We are an ensemble cast. As such, it is perhaps appropriate that one of the first places where we all came together as a team had at one point been a set for a Canadian television show. Now the buildings are owned by the First Nations, an Anishinaabek community, with whom we were partnered. We came together through a series of relationships and with a shared desire to do what we all do: address health inequity by focusing on lived experience and challenging the dominance of biomedical discourse about mental health. Drawing on Lisa Stevenson, our work alters the idea of being “less about collecting facts than about paying attention to the moments when the facts falter” to consider the fracture zone as the destruction of singular facts into multiple ways of knowing (Stevenson 2014:2).
Our fracture zone is the place where discursive power, in a Foucauldian sense, is challenged by multiple ways of knowing and being. Power from our perspective, is the ability to make and control truth and facts and to write over alternative discourses, ways of knowing, or ways of Being. In Anishinaabek traditions place is important to identity, in part because it is overwritten with multiple narratives and experiences of relations from across time. We view the fracture zone from the same perspective: it is a place where many ontological and epistemological ways meet, fracture, smear together, or blend into a new form. It may be a hybridization where the original components are still removed but are forever altered. When we leave we are altered but remain ourselves.
As a team we were, and continue to be, driven by our purpose: we focus on keeping kids alive by applying the different ways that each of us knows and understands suicide. Suicide – the act of ending one’s own life – among some Indigenous communities in Canada continues to be a significant problem (Kumar and Tjepkema 2019). Suicide is not a traditional aspect of Anishinaabek culture. Life is of great value. These deaths are a relatively new problem connected to ongoing settler colonialism in Canada. The suicide problem is not singular. In Ontario, Canada’s most populous province, there have been several suicide outbreaks since the 1970s. We work in Northeastern Ontario, the region where the outbreaks began. The variety of suicide outbreaks across the province and over the last number of decades speaks to the difference in communities where the deaths are happening. Just as there is not one, atypical, First Nations community, there is not one form of suicide epidemic in those communities.
How we understand suicide is dependent upon the many culture-informed perspectives that mediate the experiences in our lives. Our team consists of members with different life experiences, training, and values. We are from inside the community and from academic and research settings. In a very real sense, no two members of the team come from the same place; nor are we culturally or professionally disciplined, in the Foucauldian sense, to think the same. Funding for the work came from The Ontario Brain Institute and the Canadian Biomarker Integration Network in Depression (CAN BIND), organizations with strengths in biomedical mental health research and knowledge translation.
While the suicide epidemic touches the whole community, it is young people who are taking their lives in the greatest numbers. In Anishinaabek culture, an individual is connected to their community through their kinship networks, typically one of seven clans; through stories, which are both historical accounts and ontological beings in their own right; and through the places where human and other-than-human relations live. We have been taught to understand that to be Anishinaabek is to be a spiritual being living a human existence among other beings, even within the complexity of communities where many people identify as Christians. In this context, suicide is understood as a result of a disconnection from your relations.
However, the standard response to Indigenous suicide in Canada has been to focus on the risk factors in an individual. In the early 1970s, when suicides broke out on Manitoulin Island, a Coroner’s Inquest was called to investigate the sudden increase in death (Ward and Fox 1977). The 1977 report focuses on substance use, education levels, employment, and treatment of psychiatric disorders. Similarly, documents from the archive of the now-closed Sioux Lookout Zone Hospital, a segregated First Nations-only hospital run by Health Canada, which administers the country’s federal health policy, focus on the individual as the primary concern. The report from a 1990 suicide prevention conference in the region highlights substance use, educational achievement, employment status and mental illness as key causes (Sioux Lookout 1990). Alarmingly, this report and several others from the 1970-1990s tended to focus on an individual’s inability to adapt to social change as the primary cause of suicide, rather than the cause and consequences of those changes. As a rule, suicide was framed and understood as an individual action by someone who could not fit into society.
In contrast, our community partners see suicide as the result of ongoing settler colonialism. Ongoing colonization includes the legacy of Indian Residential Schools which stole children from the community, the impacts of the “Sixties Scoop,” outside control by the federal government of cradle to grave policies through the Indian Act, and, a control of health policy which begins in the early twentieth century and continues to this day. Thus, suicide is not caused by an individual’s inability to adapt, but rather, by a disruption of social relations that prevent a community from living or honouring their social responsibilities to one another,
The word bimaadiziwin is often translated to mean “health” but is really a verb for living a good life, a life of living your responsibilities. In Anishinaabek culture, the extended relationships of an individual have responsibilities to the person, who in turn has responsibilities to the community. With this “collectivist” social structure in mind, we took the perspective that the challenge was not the individual who was unable to respond but was, instead, a community that was prevented from living their responsibilities to each other through outside interferences. For example, contemporary rates of suicide among young people in First Nations communities have been linked to the legacy of Canada’s Indian Residential School system, which significantly harmed Indigenous children by taking them away from their families and depriving them of access to their ancestral languages and cultural traditions. Too often, these children also experienced physical, emotional, and sexual abuse. The end of the Residential School era brought about a rapid increase in child removal under new powers granted to Children’s Aids Societies (CAS). In the “Sixties Scoop,” the number of First Nations children in CAS care went from 1% in 1959 to 30-40% by the end of the 1960s (Alston-O’Connor 2010:54). Lavell-Harvard and Lavell (2006) link the removal of the children from First Nations communities and the above risk factors for suicide to a common aetiology: the role that colonization plays in disrupting community structures.
Considering this history, our work highlights the causes of suicide that a biomedical approach is missing. From this position we ask: Why does the health care system continue to ignore these historical antecedents and what is the role of discursive power in health research, policy, and application? How do we understand outcomes and provide care in a system that sees the symptoms of an individual as contained just to that person? Even in contexts where the health care provider may acknowledge systemic challenges, there is still a drive to treat the symptoms rather than the structural, historical, or social causes. From a health equity perspective, we argue that if risk factors are to be mitigated in an individual then work needs to take place within a community that sees the problems as being part of their shared history. In short, we establish a dichotomy between a case history in the medical sense and a community history while arguing that you can not remove the individual from their own personal history. Suicide deaths in some First Nations communities continue to be very high. The tools available in a biomedical approach alone are not working.
In the similar context of Hmong families and Western service providers in the United States, the normative social position of western educated health researchers and providers, which is also associated with our socioeconomic position, provides more authority to create and wield discourse (Culhana-Pera 2003:57). The resulting disease-focused, rather than person- or community-focused, discourse impacts policy and funding from the controlling federal government. The result is that knowledges that lay outside of the dominant power of controlled, evidence-based research are marginalized, including lived-experiences and knowledges of the impact of histories of a community. As medical anthropologists, we are able to explore the way that power is actualized to from discourse to action, and identify, in the context of our work, that a key limitation of biomedical knowledge is that it is heavily focused on acute treatment. Being both embedded in Western research settings, and partnered within a community/relationship context, we can speak back to the normative assumptions that acute treatment is the best way to respond to largely social, community-level challenges.
Our efforts are to change these relationships and disrupt the power of one normative perspective on causation and treatment. Following an approach similar to social prescription, the program was built around four seasonal workshops which integrated local Anishinaabek traditional teaching and mental health research. The first workshop, which took place in Sudbury, Ontario, focused on belonging and relationships. The goal of the workshop was to rebuild the social connections with were damaged by colonial actions and develop a “critical mass” of youth who would support each other. The second workshop focused on self-esteem and integrated programs for youth and their families. Our goal with the second workshop was the creation of a circle of care with the tools to support their youth. The third workshop took place at an Anishinaabek camp with a focus on the positives of an Anishinaabek identity. The final workshop took place in Toronto, Ontario, with a focus on purpose. Ongoing colonization has damaged social relationships, too often leaving youth isolated from the larger community. The goal of the workshop was to integrate the youth into a larger community of relationships by focusing on the importance of water to the community.
Discourse can shape how we should act. It is in the performance of our roles that the power present in interacting discourses was apparent. In health, not all discourses are considered equal. There is already a rich literature on the dominance of the biomedical approach, and the disease model in mental health. But we know that power in discourse is context dependent. In the place, and with the people, we are working there is different discourse in authority and the knowledge contained within it guides a different directive on how we acted.
We were left to act in an epistemological fracture zone, where discourses, perspectives, power, and normative assumptions overlap. Applied medical anthropology has allowed us to create our own fractures in a powerful discourse. It has allowed us to position actors in such a way as to see the set for what it is: a construction of rules and knowledges set in place but rules that should be challenged. Knowledges translation is most commonly applied in a “bench to bedside” approach. That is to say, the expert researcher generates knowledge to be applied by the expert practitioner on the sick individual. In that model, information flows one way. Applied medical anthropology is its own form of knowledge translation except our critical eye teaches us to speak back to power, allowing knowledge to circulate, and to listen to other experts, including the patient and the community-context in which they live.
Gerald P McKinley, PhD, is a Medical Anthropologist based at Western University in London, Ontario. He is core faculty in the Schulich Interfaculty Program in Public Health and in the Department of Pathology and Laboratory Medicine’s One Health team. Dr. McKinley is trained in ethnographic and social determinants of health research. He has a background in relationship-based research with First Nations partners across Ontario. Dr. McKinley focuses on translating research on the social aetiology of suicide into applied programs and is currently exploring online non-suicidal self-harm through online ethnography. Dr. McKinley was the site-PI for the joint Whitefish River First Nation-CAN BIND-OBI First Nation’s adolescent depression awareness and suicide prevention project.
Trehani M Fonseka, MSW, is a researcher with the Arthur Sommer Rotenberg Suicide and Depression Studies Unit at St. Michael’s Hospital in Toronto, ON. Ms. Fonseka is currently collaborating with a team of investigators and community groups on various projects, which includes developing sustainable programs to reduce self-harm and suicide rates among Indigenous youth. Ms. Fonseka completed her Master of Science designation at the University of Toronto where she investigated immunogenetic correlates of antipsychotic-induced weight gain. She is also a recent graduate of the Master of Social Work program at King’s University College (at Western University), where she received specialized training in mental healthcare for adults, youth, and young children.
Kirk Nylen, is the Vice President of Integrated Discovery and Informatics at the Ontario Brain Institute, an organization focused on creating collaborative research networks with the aim of improving brain research, commercialization and care. In this role, Dr. Nylen is responsible for the Institute’s research, informatics and knowledge translation activities. He has a doctorate in pharmacology and maintains an adjunct appointment in the Faculty of Medicine at the University of Toronto where he teaches regularly. A sport-for-life advocate, Dr. Nylen co-founded a not-for-profit that engages Indigenous youth in active healthy living. An insatiable traveler, sour-dough bread maker, martial artist, and former alluvial gold miner Dr. Nylen’s career is built on hard work, driving collaboration and achieving impact.
Jenine Paul leads engagement initiatives aimed at embedding community voices in health research. She is the Manager, Public Engagement and Knowledge Translation at ICES and is leading the implementation of the Institute’s strategy to engage Ontarians in decisions related to the use of health data for research. Previously, Jenine worked in Knowledge Translation and Outreach at the Ontario Brain Institute, where she developed mechanisms to support patient engagement in neuroscience and the dissemination of brain research to public audiences. Jenine runs the National Public and Patient Engagement in Research Community of Practice and has also held roles at Cancer Care Ontario, the University of Waterloo and the former Ontario Ministry of Research and Innovation. She is a trained facilitator and has a Bachelor of Science in Biochemistry and Biotechnology from the University of Waterloo’s Co-operative Education program
Andrew Kcomt is the Knowledge Translation & Research Manager at the Mood Disorders Association of Ontario and community partner with the Ontario Brain Institute (OBI) and the Canadian Biomarker Integration Network in Depression (CAN-BIND). Andrew draws upon his experience in healthcare, knowledge translation, and community advocacy, in tandem with his skills in leadership, relationship and team-building, diversity enhancement, and community collaborations. This includes fostering long-term communal partnerships in the implementation and evaluation of culture-informed initiatives that aims at wellness promotion, community building, and suicide prevention through a collaborative care model for the Whitefish River First Nation Indigenous youth program. Twitter: @Andrew_Kcomt
Leslie McGregor is an Anishinabe from Whitefish River First Nation and a helper. She is grounded in her culture, ceremonies, traditions, and family. She moved home in 2013 to work for her First Nation as the Health and Social Services Manager. Her main interest is social change and development, and she is committed to improving health, education, social development, and family wellness for children, youth, and families in Indigenous communities. She has traveled within her region, nationally, and internationally to speak on suicide prevention/life promotion and will continue to engage in activities that help our children, youth, and families thrive and flourish. Her goal is to strengthen programs and service delivery to provide the best possible health and well-being outcomes for the community. In January 2020, the Health and Social Services Department was split into two separate departments – Health and the second one Family Well-Being. She is now the Family Well-Being Manager.
Alston-O’Connor. 2010. The Sixties Scoop: Implications for Social Workers and Social Work Education. Critical Social Work. Vol 11(1):53-61.
Culhane-Pera, Kathleen A. 2003. Hmong Culture: Tradition and Change. Eds Kathleen A. Culhane-Pena, Dorothy E Vawter, Phua Xiong, Barbara Barritt, and Mary M. Solberg. Nashville: Vanderbilt University Press: 11-68/
Kumar, Mohan B., and Michael Tjepkema. 2019. Suicide among First Nations People, Métis and Inuit (2011-2016): Findings from the 2011 Canadian Census Health and Environment Cohort (CanCHEC). Statistics Canada,
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Lavell-Harvard, Dawn Memee, and Jeanette Corbiere Lavell. 2006. Until Our Hearts Are on the Ground: Aboriginal Mothers, Oppression, Resistance, and Rebith. Toronto: Demeter Press.
Sioux Lookout Zone Hospital Archive. 1990. Meeting on Mental Health Issues, January 16, 17, 1990. University of Toronto Archive.
Stevenson, Lisa. 2014. Life Beside Itself: Imagining Care in the Canadian Arctic. Berkerley: University of California Press.
Ward, J.A. and Joseph Fox. 1977. A Suicide Epidemic on an Indian Reserve. Canadian Psychiatry Association Journal. 22: 423–426.
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