In the second of two Reviews in this week's Lancet, the underlying causes of the health gap are studied, and the authors attempt to provide an Indigenous perspective to understanding these inequalities. The Review was written by Professor Malcolm King, University of Alberta, Edmonton, Canada, and Scientific Director, Institute of Aboriginal Peoples' Health (Canadian Institutes of Health Research); Dr Alexandra Smith, University of Toronto, Canada; and Professor Michael Gracey, Unity of First People of Australia, Perth, Australia. In this Review, the focus is on North American Indigenous groups, although others are discussed.
Research into Indigenous health has largely been focussed on non-Indigenous health indicators, ie, disease and treatment. However, Indigenous wellbeing is defined much more broadly, and encompasses physical, emotional, mental, and spiritual health. Thus healing can involve processes such as offerings and community gatherings as well as conventional forms of treatment. The authors say that the social determinants of health are to blame for the poor state of everyone's health, but particularly Indigenous health. Indigenous health is affected by a range of cultural factors, such as racism, loss of language, loss of connectivity to the land, and other factors also key to Indigenous identity.
Counselling strategies used by Indigenous practitioners place emphasis of reduction of alienation and introduction of positive cultural experiences. One study by Durie and colleagues claims that, with the shortage of positive Indigenous representations and role models/authority figures, '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." Language is a crucial part to Indigenous identity, and throughout the world these languages are being lost. Thus language revitalisation can be seen as a health promotion strategy.
The authors say: "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." Attempting to counsel Indigenous people from a mainstream perspective can perpetuate colonial oppression. Addictive behaviours also provide an escape from chronic stressors and are a form of self-medication.
Rural-urban migrations can cause instability and are associated with a high proportion of female single-parent families. This is turn leads to poor education attainment, divorce, crime and suicide, and even more social isolation. Kirmayer and colleagues suggest a major challenge for urban Indigenous people is to maintain social cohesion through collective activities and community strategies that reinforce Indigenous cultural identity and develop urban institutions that incorporate Indigenous values.' Many factors can push Indigenous people away from their communities, including boredom and poor quality of life, poor housing and health facilities, and lack of educational opportunities. Other factors can pull them back, including lack of success in city life, absence of affordable housing, and the perception that rural communities are the best place to raise children.
Many Indigenous groups believe that the devastation of their lands through globalisation and commercial exploitation and climate change is equivalent to a physical assault.
Isolation and incarceration issues disproportionately affect Indigenous men over Indigenous women – for example, a study showed that 31% of people in a Canadian northwest coast Indian village met criteria for a psychiatric diagnosis. A striking sex difference was recorded, with nearly 46% of men being affected, compared with only 18% of women. But rates of exposure to potentially traumatic events were very high in women and girls, indicating increased sexual and domestic violence.
The authors refer to work by Chandler and Lalonde, which emphasised the importance of not treating the Indigenous population as a whole entity. They looked at youth suicide and found that, while 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.
Canada, the USA, Australia, and New Zealand are consistently placed near the top of the UNDP's human development index (HDI) rankings, yet 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, narrowing but not closing the gap in human development. But in Australia, the Indigenous HDI fell while that of the non-Indigenous people increased, widening the gap. Referring to the Kirby report in Canada, the authors say: "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."
The authors conclude by discussing the positive steps forward that have occurred 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."
For Professor Malcolm King, University of Alberta, and Scientific Director, Institute of Aboriginal Peoples' Health (Canadian Institutes of Health Research), Edmonton, Canada, please contact David Coulombe, Media Relations, CIHR, T) +1 613-941-4563 E) malcolm.king@ualberta.ca / David.Coulombe@cihr-irsc.gc.ca
For full Review see: http://press.thelancet.com/indig2.pdf
Journal
The Lancet