Elsevier

The Lancet

Volume 374, Issue 9683, 4–10 July 2009, Pages 76-85
The Lancet

Review
Indigenous health part 2: the underlying causes of the health gap

https://doi.org/10.1016/S0140-6736(09)60827-8Get rights and content

Summary

In this Review we delve into the underlying causes of health disparities between Indigenous and non-Indigenous people and provide an Indigenous perspective to understanding these inequalities. We are able to present only a snapshot of the many research publications about Indigenous health. Our aim is to provide clinicians with a framework to better understand such matters. Applying this lens, placed in context for each patient, will promote more culturally appropriate ways to interact with, to assess, and to treat Indigenous peoples. The topics covered include Indigenous notions of health and identity; mental health and addictions; urbanisation and environmental stresses; whole health and healing; and reconciliation.

Introduction

In the companion piece1 Gracey and King explored some of the present trends in Indigenous health. In this second review we will consider more closely the underlying causes of Indigenous health disparities. Our major thrust is Indigenous perspectives on the causes of the poor health of Indigenous peoples, which are not the usual causes of health disadvantage—as brought out, for example, in the 1986 Ottawa Charter2 and the work of the WHO Commission on Social Determinants of Health.3 We focus to a considerable degree on the Indigenous people of North America, although we draw on the experiences of New Zealand and Australia as well. Within that context, much of our material is drawn from our Canadian perspective.

The idea of the analytical framework of this Review is that enabling the reader to arrive at an understanding of the interplay of the processes affecting Indigenous health in one specific context (North America), will allow readers in other contexts to better understand how Indigenous processes play out there. The main argument, implicit in our understanding, is that Indigenous social inequalities, which result from a combination of classic socioeconomic and connectivity deficits as well as Indigenous-specific factors related to colonisation, globalisation, migration, loss of language and culture, and disconnection from the land, lead to the health inequalities of Indigenous peoples. The specifics will vary across cultures, dependent on a range of external factors, but the principles are the same. Indigenous health inequalities arise from general socioeconomic factors in combination with culturally and historically specific factors particular to the peoples affected.

This analytical framework aligns with the key themes identified in the Symposium on the Social Determinants of Indigenous Health held in Adelaide in April, 2007.4 The colonisation of Indigenous peoples was seen as a fundamental health determinant. Mowbray, writing in the report4 said: “This process continues to impact health and well being and must be remedied if the health disadvantages of Indigenous Peoples are to be overcome. One requirement for reversing colonisation is self determination, to help restore to Indigenous Peoples control over their lives and destinies…Another fundamental health determinant is the disruption or severance of ties of Indigenous Peoples to their land, weakening or destroying closely associated cultural practices and participation in the traditional economy essential for health and well being.”

Section snippets

Notions of health, illness, and healing

Research into Indigenous health has been largely focused on non-Indigenous, rather than Indigenous, notions of health—ie, disease and treatment. By contrast, Indigenous peoples define wellbeing far more broadly than merely physical health or the absence of disease. For example, the Anishinabek (Ojibway) word mno bmaadis, which translates into living the good life or being alive well, encapsulates beliefs in the importance of balance. All four elements of life, the physical, emotional, mental,

Identity and health

Many Indigenous peoples have an idea of the person that can be characterised as community-centred, since other people belonging to one's own community, the land, and its animals are all viewed as inherently a part of the self. Durie and colleagues10, 11 have said that the devastations that followed from the colonial experiences resulted from disruption (among much else) of the crucial bond with the land and the natural environment that is the key feature of indigeneity, and is mirrored by

Mental health and addictions

Many people hold the belief that “Identity is a necessary prerequisite for mental health.”.11 The wide variation in rates of suicide and other indices of distress across Indigenous communities (panel 3) suggests the importance of considering the nature of communities and the different ways that these groups have responded to the continuing stresses of colonisation, sedentary lifestyle, bureaucratic surveillance, and technocratic control. In all likelihood, the mediating mechanisms contributing

Effects of rural-urban migrations

Urbanisation is part of the continuing transformation of Indigenous peoples' culture, perhaps its most apparent manifestation (panel 4). However, possibly more important than urbanisation per se is residential instability, which is marked by frequent migrations back and forth from cities to reserve communities, as well as by high mobility within cities. This instability probably diminishes the wellbeing of urban Indigenous peoples40—ie, high mobility necessarily weakens whatever social cohesion

Loss of land and destruction of environment

A Canadian Government survey in 2001 showed that two-thirds of First Nations reserves had water supplies that were at risk of contamination. In the 2001 Aboriginal Peoples Survey,19 34% of Inuit living in the north, 19% of Aboriginal people in rural areas, and 16% of those in urban areas reported that there were times in the year that their drinking water was contaminated. Aboriginal people are similarly much more likely than the non-Aboriginal population to live in crowded houses. Many

Indigenous health and gender issues

The mobility and instability affecting Indigenous peoples could have particular relevance to Indigenous men's health. Isolation, alienation from families and society, and incarceration are all issues that particularly affect Indigenous men's health.44 Indigenous people have disproportionately high rates of incarceration;45 this is common to developed nations, and possibly a worldwide occurrence. After release, such men most frequently want to go home, but their communities often reject them.

In

Elder health and healthy ageing

We need to distinguish between Elders and elderly people. Both are key in Indigenous societies. Elders are those who have shown wisdom and leadership in cultural, spiritual, and historical matters within their communities, and might not necessarily be old. Elders represent an essential connection with the past; they are keepers of the community knowledge and supporters of its collective spirit.

Multifarious issues converge to promote increasingly poor health with advancing age. Worldwide,

Whole health and community health

Holistic health has been defined as “the vision most First Nations peoples articulate as they reflect upon their future. At the personal level this means each member enjoys health and wellness in body, mind, heart, and spirit. Within the family context, this means mutual support of each other. From a community perspective it means leadership committed to whole health, empowerment, sensitivity to interrelatedness of past, present, and future possibilities, and connected between cultures.”51 The

Politics of Indigenous health

Kirmayer and co-workers18 report that continuing transformations of identity and community have led some groups to do well, whereas others face catastrophe, and that, in many cases, the health of the community seems to be linked to local control and cultural continuity. They go on, “Attempts to recover power and to maintain cultural traditions must contend with the political, economic, and cultural realities of consumer capitalism, technocratic control and globalization”.18

As stated by Durie

Reconciliation and healing

In Australia, and then in Canada, the year 2008 saw apologies on the part of the federal governments for their assimilationist policies.62, 63 After these apologies, and indeed in other countries where apologies have still not been made, healing has to occur. The Australian Government is committed to closing the 17-year gap in Aboriginal life-expectancy. Canada has set up a Truth and Reconciliation Commission. Panel 5 shows quotes about reconciliation from the Aboriginal Healing Foundation.50

Are we making progress?

Provision of these Indigenous perspectives on health and the social contexts within which many Indigenous people live might be useful to medical practitioners who treat Indigenous patients. Having framed this Review around how Indigenous notions of health inequalities can help to explain the inequalities in a particular context, we hope that the principles included in this type of analysis might also apply to non-Indigenous ethnic groups whose health deficits are related to identity-based

Search strategy and selection criteria

As in part I of this Review:1 “Indigenous”, “Aboriginal”, or “Aborigines”, linked with “health”, “nutrition”, “malnutrition”, “growth”, “infants”, “children”, “pregnancy”, “maternal health”, “adolescents”, “infections”, “parasites”, “hypertension”, “cardiovascular disease”, “diabetes”, “renal disease”, “dialysis”, “alcohol”, “drugs”, “trauma”, “accidents”, “drowning”, “poisoning”, “homicide”, “suicide”, and “mortality”. Additional search terms were: “American Indian”, “Alaska Native”,

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