The first of two reviews in this week’s edition of The Lancet discusses the standards of health and lifestyles of Indigenous people. It is the work of Professor Michael Gracey, of the Unity of First People of Australia, Perth, WA, Australia, and Professor Malcolm King, of the University of Alberta, Edmonton, Canada. There are almost 400 million Indigenous people in the world with low standards of health that are usually linked to malnutrition, poverty, environmental contamination, and prevalent infections. However, as those people shift to more modern or ‘western’ lifestyles, conditions such as obesity, cardiovascular diseases, and type 2 diabetes have been on the rise. Physical, social and mental disorders related to misuse of alcohol and other drugs are also increasing. Indigenous people must be encouraged and given the means to take responsibility for issues that affect their health. In this review, the authors discuss indigenous people worldwide but focus on Aboriginal Australians.

The origins of disease in Indigenous infants and children include poor living conditions, malnutrition, and infections. These include ear disease, tooth decay, trachoma, diarrheal 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 they are still widespread and potentially fatal in many Indigenous groups. The authors write: “This area should be a priority for action by governments and non-governmental organisations.”

Poverty is often a cause of malnutrition. It is frequently worsened by inadequate food storage facilities in the home. In Aboriginal children aged less than 5 years in Australia’s Northern Territory, 15 percent are underweight, 11 percent are underdeveloped, and 9 percent have a much lower than normal or expected weight-for-age. A solid community education involves carers and health workers. The general community can help prevent growth delay.

There are many risks for pregnant Indigenous women: strenuous physical activity such as carrying water over long distances, anemia, urinary tract infections, inadequate prenatal and postnatal care, and gestational diabetes which can predate permanent diabetes. In order to assist these pregnant women, the authors propose cooperation between traditional Indigenous midwives and healers, and health professionals.

The burden of all infectious diseases (from skin infections to HIV) is more elevated in Indigenous than non-Indigenous populations. Children often have skin infections. Widespread illness and death are commonly caused by respiratory and gastrointestinal infections. Middle ear infections (Otitis) are common and can lead to permanent deafness. Diarrheal infections are regularly accompanied by other infections, and malnutrition. In many Indigenous groups, including American Indians and Aborigines, rates of HIV/AIDS are high. The authors point out: “The AIDS epidemic is rapidly worsening in the Asia-Pacific region.” From 1994 to 2002, the rate ratios of HIV notifications (those that are formally notified diagnoses) in Western Australia, Indigenous: non-Indigenous, were 2:1 for men and 18:1 for women.

There is a shocking rise in chronic diseases related to lifestyle factors. It is related to the westernization of Indigenous populations. High-calorie, high-fat, high-salt diets, combined with decreasing physical activity and genetic predisposition have lead to an increase in cases of diabetes. 40 percent of all Aboriginal adults in northwest Australia have diabetes. The proportion rises to 60 percent for those aged 35 and over. Some children, as young as five years old, have already became overweight and insulin resistant. 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 complications related to drug, tobacco, and alcohol use are also rapidly on the rise. An alarming factor is the rate of lifestyle-related chronic diseases increasing by more than 25 percent per decade, in some Indigenous populations. This is a potential threat for an international public health catastrophe.

There are a total of eleven risks factors to collectively explain 37 percent of the Australian Indigenous disease burden:

??? 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
??? Intimate partner abuse

These factors can all contribute to disease or injuries and violence.

The authors quoted health statistics of 193 countries to illustrate the Indigenous Health Gap. All Australian men aged 15 to 60 years combined had the seventh lowest probability of dying in 2003. All Australian women combined had the 12th lowest probability. But looking at Indigenous Australians alone, they were down at 131st in the list – below East Timor.

The authors write: “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 recommend a series of interventions, in maternal and child health, nutrition, infectious diseases, and lifestyle diseases to help close the gap. They write in conclusion: “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.”

In closing, 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.”

“Indigenous health part 1: determinants and disease patterns”
Michael Gracey, Malcolm King
Lancet 2009; 374: 65-75
The Lancet

Stephanie Brunner (B.A.)