The second of two reviews in this week´s The Lancet discusses the primary origins of the health gap. In an effort to understand these inequalities, the authors attempt to give an Indigenous perspective. It is the work of Professor Malcolm King, of the University of Alberta, Edmonton, Canada, and Scientific Director, Institute of Aboriginal Peoples’ Health (Canadian Institutes of Health Research); Dr Alexandra Smith, of the University of Toronto, Canada; and Professor Michael Gracey, Unity of First People of Australia, Perth, Australia. In this review, the authors focus on North American Indigenous groups, although others are discussed.

Examination of Indigenous health has mainly been concentrating on non-Indigenous health indicators, such as disease and treatment. But Indigenous wellbeing is distinct and includes physical, emotional, mental, and spiritual health. As a result, the healing process can incorporate offerings and community gatherings as well as conventional forms of treatment. The authors explain that the social determinants of health are responsible for the poor state of everyone’s health, but it is particularly true for indigenous health. It is affected by many cultural factors, such as racism, loss of language, loss of connectivity to the land, and other factors primarily linked to Indigenous identity.

Indigenous practitioners use counseling strategies that stress the reduction of alienation and introduction of positive cultural experiences. A study which was the work of Durie and his team argues that there is a lack of positive Indigenous representations and role models and authority figures, and ‘it is a challenge not only to reclaim Indigenous identity, but to facilitate the development of health identities based on cultural strengths, not on disadvantage, disease burden and discrimination.” A fundamental part of Indigenous identity is the language. But worldwide, these languages are being lost. Therefore, language revitalisation can be considered as a health promotion strategy.

The authors mention: “In all likelihood, the mediating mechanisms contributing to high levels of emotional stress, depression, anxiety, substance abuse, and suicide are closely related to issues of individual identity and self-esteem.” The attempt to guide Indigenous people from a conventional standpoint could maintain colonial oppression. The escape from chronic stressors is often found in addictive behaviours. They are a form of self-medication.

Instability is often a consequence of rural-urban migrations which are connected with a high proportion of female single-parent families. This can lead the way to low achievement in education, divorce, crime and suicide, and further social seclusion. The main challenge for urban Indigenous people is to maintain social cohesion. This can be achieved through collective activities and community strategies that reinforce Indigenous cultural identity and develop urban institutions that incorporate Indigenous values, according to Kirmayer and colleagues. Boredom and poor quality of life, poor housing and health facilities, and lack of educational opportunities are some of the factors that can drive Indigenous people away from their communities. Other elements can pull them back, such as a poor rate of success in city life, lack of affordable housing, and the impression that it is best to raise children in rural communities.

The devastation of their lands through globalisation, commercial exploitation and climate change is perceived in many Indigenous groups as a physical assault.

There is a disproportion on how isolation and incarceration issues affect Indigenous men and women. For instance, a study in a Canadian northwest coast Indian village indicated that 31 percent of its people met criteria for a psychiatric diagnosis. The difference in gender was striking, with nearly 46 percent of men being affected, compared with only 18 percent of women. However, the rates of exposure to potentially traumatic events were very high in women and girls, signifying increased sexual and domestic violence.

There is reference to the work of Chandler and Lalonde, which warns against treating the Indigenous population as a whole entity. After studying youth suicide, there was indication that rates for Indigenous people were much higher than in the general population. Rates within individual Indigenous communities range from zero to many times the national average.

In the United Nations Development Program’s (UNDP) human development index (HDI) rankings, Canada, the USA, Australia, and New Zealand are consistently placed near the top of the list. Still, all have minority Indigenous populations with poor health and social conditions. Between 1990 and 2000, the HDI scores of Indigenous peoples in North America and New Zealand improved at a faster rate than the score of the general population. The gap was narrowed but not closed. In Australia, the Indigenous HDI fell while that of the non-Indigenous people increased, therefore widening the gap. Referring to the Kirby report in Canada, the authors comment: “Many question the role of government in providing services, when Indigenous people should be supported in the development of their own solutions, rather than having solutions imposed on or provided for them…There is hope – some of the initiatives that result in increased self-government and self-determination seem to be working.”

In closing, the authors discuss the encouraging progress that has taken place since The Lancet landmark Series on Indigenous Health in 2006: “There are the apologies from the Governments of Australia and Canada. There is the new administration in Washington, led for the first time by a man who is not white. There are international health research agreements involving agencies in Canada, New Zealand, Australia, the USA, Mexico, and the circumpolar nations. Indigenous political organisations have taken on leadership roles in health, such as the Assembly of First Nations (Canada) partnership in the Global Indigenous Stop-TB programme. The UN Declaration on the Rights of Indigenous Peoples includes the right to the ‘to enjoyment of the highest attainable standard of physical and mental health‘. We can only hope that all nations of the world will sign on and make the declaration operative.”

“Indigenous health part 2: the underlying causes of the health gap”
Malc olm King, Alexandra Smith, Michael Gracey
Lancet 2009; 374: 76-85
thelancet

Written by Stephanie Brunner (B.A.)