When you think of “health” what comes to mind?

Carol A. Hand

This morning as I greeted a bright but frigid morning, I found myself thinking of one of my many culture-bridging experiences. I was wondering why it is so difficult for us to listen to each other and find our common ground.

Maybe it was one specific job interview years ago that made this so apparent to me. In my younger years, I would often get calls begging me to take on a new project – Indian education, child welfare, or addiction prevention to name a few. I remember reluctantly agreeing to consider working on a federally-funded project to prevent chemical dependency in selected tribes. There was only one other Native American person on the research team, and he wanted to interview me to make sure I was “Indian enough.” He asked me about the research I was planning to conduct on Indian child welfare. When I explained that I was interested in learning how Ojibwe people defined effective and ineffective parenting and the systems and interventions they would recommend to address situations they saw as ineffective, my interviewer became impatient and agitated.

We already know that! Why bother?,” he replied.

I know what I think,” I replied, “but I have no idea how many other perspectives there are among community members, and I would like to know what they think.”

Needless to say, I didn’t pass the “Indian enough” test, but it wasn’t because of my response to this exchange. It was my honesty when I answered the pivotal question.

We have two finalists for the coordinator of the project for one of our tribal sites. One is traditional, and one is assimilated. Who do you think we should hire?”

I knew he wanted me to endorse hiring the person he referred to as traditional, but instead, I was honest.

It depends on the project objectives, the community context, and the fit with candidate qualifications. That really should be left to the community to decide. But honestly, I don’t know what you mean by the terms ‘traditional’ and ‘assimilated’ in this context or why it should matter.”

I wasn’t willing to say that there was only one simplistic choice – his (or mine). The exchange taught me many valuable lessons, among them, the need to ask questions that allowed people maximum freedom to share what they really thought and felt.


Photo Credit: Photo Credit: Diversity Tree

Years in the future, I remembered this lesson when I was asked to do a needs assessment for an urban Indian health center. The center was surrounded by competing factions, each with strong and divergent views of who should be in the leadership position, the types of services that should be provided, and the overall purpose of the center. I agreed to seek grant funding if we could move beyond merely cataloguing health problems and also look at individual and community strengths and visions for the future. As I began writing the proposal, I asked myself how I could use research to attempt to build common ground. Several ideas came to mind. First, we would build a multi-cultural team that would include university faculty and students, health center leadership, and community members. Second, we would use a sampling technique that would maximize the inclusion of diverse perspectives (hermeneutic dialectics). Third, by exploring strengths and future visions, we would be looking for ways to build common ground and community buy-in and excitement. But how does one craft questions that really allow people maximum freedom to answer honestly in such a conflict-ridden context?

Our proposal was funded and we built a multicultural team, although it was challenging to find a community member who was able to honor research protocols. Our first choice didn’t work primarily because it was too difficult for the community representative to respect participant privacy or solicit, respect and convey perspectives that differed from hers. Community members requested that we replace her with Euro-American graduate students who were perceived as more trustworthy for honoring confidentiality and listening carefully to what they had to say. We honored that request. Nonetheless, her help crafting the interview questions did prove invaluable.

Our first question set the tone. “When you think of “health” what comes to mind?” Unlike the questions my interviewer from years ago asked, there was no indication of the “correct” answer. We deliberately avoided defining words like “community” to see how participants would define it themselves. Would they include only their faction of the Native community? Those who shared their tribal affiliation? All Native members who lived in the community, or all residents of the community regardless of ancestry?

The next challenge was figuring out who to talk to and how to maximize inclusiveness. Although the title of the sampling technique, “hermeneutic dialectics,” is too academic and off-putting, it’s really very simple to understand and operationalize (Guba and Lincoln, 1989). At the end of each interview, one simply asks each participant if he or she can recommend someone we could interview who has different views than theirs.

The answers to all of the questions, but particularly the first, made the inclusiveness of our sample very clear.

Definitions of Health

In response to the question “When you think of ‘health’ what comes to mind?,” participants gave many types of responses. The following themes and quotes suggest that the sample of participants was diverse.

✧ Physical

“The state your body is in.”

✧ Personal Responsibility

 “Lifestyle choices.”
“Health is exercising regularly, walking, running. Eating well is healthy too. Eating vegetables, fruits, protein is very important.”
“Health is just something you need to work on all the time.”

✧ Absence of Disease

“Good health would mean the absence of all of these horrible diseases” [AIDS, diabetes, breast/cervical cancer].

✧ Holistic

“Health to me means spiritually, emotionally, mentally, physically centered.”

✧ Reliance on the Health Care System

“I have children, so I think of their healthcare coverage, and co-payments.”

✧ Family History

“Family history – diabetes, cancer, arthritis.”

✧ Structural Factors (Limited Income, Health Care System, Environment)

“We don’t eat the best foods – often we have to get what’s on sale.”
“A long wait. . . even when you are sick and in pain, you have to wait to get services.”
“Clean air is very important–like the exhaust from the cars and mills.”

What Was

Participants described the health center in terms of the role it played in the Native Community in the past – as the center of the hub that brought people together and provided a range of services. It was a place where families could bring their children for daycare, elders shared meals, and people would hang out to socialize and have coffee with others. But that changed.

cup past

Carol A. Hand, Community-University Partnership – 2007

Most of the programs were initially funded in the 1960s and 1970s as part of the War on Poverty. With the leaner, meaner years of Reagan and beyond, funding sources needed to shift to keep the center open, yet most community residents were unaware of the reasons for the changes in the types of services the center provided. They saw the changes in a different light, as a way for one faction to gain control of the center’s leadership and resources.

cup policy

Carol A. Hand, Community-University Partnership – 2007

What Is

Participants described the present status of the community as one characterized by different factions based on a number of criteria: the amount of time they had been living in the community, their tribal or national ancestry, whether they continued to practice their tribal traditions or chose to fit in more with the dominant culture. Instead of viewing the center as a hub that unified the community, it was now viewed as contributing to the divisions by only serving a select group in power at the time. Yet some participants also acknowledged the work that center staff were doing to bring in additional resources and services, such as mental health and substance abuse prevention and treatment programs.

cup present

Carol A. Hand, University-Community Partnership – 2007

What Could Be

All of the participants described clear ideas of what the center and community could, and should, be. For many, the future represented the healthiest aspects of the past and present, and the center was described as a hub that would provide not only health services, but also a range of other human services as the agency did in the past – a gathering place that would connect Native American people across generations, especially youth and elders, and across tribal and urban/reservation distinctions.

cup future

Carol A. Hand, University-Community Partnership – 2007

Many participants described a future that moved beyond the Native American community to connect with the urban community as a whole and with tribal communities scattered throughout the state, US, and Canada as well. Their future vision reached beyond ethnic and geographic boundaries, and also across time, to interweave traditions throughout center services and into other health care agencies, child day care, and schools. As participants described these visions during interviews, they often became animated, suggesting these were powerful dreams that generated a sense of hope, excitement, and real possibility.

Putting the Past, Present, and Future Together

cup all

Carol A. Hand, Community-University Partnership – 2007

I could go on to list the serious challenges the Native American community faced due to centuries of colonial oppression and ongoing discrimination, but those issues are often the only things we hear about peoples on the margins. It’s what researchers tend to study and write about. Maori researcher Linda Tuhiwai Smith (2001) makes this point very clearly.

hegemony slide

Photo Credit: Quote from Linda Tuhiwai Smith (2001)

Instead, I would like to share a story that shows what we miss when we only see people’s problems. One of the study participants first described the many physical conditions that made mobility difficult for her, the financial challenges that made accessing prevention and treatment services so difficult, and the discrimination that made her reluctant to even try. Then, she told a story about the discrimination her son faced in the public school system. White students taunted him, called him names, and pulled his braid. She and her husband met with the principal to share their concerns. The principal promised he would discipline the white youth involved and make sure the bullying ended. She and her husband offered a different solution. As a family, they proposed to share their tribal culture in a ceremony and performance for the whole school so all teachers and students would have a better understanding of their history and culture. The principal accepted their solution. Instead of perpetuating resentment through punishment, the performance did result in improved relationships and understanding. The former bullies befriended their son, as did other students and teachers. To only see this woman as a victim negates her ability to be seen for all that she is and has to offer others.

The second thing I would like to share is a little of the wisdom and future hopes of the community members we interviewed.

“Part of rebuilding the community is utilizing people who want to help. It will take the sense of belonging to the community like the branches of a tree. By doing this reaching out, it makes the community healthy, and it makes the center strong and healthy, and people are drawn to it and want to hang around.”

“I would like my children and grandchildren to learn from the community – for community members to share their tribal values and who they are with my child. It is nice to know a whole range of cultures. They are all different, still all are the same in many ways. It would be nice to visit community members who can share these things about their culture.”

One of the participants prophetically predicted the outcome of this hopeful project.

“Power sources are experts at turning us against each other, then they walk right over us. We are all like a circle, the non-profits working for Indian people. I try to tell people that the money-people toss a dollar bill in the middle and we all scramble for it. And I tell people we cannot do that anymore. When the money-people throw the dollar bill into the center of the circle we have to say “NO.” We must lock arms in the circle and ask for something more. We need to improve all of our lives, not just a handful of our lives. If we could just all get on the same page. It’s not about who is in charge – we are equals. But the power sources would prefer to have us at each other’s throats.”

Sadly, those in power at the county and federal levels were able to divide the community. It was heartbreaking to be aware not only of the serious needs that would continue to go unmet for Native American residents, but also to see the strengths and visions of the community that could be brought to bear to build a more inclusive, healthier, and kinder community. It is far easier to divide and conquer than it is to foster communities that bring elders and youth together, help foster mutual support networks, and encourage all kinds of innovative community-building initiatives. Another outcome was so possible – a community that was respectful and inclusive of all of the residents and visitors, where children and elders were cherished for their gifts, where all people had fulfilling work that paid them fair wages, and where all had equal access to safe and affordable housing, education, nutrition, and health care. A community where all had equal ability to enjoy the beauty of the wild natural areas that surrounded them. That’s what comes to my mind when I think of the word “health.”

Works Cited:

Egon G. Guba and Yvonne S. Lincoln (1989). Fourth generation evaluation. Newbury Park, CA: Sage Publications.

Carol A. Hand, Peggy Cochran-Seelye, David Schantz, Eric Diamond, and Sarah Aronson (2007). University-community partnership to improve the health of Missoula’s Native American community members. (Unpublished report, available upon request as a PDF document from Carol A. Hand)

Linda Tuhiwai Smith (2001). Decolonizing methodologies: Research and Indigenous Peoples. London, GB: Zed Books Ltd.

Acknowledgement (added May 14, 2016): With explicit permission from the former Executive Director of the Urban Indian Health Center, my dear friend Peggy Cochran Seelye, I would like to publicly acknowledge her essential help with this project. She was a pivotal partner. Without her hard work to improve services, improve community connections, and build toward a hopeful holistic future for the agency, this study would not have been possible. Chi miigwetch, dear Peggy. I miss working with you, sharing tears and laughter and hope. I wish we could have taken this work to the next level for the sake of the community.


22 thoughts on “When you think of “health” what comes to mind?

  1. I thought that you made a good point that the community should work as a whole to set a budget for funding. Divide and conquer is an old tactic. It is used because the pitfall of making one person feel privledge because they get special treatment instead of seeing how everyone getting their fair peice of the pie would better serve the whole community. I wish you that people might see that a united front would serve the needs of the many.

    Liked by 3 people

    1. Thank you so much for your thoughtful comments, Honey. I know the principle of equity is something Sweden built into their social welfare system in the past to make sure that the whole community was “getting their fair piece of the pie.” I hope we can all learn from that past to build a better future…

      Liked by 2 people

  2. What a powerful case history and model of engagement. I love asking respondents to suggest someone with different opinions. And it is so important to elicit and carry the vision of What Can (Should) Be as opposed to the negative What Is. This blog post is such a valuable eye-opener and teaching tool.

    Liked by 3 people

    1. Thank you so much for4 your thoughtful comments and kind words, Diane. I am grateful for the opportunity to learn from the visionary focus of the work you do!


  3. Hi Carol, this is lovely. What helpful examples. I am wondering if you know the work of Andrea Smith? She shares some similar ideas, by focusing on shaping a new community through being, and the possibility that imagination can build something which creates a different future. She also looks at the trauma of boarding schools on the native American community. I love her work, and I love your work too. Thanks so much for sharing.

    Liked by 4 people

    1. David, I appreciate your thoughtful comments and insights. Sometimes it’s so painful to see what could be, to see people’s strengths and possibilities, and to witness how easy it is for fearful people in power (with limited vision) to prevent love and inclusion from being manifested.


      1. yes it is hard, Carol!
        your words remind me
        of Krishna’s response to Arjuna
        in the Bhagavad Gita.
        How people continue carrying on
        in ignorant bliss/hell of the karma
        their actions cause upon themselves
        and the world 🙂

        Liked by 2 people

  4. It’s always been my impression that Native American health was destroyed by the determination of the USDA and the American Heart Association to sell America on the low fat diet as a solution to heart disease. Fifty years of research indicates the low fat diet is only increasing heart disease, mainly by causing skyrocketing obesity and diabetes right.

    The low fat diet gave the US government a great excuse to dump cheap high carbohydrate commodities on reservations – instead of the high protein/high fat diet that was the cultural norm prior to colonization. Not only does this diet increase the incidence of obesity, diabetes and heart disease, but it also increases the incidence of cancer and chronic illnesses such as arthritis, multiple sclerosis and inflammatory bowel disease.

    The cruelest aspect of all has been the campaign to blame low income minorities for their health problems by accusing them of poor lifestyle choices.

    Liked by 1 person

    1. You have raised such important issues, Stuart. The change in diet certainly had disastrous consequences, as did so many other factors. Small pox epidemics devastated communities, as did tuberculosis, measles and other previously unknown diseases. Confinement on the worst lands ended hunting and gathering, and often gardening practices, making communities dependent on federal surplus commodities, a practice that continues to this day. Every cultural system was impacted directly, and the negative consequences were intensified by profound cultural trauma.

      Food production was a spiritual expression and a shared family and community responsibility. The imposition of dominant cultural beliefs on top of these traumatic losses continue to affect health in so many ways. The process of “incorporation” (or colonial oppression) affected spiritual, social, physical, and emotional health. Add to that, boarding schools and commodity foods – often lard, spoiled meat, and starchy foods have, as you point out, led to rates of diabetes that exceed 50% for adults in many reservation communities. There is an excellent video series that describes the history and consequences of federal policies on the health of tribes in the US southwest: http://www.unnaturalcauses.org/video_clips_detail.php?res_id=71.

      And yes, I so agree with the point you make that low income people are blamed for the bad life-style choices that lead to their poor health. CDC and researchers reinforce and perpetuate these erroneous beliefs (something the above series also discusses). Unfortunately, many people who are poor believe that they are to blame as well.


  5. When I think of health the things that come to mind are often that life is so fragile even despite our best efforts but also that we must make the effort to take those steps to maximize what we can.
    My chief source of exercise is walking. However, if you saw my little village you would know that nothing is level here and there are hills everywhere. I shop organic and I am vegan. There are still health issues, and my efforts are not in vain. It could have been worse if I had not chosen to live as I do. Thank you, I’m there with you in the choir.

    Liked by 1 person

    1. Thank you so much for your thoughtful, lovely comments, Léa. I agree with your perspective – life is fragile. As the past year has taught us so well, there are many things we cannot control that affect our health profoundly despite our best efforts.

      Your village sounds beautiful. I hope it has been spared from COVID 19. Sending you gratitude for your kindness along with my best wishes, May the coming year be kinder and healthier for us all. 💜


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