Nations

Health Care of Indigenous Peoples/Nations Gerard Bodeker, University of Oxford, Oxford, UK; and Columbia University, New York, NY, USA Ó 2017 Elsevier Inc. All rights reserved.

Background

Who Are Indigenous Peoples?

Indigenous peoples have suffered from historic injustices as a result of, inter alia, their colonization and dispossession of their lands, territories, and resources, thus preventing them from exercising, in particular, their right to development in accordance with their own needs and interests. Indigenous peoples have the right to their traditional medicines and to maintain their health practices, including the conservation of their vital medicinal plants, animals and minerals. Indigenous individuals also have the right to access, without any discrimination, to all social and health services. Indigenous individuals have an equal right to the enjoyment of the highest attainable standard of physical and mental health. States shall take the necessary steps with a view to achieving progressively the full realization of this right. UN Declaration on the Rights of Indigenous Peoples (2007).

The term ‘indigenous peoples’ is widely used to characterize a reported 370 million people worldwide (WHO, 2015) – from the Arctic to the South Pacific, from the Kalahari Desert in southern Africa to Tierra Del Fuego at the southernmost tip of the Americas. With ancient roots in their local areas, these peoples are among the world’s most marginalized populations – politically, economically, and territorially – and suffer the highest burden of health challenges (Box 1).

Box 1 The health of indigenous peoples: key messages l

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Globally, indigenous peoples suffer from poorer health, are more likely to experience disability, and reduced quality of life and ultimately die younger than their nonindigenous counterparts. Indigenous women experience health problems with particular severity, as they are disproportionately affected by natural disasters and armed conflicts, and are often denied access to education, land property, and other economic resources. Differences in infant mortality between indigenous and nonindigenous populations reflect the structural inequalities of these groups on an international level. Many of the most widespread causes of mortality among indigenous children are preventable, such as malnutrition, diarrhea, parasitic infections, and tuberculosis. Indigenous youth and adolescents face particular challenges in the realization of their right to health that are often not adequately addressed, including sexual and reproductive health and rights, and mental health. Statistical and health data collection is a key challenge in addressing Indigenous health disparities across the world and within regions.

From: Inter-Agency Support Group on Indigenous Peoples’ Issues; paper for 2014 World Conference on Indigenous Peoples.

International Encyclopedia of Public Health, 2nd edition, Volume 3

Asia, according to the International Work Group for Indigenous Affairs (IGWIA), is home to an estimated 260 million (i.e., 70%) of the world’s indigenous peoples. In India alone, there are 84.3 million Advasis, or indigenous peoples. The Orang Asli, the Mon-Khmer-speaking peoples of the Malaysian peninsula, by contrast, have a population of 180 000 and claim continuous presence in the world’s most ancient rainforests. And indigenous peoples in West Asia include the Bakhtiari, Laks, Lurs, and Qashqai of Iran, and Assyrian peoples of Iran, Iraq, and Turkey. IGWIA notes that “Asian indigenous peoples face problems such as denial of self-determination, the loss of control over their land and natural resources, discrimination and marginalization, heavy assimilation pressure and violent repression by state security forces” (see Relevant Websites). Despite this large population that self-identifies as indigenous, the term ‘indigenous’ has been contested, as almost all Asians and Africans consider themselves indigenous. In Africa, the term ‘indigenous’ has come to refer to nomadic peoples, such as the Tuareg of the Sahara and Sahel, hunter gatherers such as the San people of the Kalahari, and pastoralists, including the Maasai of East Africa. Their claim to indigenous status has been endorsed by the African Union’s African Commission on Human and Peoples Rights, which has noted their status of underrepresentation in government and the need for affirmative action to ensure their survival. In North and South America, where every nation has indigenous peoples, violence, marginalization, and isolation on native reservations, and in remote locations reduced access to traditional food supplies and increased susceptibility to disease. From the seventeenth century to the early twentieth century, there were a reported 93 waves of epidemics that devastated native populations with diseases such as typhoid, malaria, smallpox, measles, cholera, a range of sexually transmitted infections, pneumonia, and yellow fever, resulting in population declines of up to 90–95% (Encarta, n.d.). In the United States, census data indicate that there are approximately 2 million Native Americans. And in Canada, where Aboriginal people, including the Inuit of the Arctic region, have been designated as members of First Nations, the population is approximately 1.4 million. In Latin America, indigenous populations now range from Bolivia and Peru with just over 40% of the nation, to 60% in Guatemala, to Uruguay where, according to the 2011 Census, 2.4% of the population reported having indigenous ancestry (Da Silva and Santiago, 2011). The total indigenous population of Latin America is estimated at 40 million (IGWIA: see Relevant Websites). In Greenland, a self-governing country within the Danish Realm, with a total population of 56 000, the Inuit, the indigenous people of the polar region, number 50 000. Other indigenous European groups include the Kumandin Peoples of Russia and the Sami of northern Scandinavia.

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Oceania, which includes Australia, New Zealand, Papua New Guinea, and approximately 25 000 Pacific Islands, including the Marshall Islands, is home to indigenous groups from Polynesian, Melanesian, and Micronesian origins, as well as to Torres Straits Islanders. It is also home to indigenous Australians, who have at least 40 000–50 000, and potentially up to 70 000 years presence on the continent, with genetic linkages to the peoples of Papua New Guinea. Indigenous Australians now represent approximately 3.0% of Australia’s population (Australian Bureau of Statistics, 2011). Appropriation of land and water and the introduction of disease were two early features of colonial presence in Australia. Introduction of alcohol, opium, and tobacco began a problem of substance abuse that has continued in epidemic proportions. In New Zealand, there were similar patterns of conflict between British settlers and the Maori, as well as the introduction of new diseases. There were, however, formal treaties covering land acquisition and ownership (Minority Rights Group International, 2008). The lives of the majority of the world’s 370 million indigenous peoples are characterized by extreme conditions of social and environmental risk and historical injustice. Through remoteness, poverty, landlessness, and political marginalization, they have minimal access to health care and are underrepresented in national health-care statistics.

among adolescent women is estimated to be at 50% (see Relevant Websites). Yet, there can also be significant regional differences in population health, arising from individual population histories, lifestyle factors, environmental pollution, and underlying biological variation (Snodgrass, 2013). This variation in health status across indigenous populations has been borne out further by a landmark study describing the health and social status of Indigenous and tribal peoples relative to benchmark populations, Anderson et al (2016) studied 28 populations across 23 countries. Data showed poorer outcomes for Indigenous populations, although the size of the rate of difference varied across populations. The study found: l l

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Public Health Status Low levels of identification of indigenous people in national vital statistics and administrative data collections constitute a global barrier to the development of accurate indigenous health information. This in turn hinders a public health response. Indigenous populations are growing rapidly in many countries, and there is a higher child-to-adult dependency ration compared to nonindigenous populations. Sexual health is of great relevance to indigenous youth and adolescents. The United Nations Population Fund (UNFPA) notes: “A special mention needs to be made with respect to indigenous adolescents, given the higher proportion of adolescent maternity that reveals ethnic-related unequal access to reproductive rights.” A report from the Inter-Agency Support Group on Indigenous Issues (2014) reports that in Latin America, the proportion of young mothers in the indigenous population is higher than that of the nonindigenous population. The countries in this region with the greatest disparity between indigenous and nonindigenous adolescent mothers are Brazil (27% vs 12%), Costa Rica (30% vs 12%), Panama (37% vs 15%), and Paraguay (45% vs 11%), respectively. The rate of pregnancies for adolescent women in indigenous communities is inextricably linked to social norms and attitudes regarding sexual protection and family planning. Thus, precautions against sexually transmitted infections and HIV/AIDS are often forgone, resulting in high rates of sexually transmitted infections among indigenous youth. In Latin America, rates of HIV infection among women have risen from 4% in 1990 to 30% in 2007; in countries like Haiti, Guyana, and Dominican Republic, the rate of infection

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life expectancy at birth for 16 of 18 populations with a difference greater than 1 year in 15 populations; infant mortality rate for 18 of 19 populations with a rate difference greater than one per 1000 livebirths in 16 populations; maternal mortality in ten populations; low birth-weight with the rate difference greater than 2% in three populations; high birth-weight with the rate difference greater than 2% in one population; child malnutrition for ten of 16 populations with a difference greater than 10% in five populations; child obesity for eight of 12 populations with a difference greater than 5% in four populations; adult obesity for seven of 13 populations with a difference greater than 10% in four populations; educational attainment for 26 of 27 populations with a difference greater than 1% in 24 populations; and economic status for 15 of 18 populations with a difference greater than 1% in 14 populations.

The authors recommend that national governments, in the context of the UN Sustainable Development Goals, develop targeted policy responses to Indigenous health, improving access to health services, and Indigenous data within national surveillance systems. An accompanying Editorial in The Lancet commented: “Policy makers should follow Australia’s lead and make Indigenous disadvantage a national policy priority. Without that, the situation will remain unchanged, with 300 million people continuing to die much earlier than they should and women dying unnecessarily in childbirth” (Editorial, Lancet, July 9, 2016, p.104). The health status of indigenous Australians drew world headlines in 2007. The Australian Government, mobilized by a report highlighting high levels of child sexual abuse and violence in indigenous communities (Northern Territory Government, 2007), declared a state of emergency in the Northern Territory, banning alcohol in indigenous communities and mobilizing police and armed forces to enter indigenous communities to seize computers and other sources of pornography held to be the source of child sexual abuse. Part of a sequenced strategy, this was designed to be followed by teams of doctors to examine children and for possible referral for placement in foster care outside their communities. Such a drastic response led to strong condemnation by indigenous leaders, while others supported

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the action as overdue and needed in the face of endemic abuse (see Relevant Websites). A change in federal government led to a review of this policy and, in February 2008, to a national apology to indigenous Australians for past injustices: see Relevant Websites. Reiterating themes found across the literature on indigenous health, the Overview of Australian Indigenous Health (2014) notes that in Australia,

There is a clear relationship between the social disadvantages experienced by Aboriginal people and Torres Strait Islander people and their current health status. These social disadvantages, directly related to dispossession and characterised by poverty and powerlessness, are reflected in measures of education, employment, and income.

Indigenous infant mortality rates varied by state, ranging from a third higher to more than double the rate for nonindigenous infants. Newborns of indigenous women were more than twice as likely to be of low birth weight as those born to nonindigenous women; the lowest average birth weights for infants were those whose mothers used marijuana with tobacco or with both tobacco and alcohol. Overall, life expectancy was lower by 17 years for indigenous women and men. The leading cause of death among males and females in most states was cardiovascular disease (CVD), with rates up to 30% higher than the nonindigenous population. The next leading cause of death for indigenous males was injuries. These included automobile accidents, intentional self-harm and assault (3.0 times that of the total male population), cancer (1.3), respiratory diseases (3.9), and endocrine, nutritional, and metabolic disorders (primarily diabetes) (7.3). The most frequent causes of death for indigenous women, after CVD, were cancer (1.6 times the total female population), endocrine, nutritional, and metabolic disorders (11.7), injuries (2.9), and respiratory diseases (3.6). Lung cancer is among the leading forms of cancer for indigenous males and females, and cervical cancer is an important cause of death for indigenous women; the death rate in several Australian states is more than seven times that of nonindigenous women. Leading communicable diseases among indigenous peoples are tuberculosis, hepatitis A, B, and C, sexually transmitted infections, HIV/AIDS, Haemophilus influenza type b, pneumococcal disease, and meningococcal disease. Poverty, overcrowding, malnutrition, smoking, alcohol, and drug abuse rank high as key risk factors for this constellation of communicable diseases. The incidence of tuberculosis, for example, is 15 times higher than that of the wider Australian-born population. Diarrheal disease, eye and ear problems, and skin infections are also significantly higher among indigenous people and especially so among young children. Levels of disability and handicap are estimated to be at least double that of the general population. Despite uncertainty over definitions of mental health/ illness and inadequate data on mental health problems, indigenous people have high levels of mental health challenges and stress. A prominent manifestation of this is the rate of suicide. Based on sex-specific rates for the Australian population, suicide rates are more than 2.8 times that expected for

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indigenous males and 1.9 times more than expected for indigenous females. MacRae et al. (2012) note that these rates mask a very high youth suicide rate: indigenous to nonindigenous ratios are 3.4 for males and 6.1 for females in the 15–24 age groups. Health risk factors include high tobacco, alcohol and other drug use, poor nutrition, low income, limited education, high unemployment, high levels of stress, social marginalization, inadequate working conditions and housing, and gender-related challenges. These, in turn, interact with cultural and traditional factors to influence behavior, health status, and health outcomes.

Intervention Programs A key theme in communities is that self-management, self-policing, and culturally based solutions offer the most viable means of tackling socially based health problems. Native North American communities have been incorporating traditional forms of treatment into health programs for some years. In the United States, Indian Health Service (IHS) alcohol rehabilitation programs include traditional approaches to the treatment of alcoholism. An early analysis of 190 IHS contract programs revealed that 50% of these programs offered a traditional sweat lodge at their site or encouraged the use of sweat lodges. Treatment outcomes improved when a sweat lodge was available (Hall, 1986). Often these sweat lodges include the presence of medicine men or healers, and the presence of a traditional healer greatly improved the outcome when used in combination with the sweat lodge. Partnerships between traditional healers and mental health professionals have been reported and advocated in the Latin American context as well (Incayawar, 2009). Although reliable data on indigenous mental health are scarce, the World Health Organization has highlighted the inevitable mental health consequences of trauma and grief resulting from invasion, dislocation, and, not infrequently, genocide (Cohen, 1999). Generational experience of these and associated trauma such as family separations, Aboriginal deaths in custody, and high levels of imprisonment are linked with the high levels of substance abuse in many indigenous communities (Thomson et al., 2006). Culturally sensitive research methodology is essential in studying indigenous mental health issues. An ethnographic and participatory approach is basic in ensuring that meaningful data are generated (Kirmayer et al., 2000). A Canadian study on indigenous mental health used a participatory research design to survey causes of sadness and happiness. It found that children and adolescents (ages 7–18) judged school and victimization as sources of sadness more frequently than did other age groups and cited alcohol less frequently. Women cited death and relatives as sources of sadness, whereas males cited boredom (Bopp, 1985). The Arctic Climate Impact Assessment has also highlighted that alterations of the physical environment can lead to rapid and long-term cultural changes and loss of traditional culture. This, in turn, can create psychological distress and mental health challenges in indigenous communities (Berner et al., 2004).

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In Australia, as noted, substance abuse and violence rank high among health concerns of many indigenous communities (Thomson et al., 2006). In the early 1990s, Yuendumu, a remote Aboriginal township on the edge of the Tanami Desert, was gripped by an epidemic of petrol sniffing among young people. This northern Australian indigenous community adopted a ‘zero-tolerance’ policy when violence and property damage fueled by petrol sniffing was destabilizing the community. With up to 70 regular ‘sniffers’ in a community of 400, elders sent young petrol sniffers to Mt. Theo, an outstation 160 km from their remote township of Yuendumu and 50 km from the nearest road. A program of recovery from addiction and instruction in traditional culture, matched by a comprehensive youth program in Yuendumu offering alternatives to petrol sniffing, succeeded in breaking the cycle of addiction and violence. Within a decade, there were no petrol sniffers in Yuendumu and the Mt. Theo program is now viewed as a model for other communities afflicted by petrol sniffing (Australians for Native Title and Reconciliation, 2007). With time, new directions have begun to be forged in Australia and in Queensland, for example, the Urban Institute for Indigenous Health conducts a number of programs on urban Aboriginal health designed and led by Aboriginal and Torres Strait Islander health workers. These include dedicated health clinics, a comprehensive maternal and child health service, prevention education such as nutritional education, smoking prevention, and an Indigenous Ambassadors school and community based education program, “which encourages Indigenous people to be healthy role models for family, friends and broader community networks” (www.iuih.org.au, 2015).

Environmental Factors Biodiversity and Human Health The environmental impact of landscape changes on health is now gaining attention in both public health and conservation arenas, where it is recognized that environmental disturbance affects the ecological balance of the hosts of diseases as well as of disease-causing pathogens and parasites. The World Health Organization has recorded over 36 new emerging infectious diseases since 1976, many of which, particularly malaria and dengue, are the direct result of landscape influencing the ecology of disease (Taylor et al., 2001). As has been noted by the Harvard Project on Biodiversity and Health, human health, biodiversity, and poverty reduction represent a nexus of interrelated issues that lie at the center of human development; biodiversity, in turn, is dependent upon human health, as undernourished communities and those weak with disease will draw heavily on their surroundings for wild food resources and fuelwood (Epstein et al., 2003; Box 2). In addition to losing traditional hunting and cultural territory, deforestation exposes indigenous forest-dwelling communities to new diseases. For example, in the case of malaria and other mosquito borne diseases such as dengue fever, the process of deforestation is known to reduce the diversity of forest mosquitoes. Yet, those species that do survive have been found to transmit malaria more effectively than the forest-dwelling species that had previously been prevalent. This outcome has been observed in all areas of

Box 2 Biodiversity Loss l

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People in developing countries face particularly heavy health burdens from a loss of biodiversity, with impacts on food supply and quality, medicines, and cultural and religious values. It has been estimated that approximately 80% of the world’s population from developing countries rely mainly on traditional medicines derived from plants and that 25% of prescriptions dispensed in United States pharmacies contained plant extracts or active ingredients derived from plants. Also, as the number of crop varieties has shrunk in the past 50 years: with 90% of the world’s calories coming from a dozen crops, people’s diets have been simplified and nutritional diseases have arisen in part as a result. Obesity and diabetes, as well as many other emerging plagues such as mental health ailments, including depression, can all in part be connected to biodiversity loss.

FROM: CBD factsheet from: Chivian, E., Bernstein, A. (Eds.), Sustaining Life: How Human Health Depends on Biodiversity. Oxford University Press, New York, NY. World Health Organization.

high malaria risk – the Amazon, East Africa, Thailand, and Indonesia (see Relevant Websites). Deforestation can affect the emergence and spread of human infectious diseases in other ways as well. With forest loss comes a loss of habitat and food for some species that serve as reservoirs for human diseases. For example, an outbreak of Nipah virus infections in Malaysia resulted from forest loss and a change of behavior of fruit bat species that are reservoirs of human disease. With the loss of forest habitats, the bats moved to mango trees surrounding large pig farms at the edge of forests and fed on these. Their infected saliva on fallen fruit and their feces were consumed by pigs who contracted the Nipah virus for which the fruit bat is a vector. This was, in turn, passed on to humans resulting in 257 human infections and 105 deaths (Looi and Chua, 2007). Deforestation also leads to disturbance of soil borne pathogens. “Approximately one-half of the people of Southeast Asia living in poverty have one or more soil-transmitted helminth infection. Indigenous populations, such as the Orang Asli communities in peninsular Malaysia, are disproportionately affected, with high levels of community prevalence and intensities” (Hotez et al., 2015) to improve the health situation of indigenous peoples, it is critical to recognize that their health and well-being are linked to their collective rights, such as rights to conserve and practice traditional knowledge. Water is a common source of infection for those living in poverty, especially indigenous communities. In Southeast Asia, intestinal protozoa such as toxoplasmosis is common among the Orang Asli indigenous communities of Malaysia (Lim et al., 2009; Romano et al., 2010; Ngui et al., 2011). Prevalence data are not available for intestinal protozoan infections or toxoplasmosis, but it is presumed that similar trends are found in other impoverished communities across Southeast Asia (Hotez et al., 2015). “To improve the health situation of indigenous peoples, it is critical to recognise that their health and well-being are linked

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to their collective rights, such as rights to conserve and practice traditional knowledge” (State of the world’s indigenous peoples, 2010). A program in India involving indigenous (so-called ‘tribal’) communities and landless and marginal farmers promoted the concept of home herbal gardens (HHG) as a means of decreasing family health problems and reducing high expenditures on health care (Hariramamurthi et al., 2007). This was part of a wider program to promote medicinal plant conservation and the forests that are their home. Medicinal plants were selected to address such common ailments as cold, cough, fever, diarrhea, dysentery, cuts and wounds, irregular menstruation and other menstrual conditions, joint pain, insect bites, indigestion and gastric complaints, mouth ulcer, and urinary infections and disorders. In each setting, a village resource person was trained in how to grow and use the medicinal plants, and she, in turn, trained the households. An independent evaluation showed that the HHG program was adopted by the poorest of the poor, namely landless (33%), marginal landholding (37%), and small landholding (21%) farmers; 86% of adopters belonged to socially deprived communities, particularly indigenous communities. HHGs benefited mainly women and children in poor communities as a first response to common conditions such as cold, cough, and fever. HHG participants reported economic benefits in the form of savings from PHC-related expenses by use of home remedies. Health expenditures by non-HHG households was approximately five times greater than for HHG households.

Climate Change and Indigenous Health Climate change is being reported globally as a challenge to indigenous communities. More than a decade ago, the Arctic Climate Impact Assessment (ACIA) evaluated Arctic climate change and its impact for the region and the world (Berner et al., 2004). Indigenous people make up approximately 10% of the total Arctic population, which includes populations from Norway, Sweden, Finland, Denmark, Iceland, Canada, Russia, and the Untied States. ACIA argued that changing weather conditions, resulting in increased storms, reduced sea ice, and thawing ground, and the accompanying reduction in species’ ranges and availability, will affect human health and food security and possibly the survival of some indigenous cultures. Of the 4 million who presently live in the Arctic, 400 000 are indigenous people. Inuit communities have reported massive drops in walrus and seal populations, both species vital to the nutritional well-being and survival of the Inuit. In Alaska, melting permafrost has undermined foundations of buildings leaving indigenous communities facing crumbling infrastructure, damaged sewage systems and destroyed schools and public facilities (Ferris and Hu, 2015). Changes in climate are occurring faster than traditional knowledge is able to adapt. Across the Arctic indigenous people are reporting changes in climate and in the fish and animal and bird populations on which they depend for food. Melting ice makes travel to traditional hunting areas difficult and reduction in summer sea ice makes ringed seals

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harder to find. Elevated ultraviolet (UV) light levels will lead to UV exposure of young people by more than 30%, thus increasing the risk of skin cancers, cataracts, and immune system disorders. Drought and associated desertification are also risks of climate change and threats to the health and livelihoods of indigenous communities. In western Arnhem Land in northern Australia, indigenous people are reviving traditional landscape burning patterns, begun soon after the rains, to reduce combustible material that can cause far larger, damaging fires and to regenerate useful plants and animals. Supported by a gas refinery, required by environmental law to reduce its greenhouse emissions, a unique carbon trading agreement has been forged with government and indigenous communities. The agreement recognizes that if, in 1 year, indigenous people could reduce the area burned in wildfires by just 7%, they would create the equivalent of at least 100 000 tonnes in greenhouse gas savings. Starting in 2007, the refinery owner, Conoco-Phillips, has contracted to pay a $1 million a year for 17 years to employ Arnhem Land people and support their fire management. Known as the West Arnhem Land Fire Abatement (WALFA), the project was the first Savanna Fire Management project using traditional fire management practices together with scientific knowledge and research to better control the extent and severity of savanna wildfires and thereby reducing greenhouse gas emissions (see Relevant Websites). The money has been used to support community health and education programs. Enhanced self-sufficiency in health care has been won through a revival of traditional practices, also contributing to reduced carbon emissions, improved global health, and environmental security – surely a sound contemporary model for integrated indigenous health development. Coastal communities in West Africa are vulnerable to the impact of rising sea levels. Desertification in the Sahel is forcing farming and pastoralist populations further south, away from their traditional lands. The resulting relocation to fringe settlements in urban centers heightens conditions of poverty, disease, including exposure to HIV/AIDS, and exploitation, including heightened risk of violence against women. Abandonment of pastoralist lifestyles in Cameroon’s Mbororo community, for example, has resulted in men moving to urban centers, with women and children being left behind in desertifying areas. Encroachment of invasive plant species has resulted from reduced grazing and land use has become further restricted. In Mauritania, drought and food insecurity have become permanent challenges associated with climate change and depletion of natural resources, with 20 and 30% of the population suffers from high food insecurity according to the World Food Program. The result has been a rapid increase in urbanization with all of the attendant problems. Examples from Pacific communities demonstrate that local solutions are also being employed with success. According to the Secretariat of the Pacific Regional Environment Program (SPREP), ‘adaptation to climate change is becoming a Pacific way of life.’ This has included installation of storage tanks and innovative drainage systems, which has helped to diffuse water contamination and potential health risks arising from unusually long periods of drought and saltwater intrusion. It

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is now widespread among Pacific communities to work on strengthening their biodiversity, planting dense vegetation and building sea walls, aware of the risks of erosion and landslides to the densely populated areas along their coastlines. In Samoa, training local people in the design and building of traditional Samoan dwellings has led to promotion of resilient housing and reduced need for relocation. Indigenous customs and knowledge have also been recognized as a tool to tackle the effects of climate change. In the Philippines, a UNESCO-led project has studied indigenous cultural practices to help policy makers devise better disaster preparedness strategies in coastal areas. According to a Minority Rights (2015) report: “The study identified a number of traditions that were used to accurately predict disasters, such as typhoons or tsunamis, and later integrated with scientific approaches. The study found that indigenous communities have developed various ways to strengthen their houses and store food ahead of disasters, offering useful lessons in strengthening local resilience.” (Minority Rights, 2015; see Relevant Websites).

Conclusion The health of indigenous people is typically influenced by histories of social injustice, loss of territorial rights, marginal social status, and limited employment and income opportunities. Overall, the intractability of indigenous health determinants and health status warrants a comprehensive global strategy, based on a human rights approach, with local action by governments in partnerships with indigenous organizations. The challenge by several governments – with significant indigenous populations – to the eventual passage on 13 September 2007, of the UN Declaration on the Rights of Indigenous Peoples through the UN General Assembly underscores the obstacles ahead in any such global strategy. Another challenge is the need for comprehensive local, national, and regional data collection, inclusive of indigenous peoples and their health conditions, as an epidemiological framework for action. Despite repeated challenges from indigenous peoples for stronger action, the World Heath Organization, through a number of World Health Assembly (WHA) resolutions, is mandated to accord special attention to the health of indigenous peoples. There is also commitment to convene partners and catalyze action to improve indigenous peoples’ health and human rights. As for the basic prerequisites for improvement and development, Health Unlimited has outlined priorities for indigenous health development: 1. Train local people to provide basic health services in remote areas. 2. Ensure that traditional practitioners are involved and that their views are appreciated, so new ideas about health are more likely to be taken on board in isolated, indigenous communities. 3. Provide safe water and improve sanitation. 4. Provide information regarding indigenous peoples’ rights and entitlement to health care (see World Directory of Minorities and Indigenous Peoples: see Relevant Websites).

5. Work with state health providers to ensure indigenous peoples are not discriminated against when it comes to accessing health services (see Relevant Websites). As the global rural–urban drift continues and indigenous peoples join marginal groups living in urban poverty, the future would seem to hold a mix of trends: continued intractability in the determinants of poor health, accompanied by isolated models of success. Where solutions do present themselves, success would seem to be based on self-sufficiency, recourse to traditional cultural practices, and equitable partnerships with agencies receptive to new models of work.

See also: Populations at Special Health Risk: Indigenous Populations.

References Anderson I, Robson B, Connolly M, et al. Indigenous and tribal peoples’ health (The Lancet–Lowitja Institute Global Collaboration): a population study. Lancet 2016; published online April 20. http://dx.doi.org/10.1016/S0140-6736(16)00345-7. Australians for Native Title and Reconciliation, 2007. Success Stories in Indigenous Health. ANTR, Rozelle, NSW, Australia. Australian Bureau of Statistics, June 2011. Estimates of Aboriginal and Torres Strait Islander Australians. http://www.abs.gov.au/ausstats/[email protected]/mf/3238.0.55.001 (accessed 19.07.15.). Berner, J., Furgal, C., Bjerregaard, P., et al., 2004. Human health. In: ACIA (Ed.), Impacts of a Warming Arctic: Arctic Climate Impact Assessment, Ch. 15. Cambridge University Press, Cambridge, UK. Bopp, M., 1985. Developing Healthy Communities: Fundamental Strategies for Health Promotion. Four Worlds Development Project: University of Lethbridge, Lethbridge, UK. Cohen, A., 1999. The Mental Health of Indigenous Peoples: An International Overview. Department of Mental Health, World Health Organization, Geneva, Switzerland. Da Silva, V., Santiago, K., August 27, 2011. “Censo 2011. Organizaciones Sociales Llaman a Decir “Sí” Para Reconocer sus Etnias – Censo: afrodescendientes e indígenas hacen campaña”. Matías Rotulo (in Spanish). LaRed21 Comunidad. Editorial, Lancet, July 9, 2016, 338, 104. Epstein, P.R., Chivian, E., Frith, K., 2003. Emerging diseases threaten conservation. Environ. Health Perspect. 111 (10), A506–A507. Ferris, E., Hu, A.C., May 29, 2015. Climate change, indigenous peoples, and mobility in the Arctic. Harv. Int. Rev. http://www.hir.harvard.edu/archives/11386 (accessed 21.07.15.). Hall, R.L., 1986. Alcohol treatment in American Indian communities: an indigenous treatment modality compared with traditional approaches. Ann. N.Y. Acad. Sci. 472, 168–178. Hariramamurthi, G., Venkatasubramanian, P., Unnikrishnan, P.M., Shankar, D., 2007. Kitchen herbal gardens: biodiversity conservation and health care at the local level. In: Bodeker, G., Burford, G. (Eds.), Traditional, Complementary and Alternative Medicine: Policy and Public Health Perspectives. Imperial College Press, London. Hotez, P.J., Bottazzi, M.E., Strych, U., Chang, L.-Y., Lim, Y.A.L., Goodenow, M.M., et al., 2015. Neglected tropical diseases among the Association of Southeast Asian Nations (ASEAN): overview and update. PLoS Negl. Trop. Dis. 9 (4), e0003575. http://dx.doi.org/10.1371/journal.pntd.0003575 (accessed 19.07.15.). International Work Group for Indigenous Affairs. http://www.iwgia.org/regions/asia (accessed 19.07.15.). Incayawar, M., 2009. Future partnerships in global mental health- foreseeing the encounter of psychiatrists and traditional healers. In: Incayawar, M., Wintrob, R., Bouchard, L. (Eds.), Psychiatrists and Traditional Healers: Unwitting Partners in Global Mental Health. Wiley-Blackwell, London, pp. 251–260. Kirmayer, L.J., Macdonald, M.E., Brass, G.M., 2000. The mental health of indigenous peoples. Proceedings of the Advanced Study Institute, the Mental Health of Indigenous Peoples. In: McGill Summer Program in Social and Cultural Psychiatry and the Aboriginal Mental Health Research Team May 29–May 31. Culture and Mental Health Research Unit, Montreal, Quebec. Montreal; Report No. 10.

Health Care of Indigenous Peoples/Nations

Lim, Y.A., Romano, N., Colin, N., Chow, S.C., Smith, H.V., 2009. Intestinal parasitic infections amongst Orang Asli (indigenous) in Malaysia: has socioeconomic development alleviated the problem? Trop. Biomed. 26, 110–122 pmid:19901897. Looi, L.M., Chua, K.B., December 2007. Lessons from the Nipah virus outbreak in Malaysia. Malays. J. Pathol. 29 (2), 63–67. MacRae, A., Thomson, N., Anomie, Burns, J., Catto, M., Gray, C., Levitan, L., McLoughlin, N., Potter, C., Ride, K., Stumpers, S., Trzesinski, A., Urquhart, B., 2012. Overview of Australian Indigenous Health Status. Retrieved 21 July, 2015 from: http://www.healthinfonet.ecu.edu.au/overview_2013.pdf. Minority Rights Group International, 2008. World Directory of Minorities and Indigenous Peoples – New Zealand: Maori. Available at: http://www.refworld.org/docid/ 49749cd8c.html (accessed 19.07.15.). Minority Rights, 2015. State of the World’s Minorities and Indigenous Peoples. http:// www.minorityrights.org/13061/attachments/_MRG-state-of-the-worlds-minorities2015-FULL-TEXT.pdf (accessed 19.07.15.). Ngui, R., Lim, Y.A., Amir, N.F., Nissapatorn, V., Mahmud, R., 2011. Seroprevalence and sources of toxoplasmosis among Orang Asli (indigenous) communities in Peninsular Malaysia. Am. J. Trop. Med. Hyg. 85, 660–666. http://dx.doi.org/ 10.4269/ajtmh.2011.11-0058 pmid:21976569. Northern Territory Government, 2007. Report of the Northern Territory Board of Inquiry into the Protection of Aboriginal Children from Sexual Abuse. Northern Territory Government, Darwin, Australia. Romano, N., Nor Azah, M.O., Rahmah, N., Lim, Y.A., Rohela, M., 2010. Seroprevalence of toxocariasis among Orang Asli (Indigenous people) in Malaysia using two immunoassays. Trop. Biomed. 27, 585–594 pmid:21399601. Snodgrass, J.J., 2013. Health of Indigenous Circumpolar Populations. Annual Review of Anthropology 42, 69–87. http://dx.doi.org/10.1146/annurev-anthro-092412155517. Taylor, L.H., Latham, S.M., Woolhouse, M.E., 2001. Risk factors for human disease emergence. Philos. Trans. R. Soc. Lond. 356, 983–989. UN Declaration on the Rights of Indigenous Peoples, 2007. http://www.un.org/esa/ socdev/unpfii/documents/DRIPS_en.pdf (accessed 21.07.15.). WHO, 2015. WHO End TB Strategy. http://www.who.int/tb/post2015_strategy/en/ (accessed 20.07.15.).

Further Reading Ahmad, A.F., Hadip, F., Ngui, R., Lim, Y.A., Mahmud, R., 2013. Serological and molecular detection of Strongyloides stercoralis infection among an Orang Asli community in Malaysia. Parasitol. Res. 112, 2811–2816. http://dx.doi.org/ 10.1007/s00436-013-3450-z pmid:23666229. Al-Harazi, T., Ghani, M.K., Othman, H., 2013. Prevalence of intestinal protozoan infections among Orang Asli schoolchildren in Pos Senderut, Pahang, Malaysia. J. Egypt. Soc. Parasitol. 43, 561–568. http://dx.doi.org/10.12816/0006413 pmid:24640856. Australian Bureau of Statistics, 2014a. Australian Aboriginal and Torres Strait Islander Health Survey updated results, 2012–13-Australia: table 6.3 [data cube]. http://www.abs.gov.au/ausstats/[email protected]/Lookup/by%20Subject/4727. 0.55.0032012-13Main%20FeaturesFeature%20article:%20%20Chronic %20disease%20results%20for%20Aboriginal%20and%20Torres%20Strait% 20Islander%20and%20non-Indigenous%20Australians134 (accessed 20.07.15.). Australian Bureau of Statistics, 2014b. Feature Article: Chronic Disease Results for Aboriginal and Torres Strait Islander and Non-indigenous Australians. http://www.abs. gov.au/ausstats/[email protected]/Lookup/by%20Subject/4727.0.55.0032012-13Main %20FeaturesFeature%20article:%20%20Chronic%20disease%20results%20for% 20Aboriginal%20and%20Torres%20Strait%20Islander%20and%20non-Indigenous %20Australians134 (accessed 19.07.15.). Bodeker, G., 2007. Traditional medicine. In: Cook, G., Zumla, A. (Eds.), Manson’s Tropical Diseases, twenty-second ed. WB Saunders, Elsevier Health Sciences, London. Bodeker, G., Burford, G. (Eds.), 2007. Public Health and Policy Perspectives on Traditional, Complementary and Alternative Medicine. Imperial College Press, London. Bodeker, G., Ong, C.-K., Burford, G., Grundy, C., Shein, K. (Eds.), 2005. World Health Organization Global Atlas on Traditional and Complementary Medicine, 2 vols. World Health Organization, Geneva, Switzerland. Canadian Development Corporation (CDC), 2008. International Group for Indigenous Health Measurement Terms of Reference. http://www.cdc.gov/nchs/data/isp/ IGIHM_Terms_of_Reference.pdf (accessed 19.07.15.).

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Chivian, E., Bernstein, A. (Eds.), 2008. Sustaining Life: How Human Health Depends on Biodiversity. Oxford University Press, New York, NY. World Health Organization. Pan American Health Organization (PAHO), n.d. Health of Indigenous Peoples. http:// www.paho.org/english/ad/ths/os/Indig-home.htm (accessed December 2007). UNICEF India, 2015. Nutrition and Tribal Peoples- A Report on Nutrition Situation of India’s Tribal Children. http://www.unicef.in/tribalchildren/Story-Nutritionand-Tribal-Peoples-A-Report-on-Nutrition-Situation-of-India-s-Tribal-Children-. html (accessed 20.07.15.). UN Permanent Forum on Indigenous Issues, 2009. WHO, n.d. The Health and Human Rights of Indigenous Peoples. http://www.who.int/ hhr/activities/indigenous/en/ (accessed December 2007). WHO, 2003. Indigenous Peoples and Participatory Health Research: Planning and Management/Preparing Research Agreements. WHO, CINE, Geneva, Switzerland. World Factbook, 1997. Central Intelligence Agency, Washington, DC. http://www.odci. gov/cia/publications/factbook/ (accessed 25.01.08.). World Factbook, 2007. CENIMAR, Troy Studios, Loomis, California. http://www. seminar.com/factbook/index.jsp (accessed 25.01.08.).

Relevant Websites http://www.hc-sc.gc.ca/ahc-asc/activit/strateg/fnih-spni/ahhri-irrhs_e.html – Aboriginal Health Human Resources Initiative – (Canada). http://www.aph.gov.au/house/news/news_stories/news_sorry.htm – APH Government Organization. http://www.healthinfonet.ecu.edu.au/ – Australian Indigenous Health InfoNet. http://news.bbc.co.uk/2/hi/asia-pacific/6229708.stm – BBC news Organization. http://www.chgeharvard.org/sites/default/files/resources/182945%20HMS% 20Biodiversity%20booklet.pdf – Biodiversity Resources. http://www.unfpa.org/webdav/site/global/shared/documents/events/2011/IASGBriefingNote. pdf – Economic Commission for Latin America and the Caribbean (ECLAC), 2007. Information on the Permanent Forum on Indigenous Peoples Issues and the Upcoming UNFPA Hosted Inter-agency Support Group Meeting on Indigenous Peoples Issues. http://www.frlht.org – Foundation for Revitalization of Local Health Traditions. http://www.iphrc.ca/ – Indigenous People’s Health Research Centre, (Canada). www.iuih.org.au – Institute for Urban Indigenous Health. http://www.un.org/en/ga/president/68/pdf/wcip/IASG_Thematic%20paper_Health.pdf – Inter-Agency Support Group on Indigenous Peoples’ Issues. Thematic Paper towards the Preparation of the 2014 World Conference on Indigenous Peoples. http://www.iwgia.org/regions/latin-americaiwgia – International Work Group for Indigenous Affairs (IWGIA) – Asia. http://www.iwgia.org/regions/latin-americaiwgia – International Work Group for Indigenous Affairs (IWGIA) – Latin America. http://www.iwgia.org/regions/asiaiwgia – International Work Group for Indigenous Affairs. http://www.iwgia.org/regions/latin-americaiwgia – International Work Group for Indigenous Affairs in America. www.minorityrights.org; www.minorityvoices.org – Minority Rights Group International. http://www.minorityrights.org/13061/attachments/_MRG-state-of-the-worlds-minorities2015-FULL-TEXT.pdf – Minority Rights International, 2015. State of the World’s Indigenous Peoples. http://www.nailsma.org.au/walfa-west-arnhem-land-fire-abatement-project – NAILSMA Organization. http://www.oxfam.org.au/campaigns/indigenous/health.php – Oxfam: Close the Gap: Indigenous Health in Crisis. http://www.new.PAHO/WHO.org/hq/dmdocuments/2009/tool%20box%2010069_ IndigPeople.pdf – PAHO/WHO, 2008. Human Rights and Health: Indigenous Peoples, p. 2. http://www.un.org/esa/socdev/unpfii/documents/SOWIP/en/SOWIP_web.pdf – Symbols of United Nations Documents. http://www.who.int/gb/EBWHA/PDF/WHA55/EA5535.pdf; http://www.un.org/esa/socdev/ pfii/index.html; www.unesco.org/culture/indigenous/index.shtmlwww.who.int/gb/EB %20WHA/PDF/WHA55/EA5535.pdf – UN Decade of Indigenous Peoples. http://www.un.org/en/ga/president/68/pdf/wcip/IASG_Thematic%20paper_Health.pdf – UN Organization. http://www.who.int/healthsystems/topics/financing/healthreport/IHNo33.pdf – World Health Report, 2010. Background Paper 33: Indigenous Health – Australia, Canada, Aotearoa New Zealand and the United States – Laying Claim to a Future that Embraces Health for Us All.