SEE ALSO community; empowerment; inequalities agenda; mental health; power
Indigenous peoples are estimated at more than 370 million or about 6% of the world population and consist of approximately 5000 distinct peoples in over 70 countries. Other terms that are used to describe indigenous peoples include ‘first nations’, ‘Aboriginal’ and ‘first peoples’ (WHO, 2007).
There is no universally accepted definition for indigenous peoples but a modern and inclusive interpretation includes peoples who:
•Identify themselves and are recognized by their community as indigenous;
•Demonstrate historical continuity with pre-colonial and/or pre-settler societies;
•Have strong links to territories and surrounding natural resources;
•Maintain distinct languages, cultures and beliefs;
•Resolve to maintain and reproduce their ancestral environments and systems as distinctive peoples and communities (WHO, 2007).
Indigenous peoples experience greater health inequalities and a health status below national averages associated with poverty, malnutrition, overcrowding, poor hygiene, environmental contamination and prevalent infectious diseases. Inadequate culturally specific clinical care, health promotion and poor disease prevention services can make health inequalities even worse. Indigenous peoples, as they move from traditional to more modern lifestyles, are rapidly acquiring chronic diseases such as obesity, cardiovascular disease and type 2 diabetes. The physical, social and mental disorders linked to the abuse of substances such as alcohol are also more pronounced in indigenous peoples (Gracey and King, 2009).
In New Zealand, a survey showed that 51% of Ma_ori peoples develop a mental disorder at some point in their life, most commonly anxiety (31%), substance abuse (27%), and mood disorder (24%). A health survey with Canadian First Nations peoples also identified high rates of depression (18%) and alcohol disorders (27%) (King, Smith and Gracey, 2009). In another study, 48% of Aboriginal children in an inland community in Australia were found to have skin sores and up to 67% of children have been estimated to have perforated tympanic membranes resulting in some degree of hearing loss (Carapetis et al., 1995). For ethnic minorities in Vietnam such as the Hmong, more than 60% of childbirths take place without prenatal care compared to 30% for the majority Kinh population (WHO, 2003) The average infant mortality among indigenous children in Panama is over three times higher than that of the overall population at 60–85 deaths per 1000 live births compared to the national average of 17.6 (PAHO, 2002).
Much of the poor overall health of indigenous peoples has been related to the psychological effects resulting from cultural destruction and dispossession of their lands. Aboriginal groups in Australia, for example, have been systematically dispossessed of their rights to lead a traditional lifestyle and were forcibly resettled into Aboriginal reserves or relocated into peri-urban areas. Unemployment, poverty and being excluded from the wider society in which they live have also contributed to both poorer physical and mental health. Social exclusion consists of dynamic, multidimensional processes driven by unequal power relationships interacting across four main dimensions: economic, political, social and cultural and at different levels including individual, household, group, community and national levels. Social exclusion is characterized by unequal access to resources, capabilities and rights which can lead to health inequalities, poverty, unemployment and social deprivation (Popay et al., 2008).
Indigenous peoples have many assets which can be used in partnership with government, private and third-sector agencies to help to improve their health. Closing the Gap, for example, is a commitment endorsed in 2008 in Australia to improve the lives of indigenous people and, in particular, to provide a better future for indigenous children. Closing the Gap has several targets including to close the life expectancy gap between indigenous and non-indigenous Australians within a single generation. In particular, it is expanding primary health care, training more local health workers, tackling chronic disease, helping people who abuse alcohol and other substances, providing more mental health services and making sure there is healthy food in remote community stores. Underpinning Closing the Gap is a new way of working across multiple levels of government and of engaging with indigenous communities with clear responsibilities, specific targets and rigorous reporting to keep governments on track. Closing the Gap is a pan-community effort involving third-sector organizations to assist indigenous communities to take more control in service delivery to improve health outcomes. Indigenous community control is a means to provide more autonomy from government interventions and provide a culturally appropriate service, owned by, and responsive to, the needs of the local community (Commonwealth of Australia, 2014).
Statistical data on the health status of indigenous peoples, especially in Africa, Asia and Eastern Europe, is limited. With improved information on indigenous peoples’ health, action can be taken to ensure access to culturally appropriate health care, as well as to safe water, adequate housing and health-related educational interventions. To address inequalities in indigenous health requires an increased awareness, political commitment, a cultural recognition and an alignment of funding, rather than government denial and neglect of these complex, social problems. Communities without access to information about their history, verbal or written, have less chance of effecting change, than those that do have access (Goodman et al., 1998). Indigenous peoples should therefore be encouraged to build their capacity and be enabled to increasingly take more control in overcoming the challenges in their lives.
KEY TEXTS
•Coates, K. S. (2004) A Global History of Indigenous Peoples: Struggle and Survival (New York: Palgrave Macmillan)
•Howard, B. R. (2003) Indigenous Peoples and the State: The Struggle for Native Rights (DeKalb, Ill: Northern Illinois University Press)
•King, M., Smith, A. and Gracey, M. (2009) ‘Indigenous Health Part 2: The Underlying Causes of the Health Gap’, The Lancet, 374 (9683): pp. 76–85
SEE ALSO disability; indigenous peoples; policy change; power; social determinants of health
The inequality agenda refers to how resources are distributed across society, for example, the difference between average incomes, and how countries redistribute resources to share the income that they produce as this directly affects the extent and depth of poverty (European Anti-poverty Network, 2014).
The inequalities agenda also refers to differences in health between population groups that are preventable through policy or through, for example, public health interventions, and not an effect of freely chosen risk (Braveman and Gruskin 2003). Countries with high levels of inequality are also likely to have high levels of poverty and those with lower levels of inequality are likely to have lower levels of poverty. This shows that poverty is fundamentally linked to the issue of how resources are distributed and redistributed. Inequality differs from poverty which concentrates on the social and economic situation of those at the bottom of society (European Anti-poverty Network, 2014).
Equality, a measure of sameness, differs from equity, as applied to health, which is a normative judgement of what is fair. These two terms are often used interchangeably and health inequality has become synonymous with health inequity (Braveman and Gruskin 2003). Health inequity is shaped by deep social structures and processes and can be enhanced by social norms and government policies that tolerate or even promote the unfair distribution of power, wealth and social resources. A major concern therefore are the social inequities that reside in the structures of society, creating systematic differences in health outcomes between different population groups such as gender differences that arise from patriarchal norms or discrimination, class differences that arise from inequalities in wealth and power and the control of capital (WHO, 2008).
Health inequalities in everyday living are seen in the conditions of early life, the nature of employment and working conditions, the quality of the built environment in which people live and in the unequal access to health care and education. This unequal distribution is the result of a combination of poor social policies and programmes, unfair economics and unjust governance. People who have, for example, high-risk lifestyles or who have poor living conditions are typically influenced more by economic and political policies, suffer greater health inequalities and consequently have more disease, premature death and less well-being (Wilkinson and Marmot, 2003).
Public health programmes can start with a commitment to address the inequalities agenda only to drift to a much narrower lifestyle intervention. A political trend that has been termed the ‘lifestyle drift’ and illustrated by the ‘Swap It, Don’t Stop It’ campaign in Australia. The main character is Eric, a blue balloon-type figure, who urges others to swap unhealthy aspects of their lifestyle, such as eating habits and physical inactivity, for healthier lifestyle habits. However, the changes necessary for Eric to lead a healthier life actually requires a change in the structures in which he lives, such as an affordable healthy diet and a safe neighbourhood. Structural changes conveniently ignored by the government (Baum, 2011) that instead focused on targeting a modification of individual unhealthy lifestyle choices.
The social gradient in health means that health inequities affect everyone especially the poorest of the poor, around the world, who have the worst health. Within countries, the lower an individual’s socio-economic position the worse his or her health (WHO, 2008). Health status actually improves at each step up the income and social hierarchy. Public health programmes no not always recognize that the way in which society is structured, institutionalized and the inequalities that this can create are a key part of the causes of poor health. Health issues such as addiction and homelessness continue to be viewed as problems of individual lifestyles rather than as a result of government policy that has resulted in inequality. In the late 1980s, for example, the government of Great Britain changed its policy on council (state) housing. The housing was demolished, reconstructed, and privatized, sold either to private corporations or cooperative resident associations. The lack of ongoing government support resulted in steeper housing costs and the exclusion of lower-income residents who were made homeless or had to move to poorer housing conditions. Throughout the 1990s, council housing continued to be demolished, destroying neighbourhoods and for many people the social safety net in which they had lived for many years. Local resistance was uncoordinated and faced a more unified and stronger lobby from privatization companies that had a vested interest in the housing market (Tracy, 2007).
Professor Sir Michael Marmot has claimed that health inequality and social injustice are killing people on a grand scale because of the imbalances in the distribution of resources and unjust decision-making by government (Marmot, Allen and Goldblatt, 2010). To address the inequalities agenda will require a redistribution of power and a transformation of unequal power relationships both within and between societies.
KEY TEXTS
•Cannon, M. and Perkins, J. (2009) Social Justice Handbook (Nottingham, UK: IVP Books)
•Costello, J. and Haggart, M. (eds) (2003) Public Health and Society (Basingstoke: Palgrave Macmillan)
•World Health Organization (2008) ‘Closing the Gap in a Generation. Commission on Social Determinants of Health’. Final Report (Geneva, World Health Organization). Available at www.who.int/social_determinants. Accessed 6 May 2012
SEE ALSO addiction; behaviour change; Health in All Policies; health promotion; non-communicable disease; peer education; violence
Injury can be categorized as being intentional, including homicide, war, violence, abuse and suicide, and unintentional, including all other forms of injury that are predictable and therefore mostly preventable (WHO, 2004a).
Injuries account for 9% of global mortality, but for every death it is estimated that there are many more hospitalizations, emergency department visits and doctors’ appointments. A large proportion of people surviving their injuries also incur temporary or permanent disabilities with associated costs to health services and the individual (WHO, 2004a). The Global status report on road safety, for example, presents information from 182 countries and estimates a total of 1.24 million road traffic deaths per year. Strategies exist that are proven to reduce road traffic injuries but only 28 countries, covering 7% of the world’s population, have comprehensive road safety laws that do actually address the five key risk factors: drinking and driving, speeding, failing to use motorcycle helmets, seat belts and child restraints. Road traffic injuries are the eighth leading cause of death globally, and the leading cause of death for people aged 15–29 years (WHO, 2013e).
Injury prevention is an effort to reduce the severity of bodily injuries caused by external mechanisms, before they occur, to improve the health of the population (Pless and Hagel, 2005). Injury prevention can be classified into three stages: primary, secondary and tertiary. Primary injury prevention applies to the initial event, when possible, to reduce or eliminate exposure to risk. Secondary prevention happens after an injury has occurred. The goal is to limit long-term disability and prevent re-injury, for example, providing suitably modified working conditions for injured workers. Tertiary injury prevention reduces long-term impairment and disabilities including rehabilitation. The focus is not on preventing the injury but its consequences, for example, the prompt transfer to a hospital to minimize brain damage after head trauma (Pless and Hagel, 2005).
One injury prevention intervention in the United States was carried out over a six-year period in nursing homes covering 552 licensed beds and aimed to reduce back injury in 1728 nursing employees. The key elements of the intervention were the use of mechanical lifting and repositioning equipment, the training of nursing personnel in the correct use of the equipment and a zero lift policy assessing each resident’s lifting needs and procedures for safe handling. The training was modified to provide instruction to two nurses at a time so as best to demonstrate how the equipment should be operated. An evaluation of the intervention found that these simple measures significantly reduced the rate, severity and cost of injuries. The number of lost and restricted work days was also significantly reduced. An additional benefit was that the number of assaults by residents towards nursing staff also declined during lifting and repositioning (Collins et al., 2004).
Harm-reduction is a pragmatic approach to reduce the harmful consequences of high-risk behaviours by incorporating strategies that cover safer use, managed use and abstinence (Ritter and Cameron, 2006). High-risk behaviours that have been included in harm-reduction interventions are needle exchange, opioid substitution therapy, substance use prevention for adolescents, smoking cessation and sex work. The principles of harm-reduction are often firmly rooted in humanistic ideals, in immediate and attainable goals and the recognition that risky behaviours have always been and always will be a part of society (Ritter and Cameron, 2006). Harm minimization is often used interchangeably with harm-reduction. However, any intervention or policy that is intended to reduce harm and problem behaviour can be considered harm reducing. The term ‘harm minimization’ is intended to reflect an overall goal of policies to minimize harm (Weatherburn, 2009).
The primary goal of most harm-reduction approaches is to work with individuals on their terms in their context and not to condemn their harmful behaviours. The goal is to work with the individual to minimize the harmful effects of a given behaviour. Unlike the moral approach, which tends to enhance the user’s shame, guilt and feelings of stigma, the harm-reduction approach is based on acceptance and the willingness of the provider to collaborate with clients in the course of reducing harmful consequences (Marlatt and Witkiewitz, 2010). One harm-reduction intervention used brief motivational interviews to reduce injuries related to alcohol abuse among adolescents treated in an emergency room. An assessment of their condition and future risk of harm and the motivational interviews were conducted in the emergency room during or after the patient’s treatment. Follow-up assessments showed that patients who were part of motivational interviews had a significantly lower incidence of drinking and driving injuries, traffic violations and other alcohol-related problems than patients who only received the standard care at the emergency room (Monti et al., 1999).
There is an opposition to harm-reduction strategies by some professionals who want to eliminate high-risk behaviours by enforcing abstinence-only policies. This is despite the evidence that harm-reduction programmes can be effective and cost efficient, for example, in slowing down the spread of HIV and other communicable diseases, overdose prevention programmes and workplace safety programmes (Marlatt and Witkiewitz, 2010).
In practice, injury prevention and harm-reduction are most viable as an approach when used in combination with other strategies, such as peer education and health promotion, to manage high-risk behaviours.
•Carlson Gielen, A., Sleet, D. and DiClemente, R. (2006) Injury and Violence Prevention: Behavioral Science Theories, Methods, and Applications (New York: Jossey-Bass Inc)
•Christoffel, T. and Gallagher, S. (2005) Injury Prevention and Public Health: Practical Knowledge, Skills and Strategies. 2nd edn (Boston: Jones & Bartlett Learning)
•Marlatt, G. A., Larimer, M. E. and Witkiewitz, K. (2011) Harm Reduction: Pragmatic Strategies for Managing High-Risk Behaviors. 2nd edn (London: Guildford Press)