Addressing global health disparities among Indigenous peoples

In countries around the world, Indigenous peoples face great social disadvantages and poor health compared with the general population. In The Lancet, Ian Anderson and colleagues have documented signifi cant disparities among 28 Indigenous populations from 23 countries compared with benchmark populations for several variables, including life expectancy at birth, maternal and infant mortality, and frequency of low birthweight and high birthweight infants. They also showed diff erences for Indigenous peoples in measures related to nutrition (eg, child malnutrition, childhood obesity, and adult obesity), and in key social indicators, including educational attainment and economic status. Although their study did not include measures of mental health, burden of chronic disease, or disability, evidence exists from regional studies of Indigenous populations of major disparities in these areas as well. Although many Indigenous peoples in Anderson and colleagues’ study had worse health than the dominant groups in their countries, the magnitude and pattern of these poor outcomes varied across countries as well as among Indigenous groups within a geographical or political region. This variation should not surprise us. Indigenous and tribal peoples are very diverse, and live in extremely varied local environments and national contexts with important consequences for their health. For example, the health and social situation for Maori people—who represent about 15% of the total population of New Zealand, which has offi cially declared itself a bilingual, bicultural country—is profoundly diff erent from that of Indigenous groups in other countries who have had little recognition by the government, or continue to face active suppression of their cultures and political aspirations. Many Indigenous populations live in poverty in regions of the world with poor infrastructure and their health problems might reasonably be attributed to an absence of local resources, but evidence exists that more specifi c social forces are at play. The fact that even in well resourced countries such as Australia, Canada, and New Zealand, Indigenous peoples still experience substantial gaps of more than 5 years in life expectancy points to the detrimental eff ects of persistent social disadvantage. The sources of these inequities are in the social structural and political arrangements that are part of the enduring legacies of colonisation, and the creation of the nation states that profoundly reshaped the conditions of Indigenous peoples’ lives and communities. Understanding the consequences of this history and the current dynamics of marginalisation is essential for the development of eff ective social policy and public health interventions. Among other crucial contextual factors, Anderson and colleagues do not account for complex migratory patterns and demographic shifts of Indigenous populations, including those associated with urbanisation. Additionally, Indigenous identity is a social and cultural construct that changes over time. The failure to acknowledge or address this issue frames Indigenous status as a static concept. The historical process of colonisation and incorporation of Indigenous peoples into the nation state took diff erent forms in diff erent parts of the world with varying degrees of violence, dislocation, and cultural oppression, on diff erent timescales. The 2015 Truth and Reconciliation Commission in Canada framed the governments’ policies and practices of forced assimilation of Indigenous peoples for more than 100 years as cultural genocide. Not all Indigenous populations in the world have endured precisely the same forms of violence, but one common factor has been the experience of enclosure in a national state that defi nes its identity and priorities in ways that ignore, marginalise, denigrate, or actively suppress Published Online April 20, 2016 http://dx.doi.org/10.1016/ S0140-6736(16)30194-5