The world's almost 400 million Indigenous people have low standards of health – traditionally related to malnutrition, poverty, environmental contamination, and prevalent infections. But as these peoples move to more modern or 'western' lifestyles, conditions such as obesity, cardiovascular diseases, and type 2 diabetes have soared, as have physical, social and mental disorders related to misuse of alcohol and other drugs. Indigenous people must be enabled and encouraged to take responsibility for issues that affect their health. These issues are discussed in the first of two Reviews in this week's edition of The Lancet, written by Professor Michael Gracey, Unity of First People of Australia, Perth, WA, Australia, and Professor Malcolm King, University of Alberta, Edmonton, Canada. The authors discuss indigenous people worldwide but focus on Aboriginal Australians.
Poor living conditions, malnutrition, and infections cause a heavy burden of disease in Indigenous infants and children – including ear disease, tooth decay, trachoma, diarrhoeal diseases, and respiratory infections. Vaccine-preventable diseases, including measles, mumps, diphtheria, rubella, whooping cough and tetanus have been controlled in most non-Indigenous populations, but are still rife and potentially fatal in many Indigenous groups. The authors say: "This area should be a priority for action by governments and non-governmental organisations."
Malnutrition is often caused by poverty and made worse by inadequate food storage facilities in the home. About 15% of Aboriginal children aged less than 5 years in Australia's Northern Territory are underweight, 11% are stunted, and 9% are wasted (wasted means much lower than normal or expected weight-for-age). Soundly based community education involving carers, health workers and the general community can help prevent growth faltering.
Pregnant Indigenous women face a number of risks during their pregnancy, including strenuous physical activity (eg, carrying water over long distances), anaemia, urinary tract infections, inadequate prenatal and postnatal care, and gestational diabetes which can predate permanent diabetes. The authors suggest that traditional Indigenous midwives and healers could collaborate with health professionals so that these pregnant women could benefit.
From skin infections to HIV, the burden of all infectious diseases is higher in Indigenous than non-Indigenous populations. Skin infections are very common, especially in children. Respiratory and gastrointestinal infections often exist together and cause widespread illness and death. Otitis (middle ear infection) is prevalent and can lead to permanent deafness. Diarrhoeal infections are often accompanied by other infections, and malnutrition. Rates of HIV/AIDS are high in many Indigenous groups, including American Indians and Aborigines. The authors say: "The AIDS epidemic is rapidly worsening in the Asia-Pacific region." During recent years in Western Australia (1994 to 2002) the rate ratios of HIV notifications (ie, formally notified diagnoses), Indigenous: non-Indigenous, were 2:1 for men and 18:1 for women.
Westernisation of Indigenous populations has caused an alarming upsurge in chronic diseases related to lifestyle factors. High-calorie, high-fat, high-salt diets, combined with decreasing physical activity and genetic predisposition, mean that, for example, 40% of all Aboriginal adults in northwest Australia have diabetes, and this goes to 60% when looking at those aged 35 and over. Some children become overweight and insulin resistant as early as 5 years old. And Aboriginal children up to 17 years of age in Western Australia have a diagnosis rate for diabetes 18 times higher than their non-Indigenous counterparts. Heart disease and problems related to drug, tobacco, and alcohol use are also increasing sharply. Alarmingly, in some Indigenous populations rates of lifestyle-related chronic diseases are increasing by more than 25% per decade. This is looming as an international public health catastrophe.
A total of 11 risk factors collectively explained 37% of the Australian Indigenous disease burden. These were tobacco use, alcohol, drug use, high body mass, physical inactivity, low intake of fruit and vegetables, high blood pressure, high cholesterol, unsafe sex, child abuse, and intimate partner abuse. These factors can all contribute to disease or injuries and violence.
To illustrate the Indignenous Health Gap, the authors quoted health statistics of 193 countries. All Australian men aged 15-60 years combined had the seventh lowest and all Australian women combined had the 12th lowest probability of dying in 2003. But looking at Indigenous Australians alone, they were down at 131st in the list – below East Timor.
The authors say: "The [Australian] Government is now committed to closing this gap and other forms of long-term disadvantage that Indigenous Australians have…These gaps will probably not be closed by the target date of 2030 despite our best efforts and irrespective of various strategies, social and medical, that have been proposed…Regrettably, inadequate attention seems to have been given to potential gains that could be achieved through more meaningful involvement of Indigenous Australians and their communities in this task."
The authors propose a range of interventions*, across maternal and child health, nutrition, infectious diseases, and lifestyle diseases to help close the gap, and conclude: "Health standards of Indigenous peoples are unacceptably poor, but there is no need to despair; correction of the present situation needs a radical reorientation of previous strategies that have been ineffective or virtually non-existent. Apart from the approaches we propose…also important is to enable, train, and encourage Indigenous people to take responsibility for programmes and services that affect their health and for them to work closely with existing health-care systems. Emphasis on the urgent need for local, regional, and international statistics about Indigenous health is important to allow assessment of future trends and usefulness of interventions...At present most countries have no statistics or only unreliable information about the health of their indigenous groups. It is virtually impossible to measure progress over time without adequate data."
They add**: "The first Australian death from swine flu occurred very recently in a young desert-dwelling Aboriginal man. He had underlying medical conditions and his demise highlights the susceptibility of large numbers of Indigenous people to such infections. Many Aboriginal people died even in very remote parts of Australia during the great influenza pandemic of 1918."
Professor Michael Gracey, Unity of First People of Australia, Perth, WA, Australia T) +61-8-9381 1702 / +61 421 646 367 E) m.gracey@optusnet.com.au
For full Review see: http://press.thelancet.com/indig1.pdf
Notes to editors: *See p73 full Review, panel 6, for panel of proposed interventions
**A quote direct from Professor Gracey and cannot be found in text of Review
Journal
The Lancet