Three healthcare designers discuss creating an inclusive and respectful project framework
By Bruce Raber, Celeste MacKay, and Vlad Bortnowski
Stantec designs healthcare facilities globally. In Canada, this often gives us an opportunity to collaborate with communities which include First Nations, Inuit, and Métis peoples. Recently, we gathered three architects who presented on the topic at the RAIC conference to talk about their experience working on healthcare projects for indigenous populations in urban, rural, and remote contexts. Our panelists include:
Bruce Raber, OAA, MRAIC, AIBC
Sector Leader for Health, Stantec Architecture Vancouver
Projects: North Island Hospital, Vancouver Island, British Columbia
Celeste MacKay, NWTAA
Former Senior Associate, Stantec Architecture Yellowknife
Projects: Various community health centers, Nunavut and Northwest Territories.
Vlad Bortnowski, OAA
Senior Architect, Stantec Architecture Toronto
Projects: Meno-Ya-Win Health Centre in Sioux Lookout, Ontario Master planning and pre-design for Anishnawbe Health (Aboriginal Community Health Centre and the Aboriginal Community Hub), Toronto, Ontario
The Taloyoak Community Health Centre in Taloyoak, Nunavut, was completed in 2015.
How important is understanding and navigating the culture of the indigenous groups involved in these projects? What are some common misunderstandings to avoid?
Vlad: Communities in Northern Ontario are very diverse, although mostly Cree and Ojibway. There are so many dialects that translation, even at the hospital, can be a challenge. But culture goes beyond language and translation, one must attempt to find the commonalities that tie the peoples together.
At Sioux Lookout, we had a chance to work with Douglas Cardinal (an aboriginal elder and a prominent Canadian architect) on the master planning of the project. Through him, and with the help of the late traditional healer Josias Fiddler, I think we managed to understand, reflect, and respond to the culture of those isolated communities spread over a very large territory.
Because of its size and economy, Toronto attracts a lot of people from all over, from up north, from the west. Finding the cohesions within the culture is an even bigger challenge for us in Toronto. Here the isolation is cultural within the urban territory.
From my perspective, the main challenge in terms of understanding our clients and the ultimate users of those facilities is to be aware of the two different worldviews. Our western worldview is very hierarchical. Traditional cultures are more based on consensus. You have to hear the stories of each member of the community that wants to speak and listen to even the smallest details. That patience pays off and things often fall in their place naturally.
We try and apply that same kind of approach of listening to the community and trying to distill the meaning of the project for Anishnawbe Health Toronto.
Bruce: Whenever you’re meeting with users or stakeholders who are going to provide you with input on your project, you want to listen more than you talk, initially. With the First Nation’s community, they often like to tell stories when they talk with you. They seem to have a story or a message behind what they want to say. You have to give them time to say that.
I think really listening and hearing what they have to say is important. There are a lot of messages in their stories.
The other thing to be aware of is that we tend to make assumptions based on what we’ve heard or what we think we might know about their culture. A typical example is “Smudging.” It seems that any healthcare project that wants to pay respect to First Nations responds by saying “Oh, we need to have space for smudging.” But it turns out that it’s not something that is universal to the First Nations, even from family to family.
If you have a little bit of knowledge, don’t assume you have all the knowledge.
For the Vancouver Island project, we spent several days visiting First Nation lands and communities, seeing how they worked, and how they lived. We learnt about their traditional crafts and ways of life practiced today, about their ancestry, and the stories that their Totems and Welcome Figures told.
Celeste: The culture can be shaped by remoteness and the extreme conditions of the climate. My team’s offices are based out of Yellowknife, Northwest Territories (NWT), Whitehorse Yukon (YT), and Iqaluit, Nunavut (NU). We’ve done healthcare projects across the three territories, from close to the North Pole all the way down to Alberta. We cover 3.5 million square kilometers of geography with only 100,000 inhabitants, of which 40-50% are indigenous. Of those indigenous people, there are at least 15 distinct cultures represented. It is a common misunderstanding to think that northern peoples are all the same. NWT alone has 11 official languages, so that gives you an idea of the diversity. With that diversity, you need to understand that cultural elements that are important in one region may have little importance in another. We have seen other consultants work in the north and recommend use of Inuksuks in the Yukon, or teepees in Nunavut, or totem poles. The references are not transferable, and care must be taken to be relevant.
Our team has helped implement prototypes for health centers in the NWT and Nunavut, but we take that prototype and adjust for each individual community to make it their own, to reflect their values in that community, as well as their health needs and specific site needs.
Design for us is about understanding the experience of “How does one go to the health center?” In a lot of the northern communities, you expect someone to bring the whole family along for support. There are subtleties around death and birth that are different in every community. Where do the mothers go to give birth? Do they fly south? Does the community have a morgue?
We consider various indigenous values in our work and our process, including decision making through discussion and conference, and acknowledging the history and memory of the community—through the makeup of the project team and through the built environment. It’s the same anywhere, really, consensus building is important.
What are some of the solutions you’ve arrived at based on cultural considerations?
Vlad: For Sioux Lookout, we created a masterplan that has the medicine wheel cut in the forest. It literally marks the earth. Visitors can see it as they fly in from far north by plane.
The main gathering space at the center of the medicine wheel is the first and main point of entry. Visitors have contact with symbolic elements of water, fire, skylight, and earth in the center of the circle. Outside, aligned with the main entrance, to the east, we created another circle where four large boulders found on the site are aligned with the four directions. These are the grandfather rocks. Community members brought earth from the 32 different communities and placed it between the grandfather rocks during a “gathering” rather than groundbreaking ceremony.
Also, many spaces can accommodate large groups—entire families often participate to the process of healing.
Using materials that resonate to the culture: wood structure, cedar cladding, and cladding accents in colors representing the four directions were among the architectural detail cultural responses.
The Anishnawbe Health project is in its incipient stages. For now, we proposed a multi-story space that not only welcomes the clients of the center but makes connections to sky and the outdoor healing gardens and sweat lodge ceremonial area. Connection to the symbolic elements and to nature will be one of the principles governing the design.
Bruce: For the project on northern Vancouver Island we also tried to use materials like cedar, which is considered the “tree of life” to the First Nation communities on the coast. Traditionally, cedar was used for everything from canoes and baskets, even clothing. We tried to use real cedar in important spaces. We created an All Nations room as a community space. The First Nations didn’t want it limited to their culture but rather made open to all people.
We included things that are important to multiple cultures, things like a fireplace, a symbol of the home. In First Nations communities, particularly in their Long Houses or Big Houses, fire was important for warmth and to cook food. But it was also important to settlers who were non-indigenous.
Certain colors and directions have certain meaning in these cultures. We tried to lay out spaces to reflect where these directions are relative to how they want to use the space for prayers or other rituals.
Meetings might begin with chanting and drumming, so making sure there are acoustics in spaces to accommodate that activity, which is not typical in a hospital, is important.
It’s important to select appropriate symbols in graphics, signage, and flooring in consultation with the First Nations so what we do is appropriate. That was a learning curve for us. We didn’t realize that certain symbols belong to certain families, tribes, or bands. You can’t just say, “I like that Thunderbird,” you have to get permission to use it.
While symbols and totems play an important role in First Nations culture, on North Island, rather than using pre-existing symbols, we developed more abstract graphics based on traditional First Nation art to create our own new pattern that would be non-offensive and not necessarily tied to a specific totem or animal but rather a piece of art symbolic of the culture.
When I was working on North Island, I asked the indigenous working group and the elders, “So tell me about the Medicine Wheel; what part does that play in your culture and how do we want to recognize that in the project?” They said, “No, it plays no significant part in our culture. It’s not part of tradition.” With many other First Nations, it would be very important.
Qikiqtani General Hospital in Iqaluit, Nunavut. (Designed by Stantec and Nycum.) Patients that can’t be treated here travel south to Ottawa, Montreal, or Yellowknife.
Celeste: In these remote areas, you don’t have regular access to physicians or specialists, so medical and wellness teams travel up on a rotation. You need to create flexible space within the health center. A room may be a dental room one day, it may be a footcare room the next, and it may be a vaccination room the day after that.
We create spaces that are like a stage—you can clear everything out and reset the stage. It requires lots of storage and flexible spaces.
You won’t see many beds intended for overnight stay but instead you see rooms for holding people and stabilizing them until a medivac plane arrives to fly them south. That’s one thing every health center will have.
Sometimes we create what looks like a board room, because the family will gather there for different reasons. Social events that happen in the health center are hard to program, so we create spaces that can be used as a social space or for training.
What kind of features speak to traditional healing in the culture?
Vlad: Both organizations we worked with are trying to promote harmonization of modern western medicine with traditional healing practices.
A traditional healing room in Sioux Lookout provides the flexibility to bring in patients in bed as well as larger family groups.
The healthcare delivery model for Anishnawbe health has traditional healers’ rooms imbedded in each program, one every floor plus the private outdoor ceremonial space, including the sweat lodge, a main element in the process of healing body, mind, and spirit.
Bruce: At North Island, we created a healing garden, where we worked with the healers, the elders, and professional medical people from the Aboriginal Working Group—and our landscape architects. It features plantings of herbs and medicinal plantings that have traditionally been used from that part of British Columbia in their own healing. Patients and visitors can pick sage to use for smudging or plants to use for traditional healing tea.
Celeste: Traditional medicine is accommodated along with western medicine at these health centers. There’s also an effort to incorporate the ability to serve country foods. That has a whole list of environmental health requirements attached to it. There’s a very strong program in the Yukon at the Whitehorse General Hospital, where country foods are available to patients. Country foods could be a caribou stew, locally caught fish, it could be moose meat. There is an effort to make provisions to offer foods from the land, part of the local diet, which can be a comfort during a hospital stay.