaries to seek treatment, in other cases there may exist great fear of an unknown healer. Finally, a "healer" is informally acknowledged and accepted by the community, (or some members of the community) as someone (either male or female) who has the knowledge, the culturally-defined right, and the inclination to heal. There is no formal mechanism of accreditation. The extent to which traditional medicine is available in the city was unknown to the researchers, although the existence of a handful of traditional Indian healers was known. Traditional medicine is not practiced openly in the city, and there are no clinics or formally available services in this area. However, it would be incorrect to say that traditional medicine is practiced "underground." Rather, it is simply not advertised or made known to non-Natives as a group. It is doubtful that many physicians or other practitioners of biomedicine are very aware of the existence of traditional medicine in the city, or care if it does exist. There are a minority of practitioners, however, who by virtue of relatively high Native patient loads, and considerably more cultural sensitivity, are more aware of the fact that some of their patients have likely seen, or will see a traditional healer, and may even take this fact into account in their discussions and treatment with Native patients. The staff of the Westside Clinic, which has a Native patient load of approximately 80%, are among this minority.

ACCESS TO TRADITIONAL MEDICAL SYSTEMS IN SASKATOON

Belief in Traditional Medicine

While it is evident that many of the Native respondents (43%) had utilized any one of a variety of herbal medicines in the previous year, for purposes of this paper I will concentrate on their utilization of, and attitudes toward, Indian healers.2 Overall, only a small minority (10.3%, n = 6) of Native respondents had consul-


334 J. B. Waldram ted with a traditional healer in the year previous to interview. However, considerably more (30.8%) had seen a healer at least once in their lifetime. Actual contacts with traditional healers may be under-reported for a variety of reasons. In some cases, individuals may have been taken as children and were unaware of the nature of the encounter. More likely, however, many respondents remained uneasy admitting to such an encounter, especially to a non-Native researcher. It is also essential not to confuse actual or reported contacts with Indian healers with use of Indian medicine, since a great deal of self-treatment likely exists. Perhaps more important than actual contact with a healer would be the existence of beliefs consistent with potential contact. Individuals may believe in the existence and efficacy of Indian medicine without ever having had recourse to consult a healer. Although we did not ask respondents directly if they believed in Indian medicine, one question in particular (regarding whether or not they wished to see healers available in a biomedical-style clinic, and why) indicated that 70.6% either believed in Indian medicine (for instance, believed that "it works"), or else were open to it (for instance, they wanted "to learn" more about it). Similar results were obtained with a sub-sample of 27 individuals, whom we interviewed in greater depth on the question of Indian medicine.3 Of these, 85% stated their belief that "some Indian people can cause other Indian people to get sick or have bad luck." While only 14.8% indicated that this had actually once happened to themselves, 69.6% responded that "it could happen" to them. The ability to cause illness or misfortune in another individual was usually referred to as "bad medicine" or "Indian medicine," and could be accurately described as forms of both "sorcery" and "witchcraft" as described within the anthropological tradition (Harwood 1977:85f f). Most respondents indicated that if they were to experience this problem, they would seek out the services of an "Indian doctor" or "medicine man" for treatment. Although we did not query where they would have to go for treatment, four individuals specifically stated that they would need to travel out of the city, in some cases to the neighbouring provinces of Alberta and Manitoba. In comparing traditional Indian healers with physicians, 60.8% of the respondents stated their belief that there were certain kinds of health problems which Indian healers could better handle. These problems ranged widely, from problems related to "bad medicine," to common non-life threatening illnesses such as colds and flu, and even to the treatment of organic diseases such as diabetes and cancers. Respondents also overwhelmingly stressed that spiritual or emotional problems could be best treated by an Indian healer. But they did not deny the efficacy of biomedicine. Some 85% of the respondents stated their belief that physicians could handle certain problems better than Indian healers. The responses here tended to focus on the better medicines and technology available to the physicians. The analysis did not demonstrate any clear cognitive separation of illnesses into those treatable only by an Indian healer, and those treatable only by a physician, with the possible exception of "bad medicine," a diagnosis often made only after consultation with a physician has failed to determine the existence of an organic illness, or provide a cure. These data suggest that a widespread adherence to traditional Indian medical beliefs exists among Native people in Saskatoon, and that treatment by an Indian healer often requires the patient to leave the city.

Access to Traditional Medicine

335


Ability to Locate an Indian Healer in the City There is no way of determining the number of Indian healers living in Saskatoon. Only 5.1% of the total Native respondents indicated that they actually knew of an Indian healer in the city, and 58.8% expressed the belief that they could probably find one if they wanted through the informal Indian network in the city. The data revealed few patterns to help us understand the dynamics of this searching process. As Table I demonstrates, slightly more Metis than status Indians reported a belief that they could find a healer in the city, and Metis were more likely than members of other major cultural groups to suggest likewise. Given that, in cultural terms, the Metis would be further rather than closer to traditional Indian culture than the status Indians, these results could reflect a more pragmatic assessment by the status Indians (i.e., there really are few healers in the city, and the Indians know it), or a more utopic assessment by the Metis of the perseverance of Indian culture, and medicine, in the city. Language variables were also not particularly useful predictors of ability to find an urban healer: slightly more (60.7%) of those whose first language was a European one reported their belief that they could find such a healer, compared to 58.9% of those with an Indian first language (x2 = 0.04, df = 1, p = .84). The results were essentially the same for those speaking only a European language today, as compared to those speaking both a European and an Indian language (x2 = 0.02, df = 1, p = .90); the frequency with which a respondent speaks their Indian language was also not remarkable (Mann-Whitney U = 982, p = .49). Even past experience with an Indian healer proved inconclusive: 53.8% of those with such experience, compared with 61.8% of those without, stated a belief in their ability to find an urban Indian healer (x2 = 0.71, df = 1, p = .40). There was little difference in educational level (t = 1.12, p = .26) and age (t = -1.17, p = .25) between those who thought they could find a traditional healer and those who thought the contrary. Annual income differences also were not marked (t = 0.54, p = .59). Interestingly, those who thought they could find a healer in the city had lived in the city for an average of 7.76 years, compared to 12.42 years for those thinking otherwise (but these data were not statistically significant; t = -1.40, p = 0.17). These data demonstrate that there does not exist any identifiable category of urban Native resident that feels an ability to locate an Indian healer to an extent greater than any other category. Even factors such as Indian language use and length of time in the city did not emerge as particularly important. Interpretation of these data is therefore difficult, but they do suggest that no particular group has an advantage in their self-perceived ability to locate an Indian healer in the city. These results could be due, in part, to a true lack of healers in Saskatoon, but this remains an empirical question at this time.

Desirability of More Formal Access to Indian Medicine Respondents in the Westside Clinic were asked if they would like to see an Indian healer available within the clinic itself; respondents at the Friendship Inn were

336 J. B. Waldram


TABLE I. Ability to locate an Indian healer in the city.

A. Native status Status Indian Non-status Indian • Metis X2 = 0.99; df = 2; P = 0.61; C = 0.09 B. Cultural background Northern Cree Plains Cree Saulteaux Metis X2 = 1.01; df = 3; P = 0.80; C = 0.09 C. First spoken language Indian European X2 = 0.04; df = 1; P = 0.84; phi = 0.02 D. Speak an Indian language today Yes No X2 = 0.02; df = 1; P = 0.90; phi = 0.01 E. Past experience with Indian healer Yes No X2 = 0.71; df = 1; P = 0.40; phi = 0.07

Yes

No

56 (58.3%) 7 (50.0%) 14 (66.7%)

40(41.7%) 7(50.0%) 7 (33.3%)

15 (62.5%) 26 (59.1%) 16 (53.3%) 14 (66.7%)

9 (37.5%) 18 (40.9%) 14 (46.7%) 7(33.3%)

43 (58.9%) 34 (60.7%)

30(41.1%) 22 (39.3%)

55(59.1%) 22 (57.9%)

38 (40.9%) 16(42.1%)

21 (53.8%) 55 (61.8%)

18 (46.2%) 34 (38.2%)

asked if they would like to see an Indian healer available at a health clinic such as the Westside. It is important to emphasize that the kinds of services that might be available from an Indian healer were not detailed; in fact, it was not even explicitly stated that traditional Indian medical practices would be available to be undertaken within the clinic. Within the various Indian medical systems in western Canada, the initial encounter with a healer is usually in the form of a request for help; the actual treatment often occurs at a later time, and frequently in a different setting. We were concerned here with the question of facilitating that initial encounter among the urban Native residents. Overall, about 60% of the respondents stated that they would like to see an Indian healer available in a clinic. A number of socio-economic and cultural variables proved relevant in this analysis. Table II presents a summary of some of these variables. In socio-economic terms, more females (67.1%) than males (49.0%) indicated their desire to see Indian healers in a clinic (x2 = 4.08, df = 1, p = .04). There were no statistically significant differences in terms of age (t = —1.45, p = .15), education (t = -0.06, p = .95) or income (t = 1.28, p = .20), although in the latter case those desiring access to a traditional healer registered a mean annual income almost one thousand dollars higher than those who did not desire this access. Similarly, there were no such differences in terms of the number of years one had lived in the city (t = -0.45, p = .66) and the degree of intracity transiency (as measured by the number of places lived in the previous year) (t = —0.17, p = .86). In socio-cultural terms, while there were no significant differences with regard to

Access to Traditional Medicine 337 TABLE II. Would like to see a healer in clinic. Yes

No

24 (49.0%) 51 (67.1%)

25(51.0%) 24 (32.9%)

59 (62.8%) 8 (53.3%) 8 (50.0%)

35 (37.2%) 7(46.7%) 8 (50.0%)

17(73.9%) 27(61.4%) 19 (63.3%) 8 (50.0%)

6(26.1%) 17 (38.6%) 11 (36.7%) 8 (50.0%)

49 (69.0%) 26 (50.0%)

22 (31.0%) 26 (50.0%)

61 (68.5%) 14 (38.9%)

28(31.5%) 22 (61.1%)

13 (81.3%) 34 (70.8%) 14 (53.8%)

3 (18.7%) 14 (29.2%) 12 (46.2%)

28 (71.8%) 45 (54.2%)

11 (28.2%) 38 (45.8%)

A. Sex

B.


C.

D.

E.

Male Female X2 = 4.08; df = 1; P = 0.04; phi = 0.18 Native status Status Indian Non-status Indian Metis X2 = 1.24; df = 2; P = 0.54; C = 0.10 Cultural background Northern Cree Plains Cree Saulteaux Metis X2 = 2.38; df = 3; P = 0.50; C = 0.50 First spoken language Indian European X2 = 4.56; df = 1; P = 0.03; phi = 0.19 Speak an Indian language today Yes No

X2 = 9.39; df = 1; P = 0.002; phi = 0.27 F. Frequency of Indian language daily use

Most of the time Occasionally Rarely/never Mann-Whitney U = 681.5; P = 0.53 G. Past experience with an Indian healer Yes No X2 = 3.41; df = 1; P = 0.06; phi = 0.17

Native status and cultural background, it is notable that a higher percentage of status Indians, and those from a Northern Cree4 cultural tradition, desired access to traditional healers in the clinic. Language variables were considerably more important in this analysis. As Table II demonstrates, those speaking an Indian language as a first language, and those still speaking an Indian language today, were more likely to desire access. Language frequency was also important, as those speaking their Indian language "most of the time" were more likely to desire such access. Finally, the data demonstrate that past experience with an Indian healer increased the likelihood that a respondent would desire access to traditional healers in the clinic (although the data fell just slightly outside the significance range). Consultations with a Clinic-Based Healer

Even though some 60% of the respondents indicated their desire to have traditional healers available in a clinical setting, a slightly higher number (67.7%) stated that


338 ]. B. Waldram they would actually consult with a healer if one were available. The data in this case reflect those data presented in the previous section; essentially the same variables are significant, or nearly so (especially the language variables). One important exception is in the case of the frequency of Indian language utilization. Whereas in the previous section this variable fell just outside the significance range, when respondents were asked if they would actually consult a healer if one were available in a clinic, a significantly higher number of those speaking their language "most of the time" answered in the affirmative (Mann-Whitney U = 491.5, p = .01). Respondents were asked for the reasons they would or would not consult a healer in a clinic, and these open-ended responses were then content analyzed and recategorized into discrete categories to facilitate analysis. Table III presents the data for the various categories identified. It is evident from these data that a belief in the existence or efficacy of Indian medicine does not mean that a respondent will want it available in a medical clinic. Some respondents indicated that Indian medicine was too frightening for them to consider, and others expressed the view that it did not belong in a clinical setting. Some comments offered in support of access to traditional healers in a clinical setting which expressed a cultural affinity for it are as follows: "Because a lot of it (Indian medicine) is used up north. It's pretty good." "Because I believe strongly in my Indian ways and I'd rather use my Indian stuff rather than the other stuff" (i.e., biomedicine). "There are times I was living on the reserve and there were medicine men. There were times when I had bad health and I saw people who knew Indian medicine and they helped me." Some respondents expressed a desire to learn about Indian medicine, and by extension their cultural heritage: "Because I grew up as a Christian and we didn't learn about Indian ways." "Just to see how it looks and if it really works." "I wouldn't mind to learn, to understand it."

TABLE III. Reasons for/against consulting with a traditional healer. Reason

N

%

Reasons indicating a belief in existence or efficacy of Indian medicine Reasons indicating a desire to learn about Indian medicine Miscellaneous other reasons indicating a willingness to consult with an Indian healer in clinic Reasons indicating a disbelief in existence or efficacy of Indian medicine Reasons indicating a belief in existence or efficacy of Indian medicine but that it should not be in a clinical setting, or should only be practiced on the reserve Reasons indicating a belief in existence or efficacy of Indian medicine but emphasizing a fear of the healers and their medicine; these respondents would likely not consult a healer unless the latter was well-known to them for fear of "bad medicine". Miscellaneous other reasons indicating an unwillingness to consult with an Indian healer in clinic TOTAL RESPONSES

38 22 15

30.2 17.5 11.8

31 7

24.5

7

5.6

6

4.8

126

5.6

100


Access to Traditional Medicine 339 Many respondents who were against having healers in a clinic expressed a clear disaffinity for Indian medicine: "Indian medicine is evil. It's the devil's way of deceiving Indian people." "I've taken some Indian medicine and it's supposed to work, but it doesn't." "I'm Native, but I don't believe in that [Indian medicine]." A few respondents expressed a belief in Indian medicine, but stated that it did not belong in a medical clinic: "You couldn't get it [Indian medicine in a clinic]. You'd have to go see the guy [healer] . . . in his own place." "If there's any Indian medicine it should go on by itself and not here [in the clinic]." "To me that stuff is very sacred. It's a different kind of medicine than the doctor prescribes. It's given to you in an altogether different way." Finally, some respondents described their fear of Indian medicine and practitioners as their reason they would not like to see healers available in a clinic: "Because some Indian medicine is bad medicine. [I've] heard bad things about some Indian medicine." "It's no good. There's a lot of old guys [healers] who do bad medicine. They used to kill a guy." "[I] don't trust those kind of people [i.e., healers]." While some respondents expressed a fear that Indian healers could make them ill or cause them misfortune, and hence they would not like to see them in a clinical setting, elsewhere in the interviews many responded that only such a healer could handle problems such as "bad medicine." The idea that Indian healers can frequently cause illness as well as cure it is common among North American Indian peoples. Table IV presents a variety of data concerning the reasons for or against having Indian healers available in a clinical setting where the data have been grouped according to whether or not the respondent wants Indian medicine available (regardless of whether or not they believe in it). The language variables once again appear to be the most significant; those whose mother tongue was an Indian language, and those speaking an Indian language today were more likely to express a belief in Indian medicine that affects their attitude towards its formalization within a clinical setting. This belief can manifest itself in either support or rejection of traditional healers in the clinic. Table V recategorizes the data from this analysis to indicate either support for or rejection of the idea of healers in the clinic for these language variables. The significance of these variables is clearly evident.

The Cultural Background of Respondents

The analysis so far has indicated the paramount importance of language variables in understanding issues surrounding access to traditional medicine in the urban context. The data have also demonstrated that of the four major Indian cultural groups in the sample, Northern Cree, Plains Cree, Saulteaux, and Metis, the Northern Cree consistently emerge as the group with the greatest belief in, and desire for access to, traditional medicine. The question then remains: is there something different in the cultural retention or urban experience of the Northern Cree people that explains this difference?

TABLE IV. Reasons for/against consulting a healer in clinic.


Reasons for* Affinity A. Native status 29 (30.9%) Status Indian Non-status Indian 6 (40.0%) Metis 3 (17.6%) X2 = 13.46; df = 12; P = 0.34; C = 0.31 B. Cultural background Northern Cree 11 (47.8%) Plains Cree 13 (30.2%) Saulteaux 8 (25.8%) 3 (17.6%) Metis X2 = 17.12; df = 18; P = 0.52; C = 0.36 D. First spoken language Indian 28 (40.6%) European 10 (17.5%) X2 = 23.67; df = 6; P = 0.006; C = 0.40 E. Speak an Indian language today Yes 35 (40.2%) No 3 (7.9%) X2 = 20.56; df = 6; P = 0.002; C = 0.38

en

Reasons against

To learn

Misc. Positive

Disaffinity

Not in clinic

Frightens

Misc. Negative

19 (20.2%) 1 (6.7%) 2 (11.8%)

10(10.6%) 1 (6.7%) 4(23.5%)

20 (21.3%) 4 (26.7%) 7(41.2%)

5 (5.3%) 1 (6.7%) 1 (5.9%)

7 (7.4%) — —

4 (4.3%) 2 (13.3%) —

5 (21.7%) 6 (14.0%) 8 (25.8%) 3 (17.6%)

1 (4.3%) 8 (18.6%) 2 (6.5%) 3 (17.6%)

4 (17.4%) 9 (20.9%) 8 (25.8%) 7 (41.2%)

— 2 (4.7%) 3 (9.7%) 1 (5.9%)

1 (4.3%) 3 (7.0%) 2(6.5%) —

1 (4.3%) 2 (4.7%) — —

11 (15.9%) 11 (19.3%)

10 (14.5%) 5 (8.8%)

9 (13.0%) 22 (38.6%)

2 (2.9%) 5 (8.8%)

7(10.1%) —

2 (2.9%) 4 (7.0%)

14(16.1%) 8 (21.1%)

12 (13.8%) 3 (7.9%)

13 (14.9%) 17(44.7%)

4 (4.6%) 3 (7.9%)

5 (5.7%) 2 (5.3%)

4(4.6%) 2 (5.3%)

Affinity—Reasons indicating a belief in existence or efficacy of Indian medicine To learn—Reasons indicating a desire to learn about Indian medicine Misc. positive—Miscellaneous other reasons indicating a willingness to consult with an Indian healer in clinic Disaffinity—Reasons indicating a disbelief in existence or efficacy of Indian medicine Not in clinic—Reasons indicating a belief in existence or efficacy of Indian medicine but that it should not be in a clinical setting, or should only be practiced on the reserve Frightens—Reasons indicating a belief in existence or efficacy of Indian medicine but emphasizing a fear of the healers and their medicine; these respondents would likely not consult a healer unless the latter was well-known to them for fear of "bad medicine". Misc. Negative—Miscellaneous other reasons indicating an unwillingness to consult with an Indian healer in clinic

Access to Traditional Medicine 341 TABLE V. Support for/rejection of traditional healers in clinic by language variables." Supports healers Rejects healers in clinic in clinic A. First spoken language Indian European X2 = 7.22; df == 1; P = 0.007; phi = 0.24 B. Speaks and Indian language today Yes No X2 = 12.2; df == 1; P = 0.0005; phi == 0.31

49 (71.0%) 26 (47.3%)

20 (29.0%) 29 (52.7%)

61 (70.1%) 14 (36.8%)

26 (29.9%) 24 (63.2%)


' Regardless of belief in or attitudes toward traditional medicine and healers.

The city of Saskatoon, in central Saskatchewan, is located within the traditional territory of the Plains Cree, and the reserves allocated to these people dominate the region. There are also Dakota reserves throughout the southern half of the province, but relatively few Dakota were sampled in this research. The Saulteaux are also interspersed throughout the southern half of the province. The Metis as a cultural group do not have reserves as the Indians do, although there exists a band of predominantly Metis communities in northern Saskatchewan. Metis are known to be fairly dispersed throughout the province, and as Clatworthy and Hull (1983) have shown, tend to be slightly better off economically than the status Indians. The Northern Cree reserves are also found in a band across the northern part of the province, often adjacent to the Metis communities amongst which there are extensive kin ties. Hence, we might postulate that, for geographical reasons, the Northern Cree, and to some extent the Metis, have had less contact with urban centres than the most southerly Plains Cree and Saulteaux. Table VI presents a variety of data for the four cultural groups. As we can see, the Northern Cree demonstrated the greatest proportion of Indian language-speakers, both as a mother tongue and as a current language. Furthermore, they demonstrated a substantially lower mean number of years of residence in Saskatoon. We may postulate, then, that the Northern Cree demonstrate the greatest commitment to traditional medicine and a strong desire for more formalized access to it in the urban context because of their strong Indian language retention, and by extrapolation their adherence to their Indian culture, in combination with their relative inexperience in the city. However, there was no statistically significant difference between the Northern Cree and the other cultural groups in terms of the frequency of language utilization on a daily basis. DISCUSSION

The research undertaken in Saskatoon demonstrates that access to traditional medical systems is indeed an issue for the Native residents. Briefly, the research has shown that: 1. Urban Native residents retain a strong belief in traditional illness etiologies and the efficacy of traditional medical systems;

342 /. B. Waldram TABLE VI. Comparison of the four major cultural groups Northern Cree

Plains Cree

Saulteaux

Metis

17(70.8%) 7(29.2%)

25 (53.2%) 22 (46.8%)

23 (65.7%) 12 (34.3%)

9(39.1%) 14 (60.9%)

20 (83.3%) 4 (16.7%)

36 (76.6%) 11 (23.4%)

25 (73.5%) 9 (26.5%)

9(39.1%) 14 (60.9%)

A. First spoken language

Indian European X2 = 6.24; df = 3; P = 0.1; C = 0.21 B. Speak Indian language today Yes No

X2 = 13.72; df = 3; P = 0.003; C = 0.31


C. Frequency of Indian language utilization

Most of the time 3 (14.3%) 8 (22.2%) Half of the time 14 (66.7%) 19 (52.8%) Rarely/never 4 (19.0%) 9 (25.0%) Kruskal-Wallis One-way Analysis of Variance: x2 (corrected for ties) = D. Mean number of total years in 5.6 13.09 Saskatoon F = 1.663; P = 0.18; overall mean = 9.25 ;years

5 (20.0%) 2 (22.2%) 12 (48.0%) 6 (66.7%) 8 (32.0%) 1 (11.1%) 0.87; P = 0.83 7.55 7.75

2. Some Natives have problems of access to traditional medical systems as a result of their residency in the city; 3. There is a clear desire for improved access to these medical systems; 4. Most Natives see few difficulties in making traditional healers available within a clinical setting. As the literature review earlier suggested, those peoples retaining elements of their traditional medical system frequently utilize it in conjunction with biomedicine. Dual use of alternative medical systems did not seem problematic for the population in this study, and the fact that many felt it appropriate to provide traditional healers within a biomedical setting further substantiates the argument advanced by Welsch (1983), Asuni (1979) and Romanucci-Ross (1983) that health consumers do not choose between medical systems, but rather between therapies, and they are not concerned about the "explanatory principles" of the various healing systems but rather are concerned primarily with symptoms and, more importantly, cures. The present research has extended these observations into the Native North American context, and argues for the continued need for investigation of medical care decision-making by consumers. The results also support Lasker's (1981) assertions that a sufficiently broad definition of "access" to medical services must be employed. In the context of the city of Saskatoon, where there exists a plethora of medical services, most of which are provided free of charge to residents, "access" obviously means more than availability and cost of services. The Native respondents in this research have retained traditional medical beliefs in the face of extensive biomedical services in the city. Insofar as there exist any biomedical services that are culturally sensitive to Native people, the Westside clinic is paramount among these, and attracts Native clientele by reputation. Yet, even regular users of this clinic retain beliefs in traditional medicine, and many would welcome increased access to this medicine through the


Access to Traditional Medicine 343 clinic. This fact not only argues for the persistence and tenacity of the traditional beliefs, it also suggests that simple availability of even culturally sensitive biomedical services will not necessarily lead to a dichotomized "hierarchy of resort." In other words, for Native urbanites, the choice is not biomedicine or traditional medicine, but rather biomedicine and traditional medicine. Hence, the impairment of access to either biomedicine or traditional medicine may represent a crisis in access for these individuals. However, the research also demonstrated the cultural and linguistic diversity that exists among urban Native residents, and the range of opinion that exists regarding the issue of access to traditional medical systems. It is likely that these differences mirror those extant on the reserves and in the rural Native communities. Language variables proved to be especially relevant to the analysis: those individuals with an Indian first language, or who will speak such a language today and who speak it fairly frequently, demonstrated the greatest desire to have increased access. This is not a particularly surprising finding, since language retention is one of the best measures of cultural adherence. Perhaps more surprising is the finding that many of the Native respondents who are less familiar with an Indian or Metis culture also expressed a desire for greater access to traditional medicine, mostly as a component of personal cultural repatriation which is increasing among Native peoples in Canada.5 But, not surprisingly, there were a number of respondents who expressed some knowledge of or experience with Indian medicine who did not believe it should be made available in a more formalized manner, such as in a clinical setting. Given that a strong desire for access to traditional medical services exists among Native residents, the next question is what form should such access take? It has been argued that more formal cooperation between biomedicine and traditional medical systems can result in the submergence of practitioners of the latter as an "auxilliary" of the former (Bichmann 1979:178), transforming him into a "secondrate paramedical worker" (Green and Makhubu 1984:1077). It has also been argued that such cooperation will necessarily require fundamental changes in the philosophy of medical treatment of traditional systems, which will in effect alter them to the extent that they are no longer "traditional" or recognizable as an alternative to Native patients (Asuni 1979:33). These are very real concerns that must be considered in any discussion of altering the current status quo regarding traditional medicine. The spirit of the Alma-Ata declaration has tied many countries to a reconsideration of attitudes towards traditional medicine. In Canada, we have seen how the Medical Services Branch, of the federal department of National Health and Welfare, has undertaken to provide funding in a few provinces to allow Indian patients to have access to traditional healers. We have also seen various urban hospitals allow traditional healers into the wards to undertake the healing of Native patients. These initiatives, while bold, are not a part of any fundamental reconsideration of biomedical attitudes towards traditional medicine, but are rather somewhat ad hoc initiatives. Whether the biomedical system is prepared to address the question of traditional Indian medical systems in a comprehensive fashion is still unclear. A recent Manitoba study by Gagnon (1989) suggests that some biomedical practitioners are willing to consider collaboration with Indian healers, yet general biomedical opposition to such practices remains.


344 J. B. Waldram If increased access to traditional medical systems is to develop, it will necessarily require adjustments on the part of the practitioners within those systems as well as adjustments by biomedical practitioners. The emergence of more "neo-traditional" healers would be an inevitable part of this process, along with the emergence of more open-minded and culturally sensitive physicians and other health care personnel. Past experience has shown that many aspects of these healing systems which their practitioners feel to be incontrovertible are in fact considerably more flexible. When the needs of a patient are central, traditional healers can and will undertake their procedures in a hospital rather than in a rural setting, and physicians will discontinue medication for a period of time if this is essential to the traditional healers treatment. And where the physician is unable to comply with a request to discontinue such medication, traditional healers have proven flexible in their own treatment regimes. The point is that cooperation is possible through compromise which does not threaten the integrity of any of the medical systems when the practitioners are prepared to enter into dialogue and when both have as their primary concern the health and well-being of the Native patient. Another question to be addressed relates to the variety of traditional Indian healing systems that operate within the province. If it is not possible to formalize access to all of them, upon which ones should there be a concentration? While there are many similarities between the systems, and while we have noted a trend toward a "pan-Indian" healing system, it would not be appropriate to assert that questions concerning the specific healing system within which a given healer operates (and, by extension, his culture and language) are unimportant. In fact, insofar as these healing systems are embedded within the cultures of the Indian peoples, this question becomes paramount in importance. Furthermore, it is also necessary to address the question of healer validation in the absence of formal regulatory mechanisms. Who is a "healer?" Who has the right or authority to designate another as a "healer?" These are fairly simple questions on the reserve, but not so in the urban context. Of course Indian cultures have their own ways of validating this status, so the relevant question may be how non-Native health professionals might tap into this. Even more complicated is the question of the existence of malevolent healers. Accusations that a given individual healer is in fact responsible for illness is likely at some point, and a mechanism for resolving this would have to be in place before any attempt at providing formalized services. A related issue pertains to the type of services to be provided. While some forms of traditional medicine can be accommodated in a clinical setting, as is now the case with hospitals, other forms requiring sweat lodges or prolonged treatments including such things as fasting and spiritual-ceremonial activities are more problematic. A linkage with a nearby reserve could reduce the costs of accessing these forms of healing for urban-based patients, if arrangements could be made. .With the questions related above properly addressed, insofar as there may ultimately be more formal access to traditional medical systems for Native people in urban settings, this access can only be provided in consultation with the Native peoples themselves. Unilateral attempts by biomedical practitioners would likely be denounced politically, and would probably be culturally inappropriate and unsuccessful even where well-intentioned. Health care, while broadly a cultural construct, is in the end another component in the Indian-government political


Access to Traditional Medicine 345

discourse, to be discussed and negotiated like other issues such as justice, selfgovernment, and so on. Indeed, it would be premature at this time to state unequivocally that increased access to traditional medicine in the city should take the form of healers in medical clinics. While one important finding of this study was that most Native residents have no problem with healers in the clinical setting, we did not explore alternative models which might be even more appropriate. For instance, we could consider the housing of traditional medical services in an Indian-operated health clinic or social service agency, or the provision of Native health liaison personnel in clinics who could then make referrals to Native healers, with the latter actually having very little contact with the clinic or the biomedical system. Alternatively, well-informed physicians could make the referrals themselves in cases where they felt it warranted. These considerations must be part of the next step in the process of considering the question of improved access to traditional medical services for Native residents in the city.

ACKNOWLEDGMENTS The author wishes to acknowledge the assistance and cooperation of the staff of the Westside Clinic, including Dr. Stephen Helliar, Dr. Philip Loftus, Sheila Braidek and Marg Cloak, and the staff at the Friendship Inn, especially the former Director, Lee Smith. Thanks are also due to Judith Martin of the Saskatoon Community Clinic for permission to undertake the research. Research assistance was provided by Mellisa Layman and Grace Leier. Funding for the research was provided by the Social Science and Humanities Research Council of Canada, through the office of the President of the University of Saskatchewan. The views expressed in this paper do not necessarily reflect those of any of these individuals or agencies, and the author alone bears responsibility for any errors or omissions.

NOTES 1. In this paper, I use the term "Native" to refer collectively to three categories of aboriginal peoples: the status Indians, the non-status Indians, and the Metis. The status Indians are those recognized by the Canadian government as "Indians" for purposes of administration, program delivery, and fiduciary responsibility. The non-status Indians are usually individuals who are culturally Indian but who, for a variety of reasons, are not federally recognized. They do not have a fiduciary relationship with the federal government, do not receive any special benefits accorded to the status Indians by the federal government, and are held to be within the jurisdiction of their provinces in which they are resident as if they were non-aboriginals. The Metis are descendents of mixed marriages between Indians and Europeans, who have developed a somewhat separate cultural identity, though the utilization of an Indian language and cultural similarities with Indians are frequently in evidence. In discussing traditional healing systems, and languages, I use the term "Indian." For a more detailed discussion of the implications of these legal and cultural distinctions, see Waldram (1987). 2. I use the term "Indian healer" throughout the paper to refer to the various practitioners of nonbiomedicine among the Native peoples in western Canada. Our respondents generally referred to these individuals as "Indian doctors," "medicine men," or "medicine women." It is recognized that within the various traditional Indian medical systems there were a variety of different types of healers, usually with different names within the Indian languages. 3. We were investigating the extent to which Indian respondents would answer more direct, and perhaps threatening, questions regarding Indian medicine as a precursor to future research. They proved to be very willing to discuss these matters.

346

J. B. Waldram

4. The ethnographic literature would refer to these Cree peoples as Rocky Cree and Swampy Cree. 5. The repatriation of Native culture in Canada is occurring at two levels. At the organizational and institutional level, or the political level, there is a strong movement toward self-government in which Native communities are reclaiming their inherent rights to control their lives. As a result, Native communities are regaining control over such diverse areas as education, child welfare, social services and health care. At the level of the individual, there is a movement of personal cultural repatriation, in which those individuals who spent years in non-Native foster homes or in residential schools, and who subsequently grew up with little or no knowledge of their Native culture, are attempting to learn more about their heritage and their language as part of their own search for identity.


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1988 Can Collaborative Programs Between Biomedical and African Indigenous Health Practitioners Succeed? Social Science and Medicine 27(11):1125-1130. Green, E.C., and L. Makhubu 1984 Traditional Healers in Swaziland: Toward Improved Cooperation Between Traditional and Modern Health Sectors. Social Science and Medicine 18(12):1071-1079. Gregory, D. 1988 An Exploration of the Contact Between Nurses and Indian Elders/Traditional Healers on Indian Reserves and Health Centres in Manitoba. In Health Care Issues in the Canadian North. D. Young, ed. Pp. 39-43. Edmonton: Boreal Institute of Northern Studies, University of Alberta. 1989 Traditional Indian Healers in Northern Manitoba: An Emerging Relationship with the Health Care System. Native Studies Review 5(1):163-174. Harwood, A. 1977 Rx: Spiritist as Needed. A Study of a Puerto Rican Community Mental Health Resource. Ithaca, NY: Cornell University Press (reprinted 1987). Jones, D.E. 1984 Sanapia: Comanche Medicine Woman. Prospect Heights, IL: Waveland. Kleinman, A. 1980 Patients and Healers in the Context of Culture. Berkeley: University of California Press. Kurup, P.N.V 1983 Ayurveda. In Traditional Medicine and Health Care Coverage. R.H. Bannerman, J. Burton, and C. Wen-Chieh, eds. Pp. 50-60. Geneva: World Health Organization. Ladinsky, J., N.D. Volk, and M. Robinson 1987 The Influence of Traditional Medicine in Shaping Medical Care Practices in Vietnam Today. Social Science and Medicine 25(10):1105-1110. Lasker, J.N. 1981 Choosing Among Therapies: Illness Behavior in the Ivory Coast. Social Science and Medicine 15(A):157-168. Mandelbaum, D.G. 1979 The Plains Cree: An Ethnographic, Historical and Comparative Study. Regina: Canadian Plains Research Centre. McCaskill, D.N. 1979 The Urbanization of Canadian Indians in Winnipeg, Toronto, Edmonton and Vancouver. Ph.D. dissertation, York University. Nchinda, T.C. 1976 Traditional and Western Medicine in Africa: Collaboration or Confrontation? Tropical Doctor 6:133-135. Nyamwaya, D. 1987 A Case Study of the Interaction between Indigenous and Western Medicine among the Pokot of Kenya. Social Science and Medicine 25(12):1227-1287. O'Neil, J. 1988 Referrals to Traditional Healers: The Role of Medical Interpreters. In Health Care Issues in the Canadian North. D. Young, ed. Pp. 29-38. Edmonton: Boreal Institute for Northern Studies. Pei, W. 1983 Traditional Chinese Medicine. In Traditional Medicine and Health Care Coverage. R.H. Bannerman, J. Burton, and C. Wen-Chieh, eds. Pp. 68-75. Geneva: World Health Organization. Press, I. 1969 Urban Illness: Physicians, Curers and Dual Use in Bogota. Journal of Health and Social Behavior 10:209-218. 1971 The Urban Curandero. American Anthropologist 73:741-756. 1978 Urban Folk Medicine: A Functional Overview. American Anthropologist 80:71-84. Romanucci-Ross, L. 1983 Folk Medicine and Metaphor in the Context of Medicalization: Syncretics in Curing Practices. In The Anthropology of Medicine: From Culture to Medicine. L. Romanucci-Ross, D.E. Moerman, and L.R. Tancredi, eds. Pp. 5-19. South Hadley, MA: J.F. Bergen.


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