Indigenous health part 1: determinants and disease patterns

Review
Indigenous health part 1: determinants and disease patterns
Michael Gracey, Malcolm King
The world’s almost 400 million Indigenous people have low standards of health. This poor health is associated with Lancet 2009; 374: 65–75
poverty, malnutrition, overcrowding, poor hygiene, environmental contamination, and prevalent infections. See Editorial page 2
Inadequate clinical care and health promotion, and poor disease prevention services aggravate this situation. Some See Perspectives page 19
Indigenous groups, as they move from traditional to transitional and modern lifestyles, are rapidly acquiring lifestyle See Review page 76
diseases, such as obesity, cardiovascular disease, and type 2 diabetes, and physical, social, and mental disorders linked Unity of First People of
to misuse of alcohol and of other drugs. Correction of these inequities needs increased awareness, political Australia, Perth, WA, Australia
commitment, and recognition rather than governmental denial and neglect of these serious and complex problems. (Prof M Gracey MD); and
Indigenous people should be encouraged, trained, and enabled to become increasingly involved in overcoming these University of Alberta,
Edmonton, AB, Canada
challenges.
(Prof M King PhD)
Correspondence to:
Introduction
We need to understand how colonisation a ected the Prof M Gracey, Unity of First
There are more than 370 million Indigenous people lives of Indigenous peoples to understand their health People of Australia, Perth, WA,
worldwide and they live in countries on every inhabited today. The e ect of colonisation was and is profound. 6005, Australia
m.gracey@optusnet.com.au
continent.1,2 The defi nition of Indigenous can be di cult, Many colonisers were European, including Belgian,
even contentious;2,3 panel 1 shows criteria that can be British, Dutch, French, German, Italian, Portuguese,
used to this end. Some Indigenous groups are easily Russian, and Spanish; but there were also Asian
identifi ed, such as native Americans, Australia’s colonists, including Chinese, Indonesian, Japanese, and
Aboriginal people, Māori in New Zealand, and the Malaysians.2 The biggest Indigenous populations are in
original inhabitants of Pacifi c Ocean nations who were the most populous countries, such as China, India,
present long before Europeans.3 Indigenous peoples are Indonesia, Asian Russia, and former Soviet Union
variously called Indigenous, Aboriginal, tribal, or countries. Some nations deny the existence of their
minority groups or peoples.3 Poor defi nition of Indigenous populations because of ignorance,
Indigenous identifi cation contributes to the groups’ embarrassment, or political expediency.
marginalisation and inadequate data for their numbers,
Foreign intruders introduced microorganisms to
health, and socioeconomic circumstances.3 Most which traditional groups had not been exposed and were
countries do not o cially recognise their Indigenous susceptible. The devastating entry of smallpox, measles,
groups, and have inaccurate or no published statistical and tuberculosis into the long-isolated Indigenous
data for these peoples. Therefore, systematic information inhabitants of Australia is a good example.4 Likewise,
about health, morbidity, and mortality is sparse.2,3 Most infections introduced by colonists seriously a ected
reports relate to specifi c conditions and small groups. In Indigenous populations in the Americas and elsewhere.
this Review we discuss issues of worldwide importance
Traditional Indigenous people were careful custodians
and draw on Australian Indigenous experience as an of the environments that provided them and future
example. Despite great diversity of Indigenous peoples, generations with sustenance, including water, plants,
many similarities in their health and illnesses and their animals that they hunted and fi shed, and from which
determinants exist.
they gathered eggs and tidal shoreline foods, such as
Indigenous people come from thousands of cultures and shellfi sh and marine plants. Habitats of local foods and
are over-represented among the poor and disadvantaged. plants were protected to ensure that they were not spoiled
Overall, their health compares unfavourably with their by human or animal predators or pests and to maintain
non-Indigenous counterparts.3 Their susceptibility to
disease is exacerbated by poor living conditions and water
supplies, often with restricted access to fresh and nutritious
Search strategy and selection criteria
food, and inadequate health services. Panel 2 summarises
We searched a combination of sources, including PubMed, concentrating on original
their main health problems.
publications and reviews from the preceding 10 years. The search was not confi ned to the
Eff ects of colonisation
English language. Keywords used included: “Indigenous”, “Aboriginal”, or “Aborigines”,
linked with “health”, “nutrition”, “malnutrition”, “growth”, “infants”, “children”, “pregnancy”,
Common to many Indigenous groups are the powerful
“maternal health”, “adolescents”, “infections”, “parasites”, “hypertension”, “cardiovascular
e ects of colonisation on their people and their lands by
disease”, “diabetes”, “renal disease”, “dialysis”, “alcohol”, “drugs”, “trauma”, “accidents”,
outsiders who later dominated societies and alienated
“drowning”, “poisoning”, “homicide”, “suicide”, and “mortality”. Information was obtained
them from their own ways of life. This colonisation
from other sources such as websites from international organisations, including UN and
adversely a ected physical, social, emotional, and mental
WHO. Some information came from earlier reviews and books of particular relevance; these
health and wellbeing in traditional societies. Extrapolation
works are in the public domain and are referenced here. We also had access to unpublished
between di erent groups is unwise because local
offi cial reports about the health of Indigenous people in Australia.
circumstances di er greatly.
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The fabric of traditional societies was shredded by
Panel : Criteria to help to defi ne Indigenous peoples1
colonisation. Traditional life was suppressed by alien
• Self-identifi cation as Indigenous peoples by individuals and acceptance as such by
regulations imposed on people who had lived, sometimes
their community
for many thousands of years, with well established
• Historical continuity and land occupation before invasion and colonisation
traditional laws, languages, dress, religions, sacred
• Strong links to territories (land and water) and related natural resources
ceremonies, rituals, healers, and remedies. This legalised
• Distinct social, economic, or political systems
disruption was worsened by socioeconomic and political
• Distinct language, culture, religion, ceremonies, and beliefs
marginalisation, and by racial prejudice which was often
• Tendency to form non-dominant groups of society
entrenched and institutionalised. This process was
• Resolution to maintain and reproduce ancestral environments and systems as distinct
hastened by the often brutal dispossession of traditional
peoples and communities
lands, and subsequent poverty, undereducation,
• Tendency to manage their own aff airs separate from centralised state authorities
unemployment, exploitation by unscrupulous employers
and landlords, and increasing dependence on social
welfare or begging in cities and towns. Many Indigenous
groups have to live on unproductive land or in towns,
Panel : Major health problems of Indigenous peoples
cities and their fringes, slums, or squatter camps that are
• High infant and young child mortality
environmentally degraded health hazards, contaminated
• High maternal morbidity and mortality
by heavy metals and industrial waste (fi gures 1 and 2).9
• Heavy infectious disease burdens
These oppressive factors caused severe inequalities in
• Malnutrition and retarded growth
Indigenous health status, unsatisfactory disease and vital
• Shortened life expectancy at birth
statistics, impaired emotional and social wellbeing, and
• Diseases and deaths associated with cigarette smoking
poor prospects for future generations.10 These issues
• Social problems, illnesses, and deaths linked to misuse of alcohol and other drugs
should be taken seriously to redress socioeconomic and
• Accidents, poisonings, interpersonal violence, homicide, and suicide
health inequities for Indigenous populations worldwide.
• Obesity, diabetes, hypertension, cardiovascular disease, and chronic renal disease
This redressal is an immense challenge, engaging
(lifestyle diseases)
di erent levels of governments, various international
• Diseases caused by environmental contamination (eg, by heavy metals, industrial
agencies, non-governmental organisations, clinicians,
gases, and effl uent wastes) and infectious diseases caused by faecal contamination
and health policy makers and administrators. Indigenous
people should be meaningfully engaged rather than
prejudicially excluded from these endeavours.
Panel : Nutritional defi ciencies of Indigenous peoples
Health of children and mothers
Besides hunger and general inadequacy of food and dietary
Poor living conditions, inadequate nutrition, and exposure
energy (calories), specifi c defi ciencies of various nutrients are
to high rates of infection cause a heavy burden of disease
widespread. Examples are iron defi ciency, which can be caused
in infants and children.11–13 These diseases are mainly skin
by dietary inadequacy or secondary to blood loss, intestinal
infections, acute and chronic ear disease, dental caries,
parasites, or malaria; hypothyroidism, shortness of iodine
trachoma, diarrhoeal diseases, parasite infestations,
aff ects hundreds of mil ions of people; poor vitamin intake
upper and lower respiratory tract infections, urinary tract
(eg, vitamins A and D, folic acid); and heavy metals, such as
infections, and viral and bacterial infections a ecting the
zinc. These defi ciencies and any underlying causes, including
nervous system. Indigenous children have high rates of
poverty and inadequate food, should be corrected to reach
low birthweight and being small-for-gestational age.
satisfactory outcomes for those aff ected.
These factors can a ect development of cardiovascular
disease, renal disease, and diabetes in adulthood.14
their long-term sustainability. Water supplies were
Unfavourable perinatal and neonatal health outcomes,
protected from loss and spoilage, and for agriculturalist including deaths, are pressing issues, especially in
groups protection of water supplies was very important developing countries.15 Several interventions could cost-
to support their crops.
e ectively save many of these lives.16 These interventions,
Colonisation had a powerful e ect on Indigenous including improved clinical care to poorly served groups,
populations. It blocked access to or destroyed traditional should engage families and communities and improve
farming, food-gathering, or hunting and fi shing places home-care practices. Better and well coordinated care
and practices.5,6 This change made the previous and supervision for mothers and babies should be
inhabitants dependent on colonisers for foods that were implemented simultaneously.17
often unfamiliar to them and of inferior nutrient quality
Some diseases are prevalent in specifi c areas, such as
(panel 3). Colonists introduced harmful substances such tropical regions. These diseases include malaria, measles,
as tobacco and alcohol, which had serious long-term dengue, haemorrhagic fevers, amoebiasis, ancylosto-
e ects on health and caused severe social, psychological, miasis, ascariasis, strongyloidiasis, schistosomiasis, and
and emotional damage.6–8
viral infections such as hepatitis and encephalitis. HIV
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infections a ect many Indigenous infants, children, and
adolescents. Childhood diseases are linked to substandard
hygiene, nutrition, and immune status, worsened by
heavy exposure to environmental microbial contamination
such as contaminated water, food, utensils, or person-to-
person or animal-vector-spread diseases such as giardiasis
or salmonellosis. Infections are also associated with
falling breastfeeding practices and contamination of non-
human milks or other fl uids.
Socioeconomic status is a major determinant of
disparities in Indigenous health, irrespective of ethnicity.18
Immunisation is e ective against vaccine-preventable
childhood viral infections in which strain variation is low
and herd immunity is high, as in measles and hepa-
titis B.19 However, universal vaccination is often not
Getty Images
feasible in Indigenous populations, especially in remote Figure : Typical housing for Australian Aboriginal people in 2008
Inadequate housing and overcrowding prevail in urban, periurban, rural, and
areas. Vaccine-preventable diseases, including measles, remote Indigenous populations; many other Indigenous people are homeless or
mumps, diphtheria, rubella, pertussis, and tetanus have live in makeshift camps and shanties.
been controlled in most non-Indigenous populations but
are still rife and potentially fatal in many Indigenous
groups. This area should be a priority for action by
governments and non-governmental organisations.
Many groups do not have access to traditional foods5,6
and depend on commercial foods sold in Indigenous
community stores or in small towns, villages, or at
roadhouses; their infants and children are often
malnourished. This malnourishment is frequently
caused by poverty and insu cient food, and is worsened
by inadequate facilities in the home to securely store and
keep food cool and uncontaminated. Substandard
nutrition of infants and young children can be associated
with maternal ill-health and malnutrition, or both, which Figure : Hazardous waste in an Aboriginal housing area in tropical
can negatively a ect pregnancy and predispose to northwest Australia in 2006
premature birth, low birthweight, and intrauterine Environmental contamination predisposes to high rates of recurrent and chronic
growth retardation.20 Childhood growth faltering and infections in many communities.
malnutrition are major challenges and are associated
with increased mortality. About 15% of Aboriginal Maternal health before and during pregnancy and while
children aged less than 5 years in Australia’s Northern nursing their infants is essential for the health, nutrition,
Territory are underweight, 11% are stunted, and 9% are and growth of infants and young children. Many
wasted.21 Soundly based and community-delivered Indigenous mothers are ill-prepared for pregnancy.
nutrition education, linked to interventions that enlist They can be very young or have been pregnant many
carers, community health workers, and community times and, consequently, at high risk of complications
members, can help to prevent growth faltering.21 to themselves or their infants. They also tend to have
Increased infant mortality is prevalent in many high rates of other risk factors, including (1) under-
Indigenous populations and is related to social and nutrition during pregnancy, which can be worsened by
economic circumstances and restricted access to adequate the necessity of many mothers to do strenuous physical
health care. Childhood malnutrition, impaired growth, work throughout pregnancy, such as labouring on
and stunting are often associated with repeated or chronic farms, harvesting and carrying crops or traditional
infections. Gastrointestinal infections and parasite foods, and carrying water daily for many kilometres for
infestations are especially important because of their domestic chores; (2) anaemia caused by nutrient
negative e ects on intestinal digestion and malabsorption defi ciencies (eg, iron) and underlying disease, or both;
of nutrients, minerals, and vitamins.22 Millions of (3) defi ciencies of other nutrients (eg, iodine, zinc, and
increasingly urbanised Indigenous youngsters now face vitamins); (4) inadequate preparation, education, and
the consequences of overnutrition rather than prenatal and postnatal clinical care; (5) high rates
undernutrition, including chronic lifestyle diseases.23
of largely preventable urinary tract infections;25 (6) gest-
Pregnant women, nursing mothers, infants, and ational diabetes, which can pre-date permanent diabetes;
children form a large part of Indigenous populations.2,24 and (7) scant human, clinical, and laboratory resources
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for safe pregnancy, delivery, and postnatal care. Many infections and invasive diseases such as nephritis or
Indigenous women, especially those in poor countries, endocarditis.29–31
have little or no access to basic clinical sta and facilities
Respiratory and gastrointestinal infections often
that should be part of the routine care of women before, coexist; they cause widespread illnesses and deaths,
during, and after pregnancy. Gestational glucose especially in infants and young children. Upper and
tolerance,26 obesity, pregravid weight, and weight gain lower respiratory tract infections are prevalent32 and
during pregnancy can adversely a ect maternal and deaths from pneumonia are “a permanent global
fetal outcomes,27 including HbA and blood pressure emergency”.33 Episodes often coincide with other
1c
measurements in later life.28
infections such as gastroenteritis, meningitis, encepha-
In many Indigenous societies, traditional midwives and litis, and locally endemic or epidemic diseases—eg,
healers give important advice and care to women before malaria. Respiratory infections can be drug-resistant
and during pregnancy and after parturition. Modern such that mortality can be very high, especially in patients
health professionals could usefully collaborate with them with malnutrition and impaired immunity. Measles can
so that mothers and infants benefi t from their cause rapidly fatal pneumonia. Tuberculosis is still widely
experience.
prevalent in many countries and should be suspected in
Indigenous adolescents have many important health-
patients with chronic symptoms.34,35
related disadvantages that cause ill-health and disability
Immunisation can help to control some respiratory
(panel 4). These disadvantages are worsened by poor infections such as pneumococcal disease, Haemophilus
educational standards, inadequate knowledge of the infl uenzae type b, tuberculosis, pertussis, diphtheria,
determinants of health, and frequent absence of access measles, and other viral infections.19 There has been
to and use of good quality clinical care and preventive improvement in controlling measles. Vaccination
health services.
programmes undertaken by the Pan American Health
Organization have reduced Indigenous transmission of
Burden of infectious disease
measles; political commitment was important in
Indigenous people have much higher rates of infection achieving this reduction and more e ective control is
than do their non-Indigenous counterparts, and these feasible in future.36 Overcrowding and indoor or outdoor
infections are likely to be more severe or more frequently air pollution (eg, from cooking and heating fi res, cigarette
fatal in Indigenous groups. The nature, frequency, and smoke, and atmospheric pollution) predispose to airway
severity of infection depends on age, nutritional status, disease and respiratory infections.32,37,38
impaired immunity, presence of diabetes, personal living
Otitis is prevalent;39 most episodes of otitis externa can
conditions and hygiene, exposure to infections and be successfully managed conservatively but otitis media
disease -carrying vectors, immunisation status, geography, is often much harder to manage and surgery might be
and climate.
necessary. Hearing loss can be permanent if the inner
Skin infections are very common, especially in children. ear is chronically damaged and if audiological
Some examples are: bacterial infections of abrasions, management is unavailable. This loss can impede future
lacerations, vesicles, burns, pustules, and furuncles; education, training, and employment.
superinfection of extensive lesions, such as impetigo;
Diarrhoeal diseases are often accompanied by other
mycoses, including tinea of the head, body, feet, and skin infections, malnutrition, and specifi c nutrient
folds (this can be very extensive); candidosis or moniliasis; defi ciencies, especially in children. Causative agents
parasitoses, including scabies, skin, and soft tissue include viruses, bacteria, parasites, protozoa, fungi, and
infestation by larvae of fl ies, pediculosis, insect stings, yeasts. Symptoms range from mild to potentially fatal, as
and bites of fl eas and ticks; cutaneous Larva migrans; with cholera, shigellosis, and other enteroinvasive
and leprosy and yaws. These infections can cause infections. Viral diarrhoeas can cause severe watery
permanent scarring and can allow entry of streptococcal diarrhoea and widespread morbidity and mortality. Many
diarrhoeal episodes do not respond to antibiotics—for
example, those caused by non-bacterial agents. Rotavirus
Panel : Health-related problems of Indigenous adolescents
vaccine research has proceeded for many years, but
vaccines are not yet generally available.40 Such protection
• Little knowledge of determinants of health and disease risk
might not be e ective in Indigenous populations for
• Increasing use of harmful substances such as tobacco,
several years because of the multiplicity of strains
alcohol, and other drugs
involved, the technical problems and costs of developing
• High-risk sexual activities
e ective stable polyvalent vaccines, and the logistical
• High-risk, unplanned, and poorly supervised pregnancies
di culties in their distribution.
• Violence and trauma in crowded communities and urban
Malaria is widespread in tropical countries and causes
environments
serious morbidity and millions of deaths. Many strains of
• Increasing rate of obesity in increasingly urban populations
plasmodium are multidrug-resistant and work is
• Mental and emotional disorders
continuing towards producing vaccines to control the
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infection.41 Preventive measures, such as spraying Transmigration to urban areas increases the risk of sexually
mosquitoes, might be unavailable or ine ective. transmitted infections, including HIV/AIDS, in Indigenous
Indigenous populations are often unaware of the populations. The upsurge of these infections in the
usefulness of simple protective equipment such as Indigenous peoples of Brazil, particularly those involved in
mosquito nets, and generally cannot a ord them. To agrarian confl icts or migrating to towns and cities, led to
reduce the vast disease burden and deaths from malaria, the establishment of Special Indigenous Health Districts.
many international non-governmental organisations are This system allowed improvement in disease surveillance,
taking part in community-based programmes, including treatment, and control, and encouraged greater
education, control of transmission of infection, and use participation of Indigenous community health workers in
of personal protective procedures.
the network’s activities and assessment.63
Invasive meningococcal infections can cause
The AIDS epidemic is rapidly worsening in the Asia-
potentially fatal illnesses, including pneumonia and Pacifi c region. Most of the Indigenous population does
septicaemia; vaccines exist42 but are often inaccessible to not have access to information, skills, methods, and
Indigenous populations. Urinary tract infections29 are infrastructure that are necessary for detection, treatment,
very common and often have serious long-term sequelae, and prevention, and mainstream health campaigns are
including renal failure.43–45 Importantly, these infections inappropriate and ine ective.60 The high rates of sexually
are generally asymptomatic and in Indigenous men and transmitted infections in Aboriginal people in Western
women can cause long-term complications, such as Australia are associated with high rates of HIV
chronic renal insu ciency, unless detected early and notifi cations.64 From 1994 to 2002, the age-standardised
managed energetically.25,46–48 Sexually transmissible rate ratios of HIV notifi cations, compared with non-
infections are prevalent49–51 and cause immense personal, Indigenous people, were 2:1 for men and 18:1 for women.
family, and community damage. The introduction of a Public health authorities are attempting to control these
vaccine against human papillomavirus infection52–54 problems but “the clock is ticking”.64
might help to reduce the risk of cervical carcinoma, but
Infections of the nervous system, such as meningitis
only for those who have access to the vaccine. and encephalitis, can have disabling long-term
Immunisation against vaccine-preventable diseases in complications and are potentially fatal. E ective treatment
Indigenous populations should be very high priority. might not be available or accessible. Some of the causative
But there are inherent problems related to costs, agents are bacteria (including tuberculosis), rickettsiae,
production of su cient vaccine stocks, adequate storage, viruses, and fungi. These infections can cause brain
transportation, and distribution facilities, and availability abscesses. Ophthalmic infections often cause visual
of trained sta to administer vaccines and to gather impairment or blindness.
together people to be vaccinated. All these considerations
Soft tissue infections, such as pyomyositis, are often
assume access to epidemiological information to alert deep-seated and serious, especially in children.
authorities of the need for vaccination.
Osteomyelitis can be blood-borne and associated with
HIV/AIDS has been called “the fi rst postmodern penetrating injuries or fractures. Dental and periodontal
pandemic”55 and HIV infection is a continuing health diseases are common and can be associated with
crisis in racial and ethnic minorities, including rheumatic and other forms of cardiovascular disease.65,66
Indigenous people.56 This situation is interwoven with
prevalent socioeconomic di culties, including poverty, Urbanisation and upsurge of lifestyle diseases
homelessness, substance misuse, and unequal access to Urbanisation has had a profound e ect in the past
health care. The AIDS epidemic disproportionately century. The process of urbanisation is usually regarded
a ects such populations, especially women.56 Maternal as the growth of cities and rural-to-urban migration.
HIV infection has particular importance to infants and Millions of Indigenous people now live in urban or
young children because of increased risk of perinatal periurban areas. The e ects of urbanisation are virtually
mortality, transplacental transmission of the virus, and worldwide and are not confi ned to large groups. These
the consequences of probable premature maternal death. e ects are caused by increasing commercialism,
Rates of HIV/AIDS are high in many Indigenous acculturation, and rapidly changing lifestyles. They
groups—for example, in American Indians, Alaskan include modern high-calorie, high-fat, high-salt, and
Native populations,57 Indigenous Canadians,58 in African low-fi bre diets, changing infant feeding practices,
races,6,59 and people in the Asia-Pacifi c region.60,61 The decreased physical activity, overcrowding, and
HIV incidence in Indigenous Mayan Guatemalans, who environmental contamination.23 The e ects of
represent 42% of the country’s population, may be three urbanisation on health, including chronic lifestyle
times as high as in the rest of the population.62
diseases, have been intensifying in industrialised
Such fi ndings led UNAIDS to take action, by studying countries for many years and are a major international
trends, vigorously promoting prevention, and engaging public health problem. These hazards have emerged
Indigenous representatives in decision making. Use of more recently in Indigenous groups that seem prone to
Indigenous languages is important in these processes. them, such as the Indigenous peoples of North America
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The worsening epidemic of lifestyle diseases includes
Panel : Major diffi culties, trends, and factors that aff ect Indigenous health
obesity, hypertension, cardiovascular disease, type 2
Persistent problems
diabetes mellitus, chronic renal disease, and renal
• Poverty, hunger, environmental contamination, frequent infections, and parasites
failure.68,69 This epidemic is part of an international “crisis
• Infant and child malnutrition and growth failure
in public health”.70 These disorders are now prevalent in
• High infant and young child mortality
Indigenous populations—for example, in Australia71–73
• Maternal ill-health and high mortality
and the Americas.74–78 These disorders have emerged
• Chronic ill-health and disabilities
recently in these groups, perhaps because of genetic
• Shortened life expectancy
predisposition and changed diet and lifestyle.72,73,79–81 This
• Poor understanding of the complexities of Indigenous health by health professionals
issue is so serious in remote Aboriginal peoples living in
• Widespread prejudice about perceived inadequacies of Indigenous people
northwest Australia that 40% of all adults and almost
• False expectations that medical strategies alone can overcome Indigenous health
60% of those aged 35 years or older have diabetes.71 Some
problems
Indigenous children become overweight and hyper-
• Government preoccupation with sickness services rather than wellness strategies
insulinaemic as young as age 5 years.82 Aboriginal
• Bureaucratic mishandling of culturally sensitive matters beyond their rigid protocols
children up to 17 years of age in Western Australia have a
• Insuffi cient chances for Indigenous people to be trained and take part in their health care
diagnosis rate of diabetes that is 18 times that of their
• Inadequate systematic data to allow surveillance and improvement of Indigenous
non-Indigenous counterparts.83 This disturbing upsurge
health care
has occurred in many Indigenous populations, especially
• Government indiff erence, ignorance, neglect, and denial about the poor state of
in recent decades. Previously, the main childhood
Indigenous health
nutritional disorders in Indigenous Australians were
malnutrition, stunting, and infections; now, increasingly,
Areas with improvement
they are obesity and related risks of lifestyle diseases.72
• Suppression of some vaccine-preventable diseases
This nutrition transition has occurred in many countries,
• Improved pregnancy outcomes, including birthweights
including in Chilean adults and children.84
• Lower rates of some infections and related deaths, especial y in infants and
Chronic diseases have become worldwide health
young children
problems that cause many millions of deaths every year.85
• Reduced maternal, infant, and young child mortality
This epidemic is worsening in low-income and middle-
• Increased life expectancy in some populations
income groups and is driven by rapid social and
• Improved education in some Indigenous groups and their employment in
environmental changes that aggravate the prevalence of
health-related fi elds
preventable risk factors.86 This situation helps to explain
• Introduction of Indigenous components to education and training of health
the importance of the risk factors in Indigenous
professionals
populations. The main risk factors for chronic disease
• Training of Indigenous people for careers in health professions
are unhealthy diet, decreased physical activity, and
• Increased participation of Indigenous people and groups in policy-making and
tobacco use. These factors apply in lower socioeconomic
political aff airs
groups in industrialised, developing, and transitional
• Widening awareness of the seriousness of health issues in Indigenous peoples
societies.85 Non-communicable diseases tend to increase
• Formal recognition by some national governments of Indigenous peoples’ rights
as rates of infectious diseases lessen. The global burden
(eg, Australia, Canada, Japan)
of disease di ers greatly around the world. Infectious
Areas of deterioration
and nutritional diseases are major problems in Africa,
• Erosion of the authority of Indigenous Elders
but are very much less so in high-income regions such as
• Illnesses associated with overcrowding and environmental contamination in squatter
Europe. Non-communicable diseases are more important
settlements, urban slums, and disaster situations
in higher-income regions, such as Europe, the Americas,
• The rapid upsurge of lifestyle diseases
and now the western Pacifi c and southeast Asia regions
• Respiratory and peripheral vascular disease associated with cigarette smoking
of WHO as these regions have become more a uent and
• Diseases and social problems associated with misuse of alcohol and other drugs
urban.87 However, such data can be misleading because
• Emotional, mental, and psychiatric illnesses
they are aggregated and do not reveal variations within
• Interpersonal and family violence, including, child abuse, homicide, and suicide
regions or countries. Chronic diseases and their risk
• Motor vehicle and other accidents and poisonings
factors need to be countered by promotion of healthy
• Sexually transmissible diseases, including HIV/AIDS
lifestyles, change in food habits, encouragement of
physical activity and sport, discouragement of cigarette
smoking and alcohol and drug misuse,85 and by fostering
and Australia. The negative health e ects of urbanisation of physical and emotional wellness (panel 5). Unless
now occur in barrios (small towns) and even in very these changes take place chronic diseases will spread
remote Aboriginal communities in the Australian more widely as more and more Indigenous people adopt
outback.23 Misuse of alcohol and other drugs, injuries, sedentary modern lifestyles. Related morbidity and
poisonings, violence, and accidental deaths and injuries mortality can be improved by control of blood glucose,
are also important hazards.23,67
blood pressure, and lipid concentrations.88 Remote
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Australian Aboriginal groups, given the opportunity, can were major contributors to cardiovascular disease,
collaborate through community-based programmes and diabetes, chronic respiratory disease, and injuries and
with conventional clinical services to keep the devastating violence, which shows their importance when designing
e ects of these disorders to a minimum.71 Indigenous and implementing strategies and interventions to lessen
people should be encouraged, trained, and enabled to the burden of disease, injury, and premature deaths.
become increasingly engaged in and take responsibility Of 193 countries, all Australian men aged 15–60 years
for their own health and wellbeing.2,89
had the seventh lowest and all Australian women the
12th lowest probability of dying in 2003, yet Indigenous
Changing patterns of Indigenous health
Australians were in a worse position than the East
Major di culties, trends, and factors that a ect Indigenous Timorese, whose probability of dying was worse than
health are summarised in panel 5. Clearly, Indigenous 130th in that list of 193 countries. These fi ndings have
people should have better health than they do at present, many important implications. The major risk factors
which will depend on recognition of the problems and should be targeted more carefully, and better health-care
resolute action to overcome them. Approaches should facilities and services are needed because mortality in ill
relate to local circumstances, interaction between Indigenous Australians is worse than in other Australians.
Indigenous and non-Indigenous parts of society, and Furthermore, the disability and mortality gaps are
provision of improved health-related services.
greatest for young Indigenous people. Risk reduction in
Is Indigenous health changing? This important but young people should have much higher priority than it
sweeping question has no simple answer, mainly because does now.
of scarcity of reliable data. Such information is urgently
The Millennium Development Goals expect that all
needed to document present health status in Indigenous people should benefi t from development.91 However,
people, develop appropriate strategies and programmes, worldwide, Indigenous populations have higher
assess e ectiveness of those activities and modify them if mortality than their non-Indigenous counterparts.92 The
necessary, compare health standards between di erent Indigenous versus non-Indigenous mortality gap is
groups of Indigenous and non-Indigenous people, and worse in Australia than in other Organisation for
study changes in Indigenous health over time.
Economic Co-operation and Development nations with
How can health or wellness be measured? Widely used disadvantaged Indigenous populations, including
indicators include infant mortality, mortality of children Canada, New Zealand, and the USA.92 This gap in
aged 0–5 years, incidence or prevalence of diseases and Australia reached a stark peak of 17 years in 1996–2001,93
their risk factors, and life expectancy at birth. These are and was partly responsible for the formal government
clinically-orientated statistical markers that give no apology to Indigenous Australians.94 The federal
indication of broader issues of physical wellness or social government is now committed to closing this gap and
wellbeing. Indicators that use mortality rates measure other forms of long-term disadvantage that Indigenous
the worst outcomes. More comprehensive indicators of Australians have.95 These disadvantages consist of
health and wellness, presence or absence of disease or housing availability and standards, community infra-
risk factors, and long-term outcomes are needed.
structure and services such as water supplies,
Disability-adjusted life year (DALY) assessment is a environmental hygiene, educational attainments,
widely accepted single summary measure of population training and employment opportunities, and accessibility
health. On the basis of this assessment to measure the to health care. These gaps will probably not be closed by
main risk factors, diseases, and causes of excess mortality the target date of 2030 despite our best e orts and
in Indigenous Australians,90 the age-adjusted rate ratios irrespective of various strategies, social and medical,
of DALYs were higher in Indigenous Australians than in that have been proposed.96 Regrettably, inadequate
the total Australian population (see table). Among attention seems to have been given to potential gains
20 diseases and injuries causing the greatest burdens in that could be achieved through more meaningful
men were homicide and violence (relative risk 6·8), involvement of Indigenous Australians and their
infl ammatory heart disease (6·3), and lower respiratory communities in this task.
tract infections (6·1). For women the greatest di erentials
Close scrutiny of the use of mortality or life expectancy
were for rheumatic heart disease (26·4), homicide and as a measure of the health of Indigenous peoples raises
violence (11·0), and alcohol dependence and harmful
use (7·9).
Men
Women
11 risk factors collectively explained 37% of the
Cardiovascular disease
4·5
5·1
Australian Indigenous disease burden. These factors
Diabetes
4·4
6·0
were tobacco use, alcohol, illicit drug use, high body
Intentional injuries
3·9
5·3
mass, inadequate physical activity, low intake of fruit and
Unintentional injuries
2·4
2·9
vegetables, high blood pressure, high cholesterol
Chronic respiratory disease
2·5
2·6
concentration, unsafe sex, child sexual abuse, and
physical abuse of intimate partners. Some of these factors
Table: Age-adjusted rate ratios of Indigenous to total Australian DALYs90
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some important issues. In Canada, for example, there Indigenous populations is their great diversity.
were substantial gains in life expectancy at birth in the Observers often think of Australian Aboriginal people
Indigenous population from the 1940s onwards so that as a single group. But there were hundreds of Aboriginal
by 2000 the unfavourable gap for Indigenous Canadian groups or nations before colonisation, and dozens of
men versus other Canadian men was only 7 years and languages and cultures. Cultural diversity persists,
for women was 5 years.97 There were also steep declines especially in remote areas.
in Canadian Indigenous infant mortality rates over a
similar period, although the reduction was more Conclusions
striking for infants of First Nations people than for the When considering Indigenous health worldwide, one
Inuit, who still have infant mortality rates three times can feel overwhelmed and discouraged by the great
those of the national Canadian rates.97 There have been disparities in health and disease statistics. Using Indi-
substantial reductions in Indigenous infant mortality genous Australians as an example,90 we see that
in Australia, too, over the past few decades, although Indigenous peoples have higher rates of physical,
the rate is still double or three-fold that of non-
mental, and emotional illness, injuries, disability, and
Indigenous Australian infants. Information from earlier and higher mortality than do their non-Indigen-
selected states has to be used because consistent, ous counterparts. The mortality gap between Indigenous
reliable, nationwide data are not available.98 Between and other Australians is considerably greater than the
1991 and 2005, the Indigenous infant mortality rate in disability gap—ie, when they are ill, they are more likely
Western Australia (WA) and South Australia (SA) fell to die than are non-Indigenous Australians. This
from roughly 23 deaths per 1000 livebirths to about ten discrepancy is probably caused by late presentation,
deaths per 1000 livebirths; the decline in WA was 39% frequent severe or complicated illnesses, inadequate
and in SA was 26%.98 Over the same period the relative access to good clinical care, and inadequate follow-up,
rate ratios (Indigenous versus non-Indigenous) of compliance with drugs, and prevention of complications.
infant mortality rates in those jurisdictions changed Diabetes, cardiovascular disease, and tobacco use
from more than 4 to about 2·5.97 Over the same period account for half the Indigenous health gap; as well as
Indigenous all-age mortality rates decreased somewhat tobacco use, these diseases share other lifestyle risk
but, despite that, in WA, SA, and the Northern Territory factors. Rather than seeing this situation as a cause for
the mortality rate ratios (Indigenous versus non-
despair, it should be seen as a potential target for greater
Indigenous) increased because non-Indigenous health gains in the sicker group. Improvement could be
mortality also declined substantially.98 To regard achieved by addressing particular diseases and risk
Indigenous people, even in one country, as a single, factors, targeting the most a ected age groups, and
homogeneous entity is hazardous. A major feature of providing e ective interventions. Infections and
neonatal disorders are examples in which targeted
interventions should produce substantial health gains.
These messages should be convincingly conveyed to
politicians, policy makers, and community leaders. They
have to be persuaded that Indigenous health demands
priority and that prevention is better than cure.
There are some simple, a ordable, and e ective ways
to improve Indigenous health. Basic hygiene could be
improved through better personal, domestic, and
community hygiene, disposal of dirty or stagnant water,
sewage, and litter, and prompt treatment of skin sores.
Clean drinking water should be provided to target
communities and families, and local people should
know the importance of it and relevant authorities
should assist by making sure that supplies are clean.
Heavy work, particularly by women and children, of
carrying domestic water over long distances should be
reduced. Local communities, their representatives, and
health committees should be encouraged to contribute
to and take responsibility for their health (fi gure 3).
These groups might need fi nancial, physical, and other
support from governments and other organisations to
be able to do so. Health and hygiene education should
Figure : Aboriginal Elders in the Kimberley region in the far northwest of Australia
They are taking part in Indigenous-driven, community-based health programmes. The local spirit fi gure of the
be provided to individuals, families, and communities,
Wandjina is on the mural.
with a focus on community participation.
72
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Review
The basic causes of illness are similar in Indigenous
and non-Indigenous peoples. But the burden of disease,
Panel : Key strategies to improve Indigenous health
disability, and death is consistently greater in Indigenous
Health of mothers and children
than in non-Indigenous people. The principles for
• Prenatal clinical care, health and nutrition education for pregnancy
improvement we mention require acknowledgment by
• Avoidance of risks in pregnancy such as smoking, alcohol, and other drugs
governments of Indigenous peoples’ special rights and
• Detection of disease and disease risk promptly in pregnancy and treat as needed
needs; adequate, regularly collected data about Indigenous
• Avoidance and treatment of anaemia and other nutritional defi ciencies
health and related factors; adequate resources to close
• Provision of adequate facilities and services for safe birthing
the gaps in health, disease, disability, and mortality
• Encouragement of breastfeeding and safe, nutritious weaning practices
between Indigenous and other peoples; and addressing
• Regular monitoring of child growth and use of appropriate nutritional and clinical care
socioeconomic inequities between Indigenous and non-
• Early referral of infants and children for clinical treatment
Indigenous populations to overcome these discrepancies
• Encouragement of healthy lifestyles, avoidance of high-risk health behaviours such as
(see panel 6).
unsafe sex, smoking, and alcohol and drug misuse
These issues should all be addressed to overcome
these problems. This process will need recognition and
Nutritional defi ciencies
improved understanding of the issues, commitment by
• Provision of enough nutritious and aff ordable food
governments to contribute much more than previously,
• Targeting of vulnerable groups such as pregnant women, infants, and elderly people
and acceptance that Indigenous people have to be more
• Provision of nutritional supplements as needed (eg, iron, iodine, zinc, and folic acid)
meaningfully engaged in these e orts. Most
• Treatment of underlying causes such as malaria, intestinal parasites, and blood loss
governments have given little attention to Indigenous
Infectious diseases
health because of ignorance, indi erence, political
• Provision of adequate housing, clean food and water supplies, and food storage places
unpopularity with the grim realities of the situation,
• Encouragement of personal, family, and community hygiene at all times
and failure to o cially recognise or enumerate
• Disposal of rubbish, sewage, and solid waste, and draining of stagnant ponds and waters
Indigenous people in o cial statistics. Agencies that
• Prevention of contamination of water supplies and areas where people meet or eat
have provided clinical and related health-care services
• Suppression of vectors of infections such as fl ies, mosquitoes, other insects, and larger
for Indigenous people have often had little success
animals
because of an absence of awareness or acceptance of
• Immunisation programmes against vaccine-preventable diseases
Indigenous cultural behaviours (including taboos) and
• Early and adequate treatment of infections
needs, such as for families to be present during clinic
Urbanisation and lifestyle diseases
visits and when patients are hospitalised, for female
• Encouragement of nutritious eating habits throughout life
patients to have female clinical sta in attendance (and
• Encouragement of regular exercise and weight control
male sta for male patients). Furthermore, specifi c
• Discouragement of cigarette smoking and alcohol and drug misuse
ethnic or tribal groups need culturally appropriate
• Regular and opportunistic screening, or both, for risk factors and follow up
clinical carers, and insensitivities to Indigenous
• Encouragement and supervision of compliance with drug treatment and follow up
attitudes and behaviours such as not keeping to rigid
• Prevention of long-term complications—eg, by diet, exercise, weight control, and
timetables for clinic visits have contributed to this
clinical care
failure. Indigenous people often need long and
• Encouragement of Indigenous involvement in community-based wel ness programmes
painstaking explanations about the causes of their
illnesses, how their drugs work, and why they should
keep to the clinical instructions they have been given. local, regional, national, and international statistics about
Many conventional clinical-carers are unaware of these Indigenous health is important to allow assessment of
needs or are too impatient or busy to appreciate their future trends and usefulness of interventions.
importance.99 Indigenous people often have di culty Contributors
understanding the language of the dominant society. MG was the primary author and did most of the search of published
Better communication is key to improvement of health. work. MK contributed to the review of published work and writing.
Large health bureaucracies often fail in many of these Confl icts of interest
areas.99
MG is a medical adviser to the Unity of First People of Australia, an
Health standards of Indigenous peoples are Aboriginal-run not-for-profi t organisation. He has no fi nancial confl icts
of interest. MK declares that he has no confl icts of interest.
unacceptably poor but there is no need to despair;
correction of the present situation needs a radical References
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