www.thelancet.com Vol 374 July 4, 2009
Indigenous health part 2: the underlying causes of the
Malcolm King, Alexandra Smith, Michael Gracey
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.
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 consider-
able 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
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
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.”
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, and spiritual, are represented in the
four directions of the medicine wheel. These four
elements are intricately woven together and interact to
support a strong and healthy person.5 Balance extends
beyond the individual realm such that good health and
healing also require that an individual live in harmony
with others, their community, and the spirit worlds. For
Lancet 2009; 374: 76–85
See Perspectives page 19
Department of Medicine,
University of Alberta,
Edmonton, AB, Canada
(Prof M King PhD); University of
Toronto, Toronto, ON, Canada
(A Smith MD); and Unity of First
People of Australia, Perth, WA,
Australia (Prof M Gracey MD)
Prof Malcolm King, Department
of Medicine, University of
Alberta, Edmonton, AB, T6G 2S2,
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”, “First Nation(s)”, “Inuit”, and “Métis”. Also,
“mental health”, “wellness”, “resilience”, “traditional
medicine”, and “indigeneity”. Finally, we had access to various
unpublished reports through Indigenous person-to-person
contacts, a process commonly known in North America as
the moccasin telegraph.
www.thelancet.com Vol 374 July 4, 2009 77
Indigenous peoples, land, food, and health are key
components of being alive well.6
Thus the Indigenous idea of sickness or illness tends
to refer to an absence of wellbeing or an imbalance.
Connections, relations, and family (as in the Māori
concept of whanau or extended family), are among the
many essential components of wellbeing. All these
factors interact to form an Indigenous notion of healing
processes that are very different from their non-
Indigenous counterparts. Healing often involves
consultation and public processes that can include
offerings and gatherings as well as shared preparing
and undertaking. Furthermore, more than the affected
person and the healer can be engaged in these healing
processes. For example, the Sundance is often
undertaken on behalf of people other than one’s self,
and the ceremonies usually include various traditional
healers (medicine men), firekeepers, drummers, and
helpers. The understanding is that toxicity—in the
environment, in the emotions, in the body—should be
cleansed, a process in which whole communities can
The root causes of poor health—the social determinants
of health—are generally to blame for the poor state of
everyone’s health,8 but especially Indigenous health.
Such determinants are universally thought to include
the classic socioeconomic indicators defined, for
example, by the 1986 Ottawa Charter for Health
Promotion—income, education, employment, living
conditions, social support, and access to health services.
These factors certainly apply to the health of Indigenous
populations (see, for example, reference 9). However,
and further, Indigenous health is widely understood to
also be affected by a range of cultural factors, including
racism, along with various Indigenous-specific factors,
such as loss of language and connection to the land,
environmental deprivation, and spiritual, emotional,
and mental disconnectedness. The definition of
indigeneity is, therefore, inherently social, and includes
major elements of cultural identity. Being isolated from
aspects of this identity is widely understood to have a
negative effect on Indigenous health.3 Panel 1 describes
the Indigenous groups of North America.
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
systems of knowledge and societal arrangements.
Furthermore, “Cultural identity depends not only on
access to culture and heritage but also on opportunities
for cultural expression and cultural endorsement within
society’s institutions. Identity [as understood within an
Indigenous context] is to a large extent a collective
experience.”11 Moreover, Brant12 has opined that in view
Panel 1: North America’s Indigenous peoples
In continental USA, the Indigenous peoples are known
collectively as Native Americans. There are some
560 federally-recognised Indian tribes—a total population
of about 2·5 million. The largest of these is the
Navajo/Dine Nation of New Mexico/Arizona, with around
210 000 members. Federally-recognised tribes receive various
services from the Bureau of Indian Affairs and the Indian
Health Service. In addition to these tribes, there are state-
recognised tribes, who are not eligible for Indian Health
Service support. For most tribes, a blood quantum of an
eighth is set as the limit for membership.
In Alaska, the Indigenous peoples are collectively known as
Alaska Natives. This group includes American Indians, Aleuts,
and Eskimos (Inuit), all of whom are federally recognised.
Native Hawaiians are the Indigenous people of Hawaii. They
are recognised by the state but not the federal government.
The Indigenous peoples of the USA represent about 1% of the
In Canada, there are three Indigenous/Aboriginal groups
recognised by the Constitution Act of 1982—First Nations,
Inuit, and Métis. There are 633 First Nations groups with a
population approaching 1 million. Métis number about
300 000 and Inuit about 60 000. The Aboriginal people of
Canada represent about 4% of the total population. First
Nations and Inuit receive a range of services from Indian and
Northern Affairs Canada and from First Nations and Inuit
Health (Health Canada). Métis people are not eligible for
For Native Americans and Canadian First Nations, the
international border crosses between traditional tribal
territories (eg, Iroquois, Ojibway, Blackfoot, and Salish
peoples), and although linguistically and culturally diverse
across North America, there are many commonalities on both
sides (eg, the Navajo/Dine of the US southwest are
linguistically related to the Dene of Canada’s northwest).
Most of the Indigenous cultural diversity in North America is
seen west of the Rocky Mountains. Many Native Americans
and Canadian First Nations view North America as one
unit—ie, Turtle Island.
The Inuit of Canada’s arctic regions are closely related to the
Inuit of Greenland and Alaska. In Canada, there are four Inuit
regions, Nunavut Territory (80% Inuit), and Inuvialuit,
Nunavik, and Nunatsiavut. Greenland (Inuut Nunaat), part of
Denmark, is mostly Inuit.
The Métis, descendants of European men and First Nations
women in western Canada, are a unique Indigenous group
with their own language and culture.
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of these losses, Indigenous peoples can often be
overtaken by repressed hostility that comes from
cultural prohibitions against showing angry behaviour.
This hostility gives rise to explosiveness under the
influence of alcohol, and to a high frequency of grief
Identity and culture are not fixed in time or location
but rather are in constant evolution. They are co-created
and renegotiated within the context of broader society.
And yet, the identities that have often been developed
for Indigenous peoples generally incorporate colonial
images (eg, the Noble Savage, an idealised notion of
exotic innocence, which effectively renders Indigenous
peoples as other, static, and fragile).13 The resulting
identities and cultures are pan-Indigenous, static, and
interpreted through another society’s values and agenda.
Positive identity, identity based on deficits, and negative
identity11 are all seen within Indigenous populations,
and are associated with predictable health outcomes.
Counselling strategies used by Indigenous practitioners
generally place emphasis on reduction of alienation,
and introduction of positive cultural experiences.14,15
Durie and colleagues11 claim that, with the shortage of
positive Indigenous representations and role models
and authority figures, “it is a challenge not only to
reclaim Indigenous identity, but to facilitate the
development of healthy identities based on cultural
strengths, not on disadvantage, disease burden and
Traditional teachings and knowledge provide a basis
for positive self-image and healthy identity. Elders are
widely seen to be pivotal for Indigenous societies to
regain their positive identity.16 In Canada and in other
colonised nations, many generations of Indigenous
children were sent to residential schools. This experience
resulted in collective trauma, consisting of, as pointed
out by Kirmayer and colleagues,17 the structural effects
of disrupting families and communities; the loss of
parenting skills as a result of institutionalisation;
patterns of emotional response resulting from the
absence of warmth and intimacy in childhood; the
carryover of physical and sexual abuse; the loss of
Indigenous knowledges, languages, and traditions; and
the systemic devaluing of Indigenous identity. The
legacies of these and other policies of forced assimilation
are also seen in the present relationships of Indigenous
peoples with the larger society. For example, the First
Nations peoples gained the right to vote only in 1960,
which is a shocking reminder for Euro-Canadians, who
have been profoundly unaware of the social realities of
Aboriginal peoples.18 Such policies are key, not only in
terms of identity (individual and community), but also
with respect to the relationship with non-Indigenous
peoples. All these assaults on identity contribute to a
self-perpetuating circle that keeps Indigenous peoples
where they are.
Language is crucial to identity, health, and relations
(panel 2).23 It is especially important as a link to
spirituality, an essential component of Indigenous health.
Throughout the world, Indigenous languages are being
lost, and with them, an essential part of Indigenous
identity. Language revitalisation can be seen, therefore,
as a health promotion strategy.
Panel 2: Indigenous language use
In Canada, according to the 2001 census, only about one in
four Aboriginal people are able to converse in an Aboriginal
language, and about 18% use an Aboriginal language
regularly, more by elderly than by young people.19
Language revitalisation is taking many
forms—for example, the Māori practice of naming places,
organisations, and events. This revitalisation is a powerful
reclamation of Indigenous identity that has become
accepted throughout most of Aotearoa (New Zealand).
Further bolstering their identity is that the Māori language
is taught in schools and is one of the country’s two official
languages, as well as the establishment of many national
events that incorporate Māori culture. Hawaii is
undergoing a similar revitalisation of its language.20 In
Canada, the Northwest Territories have 11 official
languages, of which nine are Indigenous; one can use any
of these languages in the legislative assembly.21 Another
Canadian example is Nunavut—its creation, its vision (self-
government, self-determination) is Inuit, and its working
language is Inuktitut.22
Panel 3: Mental disorders and addictions
In New Zealand, a survey showed that 51% of Māori
develop a mental disorder at some point in their life.24 The
most common lifetime disorders were anxiety (31%),
substance abuse (27%), and mood disorder (24%). Disorder
prevalence was greatest in Māori with the lowest income
and least education. Other surveys of Indigenous groups
using symptom measures also indicate high rates of
common mental disorders—for example, the 2002–03
Canadian First Nations Regional Health Survey25 identified
high rates of depression (18%) and alcohol disorders (27%).
Although, relative to the general population, a small
percentage of Indigenous people in Canada consume
alcohol, the rate of disordered drinking is substantially
higher. Inhalant use is increasing in young Indigenous
people worldwide. In a survey of Inuit youth, individuals
who had used solvents were eight times more likely to have
made a suicide attempt.26 As Kirmayer and colleagues18
point out, service utilisation studies are usually only a
low-end estimate of the true rate of distress in the
community and might not provide an accurate profile of
difficulties in the community. However, delay in
help-seeking might well ultimately translate into higher
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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 to high levels of emotional stress,
depression, anxiety, substance abuse, and suicide are
closely related to issues of individual identity and self-
esteem,27,28 which in turn are strongly determined by
collective processes in the community or larger political
Indigenous mental health constructs are fundamentally
different from those that form non-Indigenous frame-
works in developed countries. Counselling of Indigenous
patients from the perspective of the cultural mainstream
has been said to perpetuate colonial oppression.31
Furthermore, many Indigenous people have little success
with, and in fact often will not engage in, treatment that
does not value their ways of knowing—especially those
pertaining to health and wellness. This failure might
account for, in part, the underuse of non-Indigenous-
specific mental health services by Indigenous people,
despite their disproportionately high burden of mental
Intersecting metathemes of community, cultural
identity, holistic approaches, and interdependence have
been identified as integral to culturally appropriate
counselling methodology. Some32 have suggested
incorporation of Indigenous values (respect, non-
judgmentalism, and non-interference) and the medicine
wheel, with its emphasis on balance in life and healing.
A Canadian Government report33 of mental illness and
addiction had this to say: “Experts in the field suggest
that, while many of the causes of mental illness,
addiction and suicidal behaviour in Aboriginal and non-
Aboriginal communities may be similar, there are added
cultural factors in Aboriginal communities that affect
individual decision making and suicidal ideation. These
cultural factors include past government policies,
creation of the reserve system, the change from an active
to a sedentary lifestyle, the impact of residential schools,
racism, marginalization and the projection of an inferior
There is a widespread victim-blaming ideology in terms
of addictions—that those who are addicted have moral
failings or are genetically inferior. This belief masks
social causation and thereby absolves the larger non-
something that has been seen even in Indigenous
Research has shown that addictive behaviour has a
strong inverse relation with socioeconomic status.35
of social responsibility,
disadvantaged people are not otherwise getting as a result
of their diminished social opportunities. Addictive
behaviours also provide an escape from chronic stressors
and are a form of self-medication. For many Indigenous
people, there are many layers of stressors—racism,
poverty, poor education,
instability, and residential instability. Learned help-
lessness, rather than active coping, has also been seen in
response to many of these stressors.36
Indigenous peoples worldwide have undergone rapid
culture change, marginalisation, and absorption into the
global economy, with very little respect for their
autonomy. These profound transformations have been
linked to high rates of depression, alcoholism, suicide,
and violence in many communities, with the most
pronounced effect on youth.37 Indigenous peoples
everywhere share similar social, economic, and political
predicaments that have resulted from colonisation.
Despite these challenges, however, some communities
have done well, as pointed out by Kirmayer and
colleagues,18 enjoying high levels of health and wellbeing
and continuing to transmit their cultural knowledge,
language, and traditions to the next generation.
behaviours provide the rewards that
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 might
otherwise exist in communities and neighbourhoods
where large concentrations of Indigenous people live.
Residential instability is associated with family
instability and with a high proportion of female lone-
parent families with low incomes. Individuals and
families living in residential instability experience great
social difficulties, such as poor education attainment,
divorce, crime, and suicide, which in turn lead to even
greater social disintegration.
Panel 4: Urbanisation
In New Zealand, Māoris have become overwhelmingly (83%)
urban,38 which is also true for the Aboriginal people of
Australia, who do not generally have a formal land base
(roughly 75% urban in 2001).39 In the USA and Canada, in
groups with a recognised land base (reservations), the rate of
urbanisation is about 50%. The most urbanised groups are
those without recognised status—in Canada, non-status
Indians and Métis, with 73% and 66%, respectively, living in
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As suggested by Kirmayer and colleagues,18 a major
challenge for urban Indigenous people is to maintain
social cohesion through collective activities and
community strategies that reinforce Indigenous cultural
identity and develop urban institutions that incorporate
Indigenous values (see figure). This challenge is made
more complex by the multinational or multitribal nature
of many urban Indigenous populations, which further
reduces social cohesion and the ability to establish
Indigenous institutions. Instead, one ends up with many
generic pan-Indigenous cultural programmes that do
little to help with identity. Consequently, the process of
urbanisation often results in fragile, diverse communities
coming together, all carrying definitions of themselves
Figure: An Indigenous view of urbanisation and its effect on Indigenous health practices
Dawn Marsden, PhD, National Aboriginal Health Organization, Ottawa (reproduced by permission of the artist). These images were painted by Dawn Marsden, a member
of the Mississaugas of Scugog Island (Ontario). The scenes represent a life cycle: (A) the beginning, the unspoiled Indigenous world of culturally integrated health
practices; (B) the migration to the city and the death of the spirit; (C) the revitalisation of isolated Indigenous health practices; and (D) the return to a state of balance
through the communally supported transmission of mino bimaadziwin or good-life practices. These images were drawn by Marsden as part of her research presentation
at the 2003 Gathering of Graduate Students in Aboriginal Health, sponsored by the CIHR Institute of Aboriginal Peoples’ Health, held in Edmonton, Canada.41 After the
gathering, Marsden gifted the paintings to the Alberta ACADRE Network, and they now hang proudly in the ACADRE office at the University of Alberta.
www.thelancet.com Vol 374 July 4, 2009 81
and each other, as provided by colonial and the non-
Whether in cities or rural or reserve communities, the
burden of distress and despair wrought by generations of
colonial oppression often renders relationships and
social cohesion within and between Indigenous
communities fragile, and internal critics face tremendous
challenges in their efforts to develop modes of
constructive social and political criticism. However,
ignoring or keeping internal inequalities to a minimum
risks perpetuating injustices paid for in terms of poor
health and high levels of social suffering in those who are
most marginalised and exploited: women, Elders, youth,
two-spirited people (ie, male or female homosexuals),
and disabled and ill people.18
Before the past few decades, various policies ensured
that Indigenous peoples were excluded from urban
centres.18 For example, in Canada until the 1950s, Indians,
as they were then known, had to ask for permission from
the Indian Agent to leave the reserve to seek employment
or education. Enrolment in a higher education meant the
loss of Indian status and exclusion from the reserve.
Now, however, the increased urbanisation could be
caused in part by the very programmes that have now
been put in place to educate and employ Indigenous
people, combined with the absence of economic
development and the erosion of resources in their home
communities burdened with expanding populations.
Many push-and-pull factors determine the patterns of
rural-urban migration in Indigenous peoples. The push
factors that prompt individuals to move from their
traditional communities include unemployment and the
consequent poor social and economic conditions;
boredom and low quality of life; scarcity of housing,
health facilities and educational opportunities; and
political pressures. Factors pulling people back to their
communities include the failure to find employment or
otherwise thrive in the city, the absence of affordable or
acceptable housing, and the perception that rural
communities are better places to live and raise children.18
Emotional and spiritual connections to the land and
culture are also major factors drawing people back to
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 groups believe that the devastation of their
lands through globalisation and commercial exploitation
and climate change is equivalent to a physical assault.
Sioui42 believes that “Damage to the land, appropriation
of land, and spatial restrictions all constitute direct
assaults on the person.” Kirmayer and colleagues18 thus
point out that the widespread destruction of the
environment through commercial developments should
be understood as attacks on Aboriginal individuals and
communities that are equivalent in seriousness to the
loss of social role and status in a large-scale urban society.
As traditional custodians of the land, dispossessed
Indigenous peoples have lost their primary reason for
being. Additionally, these investigators,43 in their studies
of the Inuit of northern Canada, showed that mental
health and healing can be powerfully affected by eating
country food, hunting, and camping on the land. These
Indigenous notions of an environmental or land-based
psychology offer an important
increasingly contextualised models of the person that
have come to prominence in contemporary mental health
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 the USA, Kinzie and colleagues46 showed that 31% of
people in a northwest coast Indian village met criteria for
a psychiatric diagnosis. A striking sex difference was
recorded, with nearly 46% of men being affected,
compared with only 18% of women. In a large-scale
survey of rural Indian reservations, Beals and colleagues47
showed that the overall rate of psychiatric disorders in
two tribes was similar to that in the general population;
however, alcohol dependence and post-traumatic stress
disorder were more frequent in the American Indian
communities, while major depressive disorder was
actually seen less frequently. In view of the rate of social
difficulties and evident distress in the communities, the
investigators speculated that culturally mediated ways of
expressing depression might not be identified by standard
surveys. Rates of exposure to potentially traumatic events
were very high, particularly in women and girls,
indicating an increasing frequency of sexual and domestic
Indigenous women have been especially marginalised
by colonisation and discrimination in that maternal
heritage has not generally been recognised by developed
society. Before European contact, Indigenous women
and men were much more equal in their different roles.
In Canada, before 1986, Indian women automatically lost
their Indian status when they married a non-Indian.
They were forever excluded from living on the reserve,
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even if the marriage was dissolved. Indigenous women
are all too often left with the responsibilities of child-
rearing for which they receive little support, neither from
society at large nor, in many cases, from their own
communities.49 Historically, grandparents and the
extended family helped to raise the children in their
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
Multifarious issues converge to promote increasingly
poor health with advancing age. Worldwide, Indigenous
populations are young, with proportionately fewer elderly
people. Many elderly people have experienced residential
schools, lost children to non-Indigenous adoptions, and
lived with the consequences of policies (government
appointed leadership, loss of language, loss of culture),
which reduced the role of Elders—all within their
lifetimes. Many of them have not had Elder training
(separation from their families and communities meant
that they did not experience their grandparents raising
them, consulting the Elders in their communities) and are
themselves weakened or sick. As Elders, they “need to
address the anger they are carrying from attending
residential school, growing up in foster homes, or being
adopted out of the community. They might just heal
themselves and our communities in the process.”50
Increased individualism and residential instability
(urbanisation and sedentarisation) have all contributed to
the diminished role of Elders in Indigenous societies.
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
empowerment, sensitivity to interrelatedness of past,
present, and future possibilities, and connected between
cultures.”51 The interactions between mental, emotional,
and spiritual stress and physical health are relevant and
important to Indigenous health. For example, the
increasing rates of diabetes in various Indigenous
populations have been associated with environmental
factors related to the rapid sociocultural changes that
occur with migration to the urban setting and
acculturation.52,53 Interactions and comorbidities between
mental and physical health are also important. Mental
to whole health,
health disorders are known to amplify the effects of
physical disorders on functionality.54 Interactions between
disability and mental health have been reported in the
2002–03 Canadian First Nations Regional Health Survey,25
and suicidal ideation was more frequent in those who
reported poor or fair health status than in those with
good or excellent self-reported health.
Like illness, wellbeing is similarly multidimensional
within the person, including a balance between the
person and others—their family and community—and
the environment. The work of Chandler and Lalonde29,55
identified community factors, related to empowerment
and self-control, which were protective of health, in the
particular case of youth suicide in British Columbian
First Nations. Their work emphasised two important
aspects with respect to the health of communities. For
youth suicide, although the rates overall were well above
the rates for the population as a whole, there was no one
Indigenous suicide rate, ranging from many times the
national average to zero. Some communities had not
had any suicide in more than a decade. The variation
between communities was key to understanding the
underlying factors. Communities with programmes and
measures of self-determination had the lowest suicide
Social capital and resilience are also important
relational notions that affect health. Social capital has
been defined in various ways, and refers to sociability,
social networks, and social support, trust, reciprocity, and
community and civic engagement.56 Resilience—what
keeps people strong in the face of adversity and
stress—has many Indigenous
connections, cultural and historical continuity, and the
ties with family, community, and the land.57
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 and colleagues,11 the means by
which disadvantaged populations worldwide are
enabled to control their destinies is crucial to self-
esteem and health: “Autonomy is closely linked with
self esteem and the earning of respect. Both are basic
and linked. Low levels of autonomy and low self esteem
are likely to be related to worse health.” “Health
professionals need to be aware that interventions within
the arena of indigenous health necessarily have political
implications. Involvement in this area of professional
practice often involves challenging government policy
and community attitudes which have the potential to
www.thelancet.com Vol 374 July 4, 2009 83
impact negatively on social, emotional, cultural and
Canada, the USA, Australia, and New Zealand are
consistently placed near the top of the UNDP’s human
development index (HDI) rankings, yet all have minority
Indigenous populations with poor health and social
conditions. Between 1990 and 2000, the HDI scores of
Indigenous peoples in North America and New Zealand
improved at a faster rate than the score of the general
population, narrowing but not closing the gap in human
development. In Australia, by contrast, the HDI scores of
Indigenous peoples decreased while that of the general
population improved, widening this gap. Although these
countries have high human development according to
the UNDP, the Indigenous populations that reside within
them have only medium levels of human development.
As Cooke and colleagues58 indicate, this inconsistent
progress in improving the health and wellbeing of
Indigenous populations points to the need to increase
our efforts in the social and economic realms, as they
relate to health.
Services and support for health and social programmes
are typically fragmented in Indigenous populations (see
the Kirby Report59 in Canada), which is true in terms of
the different levels of government, and different
departments and divisions, all generally working
without collaboration. Fragmentation results in the
isolation of symptomatic issues—addiction, suicide,
fetal alcohol syndrome,
unemployment—followed by the design of stand-alone
programmes to try to manage each issue separately.
Many question the role of government in providing
services, when Indigenous people should be supported
in the development of their own solutions, rather than
having solutions imposed on or provided for them.
Such a change would foster the development of more
culturally appropriate and more effective services and
Although the need to improve overall socioeconomic
conditions of vulnerable populations is self-evident, the
actual health benefits that will result are less obvious.
Intervention research into the social determinants of
health is needed. The health benefits that will accrue
from a social determinants intervention need to be
delineated. Research is also needed to monitor the health
benefits of interventions such as programmes to improve
educational attainment in Indigenous populations, and
programmes to revitalise languages and to support
cultures. Such programmes should be viewed as complex
clinical interventions, and health researchers and
clinicians should work with social scientists and with
Indigenous communities themselves to assess outcomes
that will allow for knowledge translation to other
We should be concerned about the overpoliticisation
of poor health and excessive blaming of external factors
for the state of Indigenous health.60 As pointed out by
poor housing, and
Helin,34 a Canadian First Nations person, Indigenous
peoples should reduce their culture of financial and
psychological dependency on the external system, and
take more control over their own economic and social
recovery, which would inevitably include striving for
There is hope—some of the initiatives that result in
increased self-government and self-determination seem
to be working. Interventions at the level of the community
can lead to improvements in individual health.55 There
are many programmes and initiatives, and these take
many different forms. Development of capacity and
infrastructure will promote extension and replication
elsewhere in locally appropriate fashion. Indigenous
communities appreciate even more than outsiders the
programmes that need to be undertaken.61
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
For Indigenous society healing to occur, there is a need
for national and international collaboration with respect
to health research—necessary resources, necessary
perspective to identify commonalities in difficulties and
solutions. True healing cannot occur until mainstream
society also heals—together.
Panel 5: Quotes from the Aboriginal Healing Foundation50
“Some will need personal reconciliation to be able to move
forward from the pain of the experience. There are several
layers: collective, spiritual, mental, physical.” (p 305)
“In talking about reconciliation and healing, we cannot forget
that it is the strong ones that need to initiate. The
compassion of our grandparents shows us the way.” (p 317)
“If reconciliation is to work, restoration of Indigenous
languages, cultures, social structures, and traditional
institutions for governance must occur.” (p 324)
“Reconciliation does not begin and then end on certain
dates; it is a process of acknowledging and coming to terms
with oppression of the people and moving forward. Every
country that has gone through a truth and reconciliation
process has done so because of oppression. The fear is that
the government will see the residential schools as the only
reason for the process and say, ‘we have discussed this, we
have offered compensation, and it is time to move on.’
There is potential for this commission to go much deeper.”
www.thelancet.com Vol 374 July 4, 2009
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 considerations, in
the context of ethnic inequalities of health more
In 2006, The Lancet published a Series on Indigenous
health, covering the former New World British colonies,
Latin America, Africa, and Asia. The Reviews64–67 pointed
out the need for increased surveillance, research intensity
(particularly related to policy), capacity building, and
community engagement and partnership in dealing with
Indigenous health issues. These reports have drawn a lot
of attention, and have sensitised many health professionals
and researchers, who are now taking up the challenges of
Indigenous health. Not enough time has passed, however,
to see real results in terms of health indicators. Nevertheless,
there are several positive indicators, perhaps as much in
the political arena as in the health sector itself. There are
the apologies from the Governments of Australia and
Canada. There is the new administration in Washington,
led for the first time by a man who is not white. There are
international Indigenous health research agreements
involving agencies in Canada, New Zealand, Australia, the
USA, Mexico, and the circumpolar nations. Indigenous
political organisations have taken on leadership roles in
health, such as the Assembly of First Nations (Canada)
partnership in the Global
programme.68 The UN Declaration on the Rights of
Indigenous Peoples69 includes the right to “the enjoyment
of the highest attainable standard of physical and mental
health” (Article 24). We can only hope that all nations of
the world will sign on and make the declaration operative.
MK was the primary author; all authors contributed to the search of
published work and writing.
Conflicts of interest
We declare that we have no conflicts of interest.
We thank Michael Chandler and Angeline Letendre for reading and
commenting on draft versions of the manuscript. Michael Chandler and
Laurence Kirmayer kindly provided us with advance copies of
manuscripts in press. Special thanks to Dawn Marsden for permission
to reproduce her pictorial essay.
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