United Nations
Indigenous Peoples’
access to Health Services
United Nations
Indigenous Peoples’ access
to Health Services
sta of e world’s
indigenous peops
ii ξ
State of the World’s Indigenous Peoples
DESA
The Department of Economic and Social Aairs of the United Nations is a vital interface between
global policies in the economic, social and environmental spheres and national action. The De-
partment works in three main interlinked areas: (i) it compiles, generates and analyses a wide
range of economic, social and environmental data and information on which Member States of
the United Nations draw to review common problems and to take stock of policy options; (ii) it
facilitates the negotiations of Member States in many intergovernmental bodies on joint course
of action to address ongoing or emerging global challenges; and (iii) it advises interested Govern-
ments on ways and means of translating policy frameworks developed in United Nations confer-
ences and summits into programmes at the country level and, through technical assistance, helps
build national capacities.
Note
The views expressed in this publication do not necessarily reflect those of the United Nations.
The designations employed and the presentation of the material in this publication do not imply
the expression of any opinion whatsoever on the part of the Secretariat of the United Nations
concerning the legal status of any country or territory or of its authorities, or concerning the de-
limitations of its frontiers.
The designations of country groups in the text and the tables are intended solely for statistical or
analytical convenience and do not necessarily express a judgement about the stage reached by a
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Mention of the names of firms and commercial products does not imply the endorsement of the
United Nations.
Symbols of United Nations documents are composed of capital letters combined with figures.
ξ iii
Indigenous Peoples’ access to Health Services
Acknowledgements
The State of the World’s Indigenous Peoples has been a collaborative eort of experts and orga-
nizations. The introduction was written by the secretariat of the Permanent Forum on Indigenous
Issues within the Division for Social Policy and Development of the Department of Economic and
Social Aairs. The thematic chapters were written by Ms. Oksana Buranbaeva, Dr. Myriam Conejo
Maldonado, Dr. Ketil Lenert Hansen, Dr. Mukta S. Lama, Dr. Priscilla S. Migiro and Dr. Collin Tukui-
tonga. The Secretariat of the Permanent Forum on Indigenous Issues oversaw the preparation
of the publication. Special acknowledgements go to the editor, Jerey Reading, translator Raul
Molina, and also the UN Graphic Design Unit, Department of Public Information.
Ms. Shamshad Akhtar, Assistant-Secretary-General for Economic Development and Senior Ad-
visor on Economic Development and Finance, of the Department of Economic and Social Aairs
provided invaluable comments.
ξ v
Indigenous Peoples’ access to Health Services
Foreword to the State of the
World’s Indigenous Peoples
By Mr. Wu Hongbo, Under-Secretary-General for Economic and Social Aairs
Over the past two decades, international eorts have been made to improve the rights of indige-
nous peoples, to bring awareness to their issues, including their engagement in developing policy
and programmes in order to improve their livelihoods. In the First Decade of the World’s Indig-
enous People (1995-2004) the United Nations created the United Nations Permanent Forum on
Indigenous Issues as well as the Special Rapporteur on the rights of indigenous peoples. During
the Second Decade of the World’s Indigenous People (2005-2015), there have been further initia-
tives such as the creation of Expert Mechanism on the Rights of Indigenous Peoples. The adoption
of the United Nations Declaration on the Rights of Indigenous Peoples in September 2007 was a
major step for the United Nations as the Declaration had been debated for over 20 years.
The United Nations Permanent Forum on Indigenous Issues is an advisory body to the Economic
and Social Council with a mandate to discuss indigenous issues related to economic and social
development, culture, the environment, education, health and human rights. At its twelfth ses-
sion, the Permanent Forum on Indigenous Issues reviewed health as one of its mandated areas
and stated the right to health materializes through the well-being of an individual as well as the
social, emotional, spiritual and cultural well-being of the whole community.
1
The United Nations Declaration on the Rights of Indigenous Peoples states that indigenous peo-
ples have the right to be actively involved in developing and determining their health programmes;
the right to their traditional medicines, maintain their health practices, and the equal right to the
enjoyment of the highest attainable standard of physical and mental health. Unfortunately, indig-
enous peoples suer higher rates of ill health and have dramatically shorter life expectancy than
other groups living in the same countries. This inequity results in indigenous peoples suering
unacceptable health problems and they are more likely to experience disabilities and dying at a
younger age than their non-indigenous counterparts.
Indigenous peoples’ health status is severely aected by their living conditions, income levels,
employment rates, access to safe water, sanitation, health services and food availability. Indige-
nous peoples are facing destruction to their lands, territories and resources, which are essential
to their very survival. Other threats include climate change and environmental contamination
(heavy metals, industrial gases and euent wastes).
Indigenous peoples also experience major structural barriers in accessing health care. These in-
clude geographical isolation and poverty which results in not having the means to pay the high
cost for transport or treatment. This is further compounded by discrimination, racism and a lack of
cultural understanding and sensitivity. Many health systems do not reflect the social and cultural
practices and beliefs of indigenous peoples.
1
E/2013/43 p. 2.
vi ξ
State of the World’s Indigenous Peoples
At the same time, it is often dicult to obtain a global assessment of indigenous peoples’ health
status because of the lack of data. There has to be more work undertaken towards building on
existing data collection systems to include data on indigenous peoples and their communities.
This publication sets out to examine the major challenges for indigenous peoples to obtain ad-
equate access to and utilization of quality health care services. It provides an important back-
ground to many of the health issues that indigenous peoples are currently facing. Improving
indigenous peoples’ health remains a critical challenge for indigenous peoples, States and the
United Nations.
ξ vii
Indigenous Peoples’ access to Health Services
Contents
Foreword to the State of the World’s Indigenous Peoples
by Mr. Wu Hongbo, Under-Secretary-General for Economic and Social Aairs .............iv
Introduction ...............................................................002
The concept of indigenous peoples ..........................................003
Article 33 ...............................................................005
About this publication ....................................................006
Overview of major international responses to indigenous peoples ..................008
Chapter One
Access to Health Services by Indigenous Peoples in the African Region
by Dr. Priscilla Santau Migiro . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 010
Introduction ..............................................................011
Conclusion ..............................................................028
References: .............................................................028
Chapter Two
Access to Health Services by Indigenous Peoples in Asia
by Dr. Mukta Lama .......................................................... 032
Introduction .............................................................033
Conclusion ..............................................................054
References .............................................................. 055
Chapter Three
Access to Health Services by Indigenous Peoples in the Arctic Region
by Ketil Lenert Hansen, PhD .................................................. 058
Introduction .............................................................059
Conclusion .............................................................. 077
References ............................................................. 077
Chapter Four
Access to Health Services by Indigenous Peoples in Central, South America and
the Caribbean Region
by Dr. Myriam de Rocio Conejo Maldonado ........................................081
Introduction .............................................................082
Conclusion ..............................................................098
Bibliography ............................................................099
Internet sites .............................................................101
Special documents ........................................................101
viii ξ
State of the World’s Indigenous Peoples
Chapter Five
Access to Health Services by Indigenous Peoples in North America ....................103
Introduction ............................................................. 104
Conclusion ...............................................................126
Bibliography .............................................................126
Chapter Six
Access to Health Services by Indigenous Peoples in the Pacific Region
by Dr. Collin Tukuitonga ......................................................130
Introduction .............................................................131
Discussion ..............................................................151
Bibliography .............................................................155
Appendix ................................................................157
Chapter Seven
Access to Health Services by Indigenous Peoples in the Russian Federation
By Oksana Buranbaeva .......................................................158
Introduction .............................................................159
Conclusion .............................................................. 180
List of references .........................................................181
UN Photo
Introduction ξ 001
Indigenous Peoples’ access to Health Services
Introduction
UN Photo
Introduction
At its first session, the United Nations Permanent Forum on Indigenous Issues requested the Unit-
ed Nations System produce such a report on the state of the world’s indigenous peoples.
2
It was
also suggested the report be a key advocacy tool for raising awareness on indigenous peoples’
issues in general and in particular to raise the profile of the Permanent Forum. In addition, the
report should be of value for deliberations within the Economic and Social Council, the General
Assembly and other bodies of the UN system.
The first publication of The State of the World’s Indigenous Peoples was published in 2009 and
its major focus was on: Poverty and Well-being; Culture; Environment; Contemporary Education;
Health; Human Rights and Emerging Issues. The report was well received, and, according to press
reports, the publication revealed alarming statistics on indigenous peoples’ poverty, health, edu-
cation, employment, human rights, the environment and more. This was the first United Nations
publication and provided much needed information on the status of indigenous peoples through-
out the world.
The State of the World’s Indigenous Peoples will remain a recurrent “flagship” publication pro-
duced by the United Nations. It is intended that publications such as this will deal with a broad
spectrum of indigenous peoples’ issues. It is hoped that such a publication, given its function
of supporting the United Nations Permanent Forum, will also promote awareness of indigenous
peoples’ issues within the United Nations system, with States, academia and the broader public.
The current situation of indigenous peoples remains a concern within the United Nations. It has
been estimated that the world’s 370 million indigenous peoples reside in approximately 90 coun-
tries of the world.
3
They are among the world’s most marginalized peoples, and are often isolated
politically and socially within the countries where they reside by the geographical location of their
communities, their separate histories, cultures, languages and traditions. They are often among
the poorest peoples and the poverty gap between indigenous and non-indigenous groups is in-
creasing in many countries around the world. This influences indigenous peoples’ quality of life
and their right to health.
Indigenous peoples’ access to adequate health care remains one of the most challenging and
complex areas. There is an urgent need to focus on health issues as well as alternative health
care frameworks. As previously stated, health is one of the six mandated areas of the United
Nations Permanent Forum on Indigenous Issues and is one of the focuses of the World Health
Organization, which recognizes the right to health as a fundamental human right in its consti-
tution. The United Nations Declaration on the Rights of Indigenous Peoples includes articles (21,
23, 24 and 29) that refer specifically to the right to health, including indigenous peoples’ right to
improving their economic and social conditions in the area of health, with particular attention
to the needs of indigenous elders, women, youth, children and persons with disabilities. Further,
indigenous peoples have the right to determine their health programmes and to administer these
programmes through their own institutions, as well as maintain their traditional health practices.
2
Permanent Forum on Indigenous Issues, Report on the First session (12-24 May 2002) E/2002/43.
3
Harry Patrinos and Gillette Hall, Indigenous Peoples, Poverty and Development, 2010, p. 8.
Introduction ξ 003
Indigenous Peoples’ access to Health Services
Also, that States take eective measures to ensure that programmes for monitoring, maintaining
and restoring the health of indigenous peoples, as developed and implemented by the peoples
aected by such materials, are duly implemented.
Indigenous peoples face a myriad of obstacles when accessing public health systems. These in-
clude the lack of health facilities in indigenous communities and cultural dierences with the
health care providers such as dierences in languages, illiteracy and lack of understanding of in-
digenous culture and traditional health care systems. There is also an absence of adequate health
insurance or lack of economic capacity to pay for services. As a result, indigenous peoples often
cannot aord health services even if it is available. Marginalization also means that indigenous
peoples are reluctant or have diculties in participating in non-indigenous processes or systems
at the community, municipal, state and national levels.
There are also major concerns regarding the lack of data on indigenous peoples’ health and social
conditions. Not only is there a lack of disaggregated data based on ethnicity but also data related
to the location of indigenous peoples’ residence such as urban, rural or isolated areas. As a result,
there is a lack of information, analysis and evaluation of programmes and services relating to in-
digenous peoples’ health situation.
One of the important areas for health care for indigenous peoples lies in intercultural frameworks
and models of care. Health care services need to be pluricultural in order to develop eective
models of care and best practices so that such programmes and services are culturally and lin-
guistically appropriate for indigenous peoples. Also, indigenous peoples must be able to partici-
pate in the design and implementation of comprehensive health plans, policies and programmes.
It has been estimated that over 80 per cent of the world’s indigenous peoples live in Asia, Latin
America and Africa,. However, there is still little information known about their health status and
their levels of access to health services. Even in wealthy nations, most studies indicate an alarm-
ing health disadvantage for indigenous peoples. Historically, indigenous peoples have suered the
impact of colonization and assimilation policies as well as the imposition of foreign development
models. Indigenous peoples continue to suer discrimination in their own countries which has a
major impact on their lives, in particular, their health. Indigenous peoples are not only a marginal-
ized group with health problems, they are also highly aware of their situation, quite political and
willing to work to towards improving their health and social status. Therefore, indigenous peoples
have the right to determine their own policies, strategies and interventions in order to obtain the
highest attainable standards of health and health services, as set out in the United Nations Dec-
laration on the Rights of Indigenous Peoples.
The concept of indigenous peoples
There has been considerable debate devoted to the question of the definition or understanding
of “indigenous peoples” however, no such definition has ever been adopted by any United Nations
body, and the prevailing view today is that no formal universal definition is necessary for the rec-
ognition and protection of their rights.
One of the most cited descriptions of the concept of “indigenous” was outlined in the José R.
Martínez Cobo’s Study on the Problem of Discrimination against Indigenous Populations. After
004 ξ Introduction
State of the World’s Indigenous Peoples
consideration of the issues involved, Martínez Cobo oered a working definition of “indigenous
communities, peoples and nations”. In doing so, he expressed a number of basic ideas forming
the intellectual framework for this eort, including the right of indigenous peoples themselves to
define what and who are indigenous peoples. The working definition is as follows:
Indigenous communities, peoples and nations are those which, having a historical continu-
ity with pre-invasion and pre-colonial societies that developed on their territories, consider
themselves distinct from other sectors of the societies now prevailing on those territories,
or parts of them. They form at present non-dominant sectors of society and are determined
to preserve, develop and transmit to future generations their ancestral territories, and their
ethnic identity, as the basis of their continued existence as peoples, in accordance with their
own cultural patterns, social institutions and legal system.
This historical continuity may consist of the continuation, for an extended period reaching into
the present of one or more of the following factors:
a. Occupation of ancestral lands, or at least of part of them.
b. Common ancestry with the original occupants of these lands.
c. Culture in general, or in specific manifestations (such as religion, living under a tribal sys-
tem, membership of an indigenous community, dress, means of livelihood, lifestyle, etc.).
d. Language (whether used as the only language, as mother tongue, as the habitual means
of communication at home or in the family, or as the main, preferred, habitual, general or
normal language).
e. Residence in certain parts of the country, or in certain regions of the world.
f. Other relevant factors.
On an individual basis, an indigenous person is one who belongs to these indigenous popula-
tions through self-identification as indigenous (group consciousness) and is recognized and
accepted by these populations as one of its members (acceptance by the group). This preserves
for these communities the sovereign right and power to decide who belongs to them without
external interference.
4
During the many years of debate at the meetings of the Working Group on Indigenous Popula-
tions, observers from indigenous organizations developed a common position that rejected the
idea of a formal definition of indigenous peoples at the international level to be adopted by States.
Similarly, government delegations expressed the view that it was neither desirable nor necessary
to elaborate a universal definition of indigenous peoples. Finally, at its fifteenth session, in 1997,
the Working Group concluded that a definition of indigenous peoples at the global level was not
possible at that time, and this did not prove necessary for the adoption of the Declaration on the
Rights of Indigenous Peoples.
5
Instead of oering a definition, Article 33 of the United Nations
4
Martínez Cobo (1986-1987), paras. 379-382.
5
Working Group on Indigenous Populations (2006a) and (2006b), paras. 153-154.
Introduction ξ 005
Indigenous Peoples’ access to Health Services
Declaration on the Rights of Indigenous Peoples underlines the importance of self-identification,
that indigenous peoples themselves define their own identity as indigenous.
Article 33
1. Indigenous peoples have the right to determine their own identity or membership in accor-
dance with their customs and traditions. This does not impair the right of indigenous indi-
viduals to obtain citizenship of the States in which they live.
2. Indigenous peoples have the right to determine the structures and to select the member-
ship of their institutions in accordance with their own procedures.
ILO Convention No. 169 also enshrines the importance of self-identification. Article 1 indicates
that self-identification as indigenous or tribal shall be regarded as a fundamental criterion for
determining the groups to which the provisions of this Convention apply. Furthermore, this same
Article 1 contains a statement of coverage rather than a definition, indicating that the Convention
applies to:
a. tribal peoples in independent countries whose social, cultural and economic conditions dis-
tinguish them from other sections of the national community and whose status is regulat-
ed wholly or partially by their own customs or traditions or by special laws or regulations;
b. peoples in independent countries who are regarded as indigenous on account of their de-
scent from the populations which inhabited the country, or a geographical region to which
the country belongs, at the time of conquest or colonization or the establishment of pres-
ent state boundaries and who irrespective of their legal status, retain some or all of their
own social, economic, cultural and political institutions.
The concept of indigenous peoples emerged from the colonial experience, whereby the aboriginal
peoples of a given land were marginalized after being invaded by colonial powers, whose peoples
are now dominant over the earlier occupants. These earlier definitions of indigenousness make
sense when looking at the Americas, Russia, the Arctic and many parts of the Pacific. However,
this definition makes less sense in most parts of Asia and Africa, where the colonial powers did
not displace whole populations of peoples and replace them with settlers of European descent.
Domination and displacement of peoples have, of course, not been exclusively practised by white
settlers and colonialists; in many parts of Africa and Asia, dominant groups have suppressed mar-
ginalized groups and it is in response to this experience that the indigenous movement in these
regions has reacted.
It is sometimes argued that all Africans are indigenous to Africa and that by separating Africans
into indigenous and non-indigenous groups, separate classes of citizens are being created with
dierent rights. The same argument is made in many parts of Asia or, alternatively, that there can
be no indigenous peoples within a given country since there has been no large-scale Western
settler colonialism and therefore there can be no distinction between the original inhabitants and
newcomers. It is certainly true that Africans are indigenous to Africa and Asians are indigenous to
Asia, in the context of European colonization. Nevertheless, indigenous identity is not exclusively
determined by European colonization.
006 ξ Introduction
State of the World’s Indigenous Peoples
The Report of the Working Group of Experts on Indigenous Populations/Communities of the Afri-
can Commission on Human and Peoples’ Rights therefore emphasizes that the concept of indige-
nous must be understood in a wider context than only the colonial experience:
The focus should be on more recent approaches focusing on self-definition as indigenous
and distinctly dierent from other groups within a state; on a special attachment to and
use of their traditional land whereby ancestral land and territory has a fundamental impor-
tance for their collective physical and cultural survival as peoples; on an experience of sub-
jugation, marginalization, dispossession, exclusion or discrimination because these peoples
have dierent cultures, ways of life or modes of production than the national hegemonic
and dominant model.
6
In the 60-year historical development of international law within the United Nations system, it
is not uncommon that various terms have not been formally defined, the most vivid examples
being the notions of “peoples” and “minorities”. Yet the United Nations has recognized the right
of peoples to self-determination and has adopted the Declaration on the Rights of Persons Be-
longing to National or Ethnic, Religious and Linguistic Minorities. The lack of formal definition of
“peoples” or “minorities” has not been crucial to the Organization’s successes or failures in those
domains nor to the promotion, protection or monitoring of the rights accorded to these groups.
Nor have other terms, such as “the family” or “terrorism” been defined, and yet the United Nations
and Member States devote considerable action and eorts to these areas.
In conclusion, in the case of the concept of “indigenous peoples”, the prevailing view today is that
no formal universal definition of the term is necessary, given that a single definition will inevitably
be either over- or underinclusive, making sense in some societies but not in others.
About this publication
The publication includes seven chapters that examine indigenous peoples’ access to and utili-
zation of quality health care services within the seven sociocultural regions of the Permanent
Forum: Africa; Asia; Central and South America and the Caribbean; the Arctic; Central and Eastern
Europe, Russian Federation, Central Asia and Transcaucasia; North America; and the Pacific.
Each of the authors provides an overview of health issues in their sociocultural regions as well the
challenges that indigenous peoples face in trying to access and utilize health services.
The first chapter by Dr. Priscilla S. Migiro emphasizes the diculties that indigenous peoples in
Africa face in being recognized, firstly, as indigenous peoples and, secondly, accessing health ser-
vices within the region’s population of about 960 million people who already face health chal-
lenges with a high burden of communicable and emerging non-communicable diseases. Access
to health care is not uniform across the continent, with variations from one country to the next
and also within countries. National figures of morbidity and mortality often mask inequities within
countries. Dr. Priscilla S. Migiro also focuses on the barriers to the enjoyment of the right to health,
the lack of data on indigenous peoples’ health status and the loss of land in which indigenous
peoples depend for their livelihoods and traditional medicines.
6
Report of the African Commission’s Working Group of Experts on Indigenous Populations/communities.
Introduction ξ 007
Indigenous Peoples’ access to Health Services
In the second chapter, Dr. Mukta S. Lama provides an overview and analysis of the situation of
indigenous peoples in the Asian region. The Asian subregions include a multitude of indigenous
groups who comprise 70 per cent of the estimated 350 million indigenous peoples worldwide.
Indigenous peoples in Asia die younger, have higher rates of malnutrition and child mortality, and
carry high burden of “diseases of the poor”, namely undernutrition and infectious diseases. Dr.
Lama points out that the health of indigenous peoples is often not considered a priority by na-
tional governments and as a result, health care needs remain unheard in health care planning with
weak representation of indigenous peoples in the government system. Dr. Lama concludes that
the exercise of right to self-determination is important in enabling indigenous peoples to revive
and reclaim their cultural traditions and indigenous identity and self-esteem based on positive
images that are crucial for their overall health and well-being. Such autonomy would also involve
empowering indigenous peoples to preserve and develop their own solutions and plans to im-
prove their health rather than imposing solutions upon them.
The third chapter by Dr. Ketil Lenert Hansen analyses the major health issues confronting Sami
peoples in Norway, Finland, Sweden and Russia and the Inuit in Greenland. The chapter includes
an analysis of the unique challenges faced by the indigenous peoples living in the far north due
to their specific socioenvironmental location with an increased risk of health problems compared
with the average national statistics. Dr. Ketil Lenert Hansen specifies the major constraints to
delivering good quality health care in the North and at the same time outlines how traditional
healing is being integrated within health services for indigenous peoples.
In the fourth chapter, Dr. Myriam Conejo Maldonado provides an overview and analysis of the
situation of indigenous peoples in the Central and South America and the Caribbean region
and illustrates the stark contrast in access to health services between the indigenous and non-
indigenous populations. Indigenous peoples live in poverty and comprise 60 per cent of the poor
in the region. Several countries in the region have included an intercultural approach to health in
their development plans. However, sociocultural and linguistic barriers still exist, as well as barriers
in terms of geographical location and lack of access to health care. Dr. Myriam Conejo Maldonado
concludes that there must be a new approach to health services for indigenous peoples based on
interculturality, human rights, and collective rights.
The fifth chapter on North America emphasizes the complex arrangements that the United States
and Canada has with indigenous peoples in terms of health policies. To a large degree, jurisdic-
tional conflict between state/provincial and federal governments impact on the accessibility and
comprehensiveness of health services for indigenous peoples. The challenges for indigenous peo-
ples in both Canada and the United States are to 1) take control of their own personal health to
achieve balance in life; 2) assume authority and control over health and social services which
impact their lives; and 3) design and implement a sustainable health system which meets their
unique needs. The role of the federal and provincial governments is to work in partnership with
indigenous peoples to design and implement health systems.
In chapter six, Dr. Collin Tukuitonga provides a background of the historical, political and cultural
factors that have shaped events in Pacific countries that have influenced the health status of
indigenous peoples. Dr. Collin Tukuitonga describes the current health situation; the social deter-
minants of health, health service funding and delivery; and the initiatives that have been shown
to be eective in improving indigenous peoples’ access to all levels of health care. While there are
number of initiatives under way in developed countries that are designed to improve access to
008 ξ Introduction
State of the World’s Indigenous Peoples
health care services, there is limited information on the impact of these programmes. There are
however, encouraging signs that health initiatives provided “by indigenous peoples for indige-
nous people” is improving access to services.
The seventh chapter by Ms. Oksana Buranbaeva outlines indigenous peoples’ access to health
in the Russian Federation. Russian federal legislation protects the “numerically small indigenous
peoples” or “small-numbered indigenous peoples of Russia”, defined as those who live in territories
traditionally inhabited by their ancestors; maintain a traditional way of life and economic activity;
number fewer than 50,000; and identify themselves as separate ethnic communities. Ms. Oksana
Buranbaeva describes the situation and policies that the Soviet Union adopted vis-à-vis indige-
nous peoples which had both negative and positive consequences on indigenous peoples’ current
access to health services. Ms. Oksana Buranbaeva concludes that a comprehensive strategy is re-
quired in order to develop in partnerships and consultation with indigenous peoples that draw on
the experiences of other Arctic countries to enhance access to indigenous peoples health services.
Overview of major international responses to indigenous peoples
1957 – ILO Convention 107 on Indigenous and Tribal Populations is adopted
(http://www.ilo.org/ilolex/english/convdisp1.htm)
1972 – The Study of the Problem of Discrimination against Indigenous Populations is launched
(also known as the Martínez Cobo study)
1982 – The Working Group on Indigenous Populations is established by the United Nations
(http://www.ohchr.org/english/issues/indigenous/groups/groups-01.htm)
1984 – The Study of the Problem of Discrimination against Indigenous Populations is submitted
to the UN
1985 – The Voluntary Fund for Indigenous Populations is created
1989 – ILO Convention No. 169 concerning Indigenous and Tribal Peoples in Independent States
is adopted (http://www.ilo.org/ilolex/english/convdisp1.htm)
1992 – The Rio Earth Summit adopts the Convention on Biological Diversity
(http://www.biodiv.org/convention/default.shtml)
1993 – The World Conference on Human Rights recommends the establishment of a Permanent
Forum on Indigenous Issues
1993 – International Year of the World’s Indigenous People
1994 – The first International Decade for Indigenous People is launched (1994-2004)
1994 – The Voluntary Fund to support small-scale projects during the Decade is created
1998 – First Roundtable on Intellectual Property and Indigenous Peoples organized by the
World Intellectual Property Organization - WIPO (http://www.wipo.int)
2000 – Establishment of the United Nations Permanent Forum on Indigenous Issues (UNPFII)
(http://www.un.org/esa/socdev/unpfii/index).
2001 – The mechanism of a Special Rapporteur on the Human Rights and Fundamental
Freedoms of Indigenous People is established by the Commission on Human Rights
(http://www.ohchr.org/english/issues/indigenous/rapporteur/).
Introduction ξ 009
Indigenous Peoples’ access to Health Services
2002 – A Voluntary Fund for Indigenous and Local Communities is established by the
Convention on Biological Diversity (http://www.cbd.int).
2003 – A Voluntary Fund is established by the United Nations to support the Permanent Forum.
2005 – The Second International Decade for Indigenous People is launched (2005-2015),
including a fund to support small-scale projects.
2005 – A Voluntary Fund for Indigenous and Local Communities is created by World Intellectual
Property Rights.
2007 – The UN Declaration on the Rights of Indigenous Peoples is adopted by the UN General
Assembly (http://www.un.org/esa/socdev/unpfii/en/declaration.html).
2007 – The new Expert Mechanism on the Rights of Indigenous Peoples is established by the
Human Rights Council.
2014 – High Level Plenary Meeting of the United Nations General Assembly also known as the
World Conference on Indigenous Peoples.
UN Photo/Broddi Sigurdarson
Chapter 1 ξ 011
Indigenous Peoples’ access to Health Services
Chapter One
Access to Health Services
byIndigenous Peoples
in the African Region
Dr. Priscilla Santau Migiro
UN Photo/Broddi Sigurdarson
012 ξ Chapter 1
State of the World’s Indigenous Peoples
Chapter One
Access to Health Services
by Indigenous Peoples
in the African Region
Dr. Priscilla Santau Migiro
7
Introduction
Definition of indigenous peoples in the African region
A strict definition of indigenous peoples is neither necessary nor desirable. It is much more rele-
vant and constructive to try to outline the major characteristics, which can help us identify who
are the indigenous peoples and communities of Africa.
The approach that has been advocated by the African Commission’s Working Group of Ex-
perts on Indigenous Populations/Communities includes the following overall characteristics
of groups identifying themselves as indigenous peoples:
ɜ Their cultures and ways of life dier considerably from the dominant society;
ɜ Their cultures are under threat, in some cases to the extent of extinction;
ɜ The survival of their particular way of life depends on access and rights to their tradi-
tional lands, territories and natural resources;
ɜ They suer from discrimination as they are regarded as less developed and less ad-
vanced than the more dominant sectors of society;
ɜ They often live in inaccessible regions, often geographically isolated and suer from
various forms of marginalization, both politically and socially.
ɜ They are subject to domination and exploitation within the national political and eco-
nomic structures that are commonly designed to reflect the interests and activities of
the national majority.
7
Dr. Migiro is a Masaai woman from Kenya. She received her undergraduate degree in medicine and postgraduate qual-
ifications in Paediatrics and Child Health from the University of Nairobi. She has worked in various capacities in the
Ministry of Health and in private health sector. Since 2004, Dr. Migiro has worked in the ministry’s headquarters where
she worked her way to become the Head of the Division of Child and Adolescent Health, where she has been involved
in development of policies, strategies and guidelines in child survival and development. Since June 2012, Dr. Migiro
has worked in the Department of Health Promotion involved in development of policies, strategies and guidelines of
health promotion.
Chapter 1 ξ 013
Indigenous Peoples’ access to Health Services
Discrimination, domination and marginalization violates indigenous peoples human rights as
peoples/communities, threatens the continuation of their cultures and ways of life and prevents
them from genuinely participating in decisions on their own future and forms of development.
8
Africa’s population of about 960 million people already faces health challenges with a high bur-
den of communicable and emerging non-communicable diseases. Access to health is not uniform
across the continent, from one country to the next nor within countries. National figures of mor-
bidity and mortality often mask inequities within countries. The vulnerable populations include the
poor, the hard to reach, women and children, persons with disabilities and the marginalized.
Indigenous peoples often live in remote and hard-to-reach areas, and many are less educated,
few in number and culturally dierent from their more populous neighbours. They face additional
challenges of access to health services. This constitutes a violation of the African Charter such as:
ɜ The right of equal access to the public services of one’s country (Article 13 (2))
ɜ The right to education (Article 17(1))
ɜ The right to medical care and attention (Article 16(2)).
9
Further, they are also discriminated against by health service providers and considered to be
”backward”. This can be seen from the view of a President of an African country who said, “How
can you have a stone-age creature continuing to exist in the time of computers? If the Bushmen
want to survive, they must change, otherwise, like the dodo they will perish”.
10
Indigenous Africans and the Millennium Development Goals (MDG)
The Millennium Declaration, signed by 147 Heads of State and Government in September 2000,
and the Millennium Development Goals have provided an opportunity for a renewed focus on
indigenous peoples in the international development debate. The report of the Fourth Session of
the United Nations Permanent Forum on Indigenous Issues, stated that “Indigenous peoples have
the right to benefit from the Millennium Development Goals and from other goals and aspirations
contained in the Millennium Declaration to the same extent as all others”.
11
However, by failing to
ground the goals in an approach that upholds indigenous peoples’ individual and collective rights,
the MDGs fall short in addressing the health disparities that persist between indigenous peoples
and other poor, marginalized groups. By advancing the dominant paradigms of health and devel-
opment rather than an approach based on individual and collective human rights, the MDGs also
promote projects that are potentially detrimental to indigenous peoples by violating their rights
to their collective lands, territories and natural resources.
8
Report of the African Commission’s Working Group of Experts on Indigenous Populations/Communities by the African
Commission on Human and Peoples’ Rights and the International Working Group on Indigenous Aairs (2005).
9
African Charter on Human and Peoples’ Rights: OAU Doc. CAB/LEG/67/3 rev. 5, 21 I.L.M. 58 (1982), entered into force 21
October 1986).
10
Suzman, J .,An Introduction to Regional Assessment of the San in Southern Africa.2001, Legal Assistance Centre,
Windhoek. Namibia.
11
E/2005/43 United Nations Permanent Forum on Indigenous Issues, Report of the Fourth Session (2005).
014 ξ Chapter 1
State of the World’s Indigenous Peoples
Moreover, because the cultures and world views of indigenous peoples are not taken into account
in the formulation of the MDGs, the goals do not consider indigenous peoples’ concept of health,
which extends beyond the physical and mental well-being of an individual to the spiritual bal-
ance and well-being of the community as a whole. To improve the health situation of indigenous
peoples, there must thus be a fundamental shift in the concept of health so that it incorporates
the cultures and world views of indigenous peoples as central to the design and management of
state health systems.
12
Reports from countries reviewing progress on MDGs have shown that data on indigenous peoples
are missing in national monitoring and reporting. The reviews also reveal that there is no clear
mechanism identified to include indigenous peoples in the design, implementation and monitor-
ing of policies designed to achieve the MDGs.
13
An analysis of the health situation of indigenous peoples in the African region
Maybury-Lewis
14
estimates that there are over 14.2 million self-identifying indigenous peoples in
the African region. The African Charter on Human and Peoples’ Rights (ACHPR)
15
report lists some
of the best known indigenous peoples whom they divide into two groups, hunter-gatherers and
pastoralists. The report gives 11 examples of hunter-gatherers in 13 countries and 23 examples
of pastoralists in 22 countries. These indigenous peoples often occupy hard-to-reach areas with
poor infrastructure and harsh terrain. To further compound the problem is the lack of recognition
of indigenous peoples by African states. This means that disaggregated data on indigenous peo-
ples’ health status are hard to find. In fact, because indigenous peoples are essentially invisible in
the data collection of many international agencies and in most national censuses, the disparities
in their health situation as compared to other groups continues to be obscured.
16
For example, in
Kenya, demographic and health surveys have been undertaken every five years since 1989, exclud-
ing the hard-to-reach areas of North-Eastern Kenya because of the terrain. It is only the last two
surveys of 2003 and 2008-2009 that these areas were included. The reason given for this omis-
sion is that those districts account for less than 4 per cent of Kenya’s population.
17
These areas are
occupied by nomadic pastoralists and hunter gatherers, all of whom have poor health indicators
which, as a vulnerable minority, should justify their inclusion instead of exclusion.
Indigenous peoples of Central Africa
The indigenous people in central Africa have often been collectively identified as “Pygmy”. Due to
the fact the term “Pygmy” carries negative connotations due to its association with the assump-
tion of inferior status, there is now a policy in some central African countries to ocially designate
such groups as indigenous peoples or populations autochtones.
12
State of the World’s Indigenous Peoples, United Nations publication (2009)
13
Ibid.
14
Maybury-Lewis D. 2002. Indigenous peoples, ethnic groups and the state. Needham, Massachusetts: Allyn & Baker.
15
Report of the African Commission’s Working Group of Experts on Indigenous Populations/Communities by the African
Commission on Human and Peoples’ Rights and the International Working Group on Indigenous Aairs (2005).
16
State of the World’s Indigenous Peoples, United Nations publication (2009).
17
Kenya Demographic and Health Service 1989, 1993, 1998: National Council for Population and Development, Central
Bureau of Statistics.
Chapter 1 ξ 015
Indigenous Peoples’ access to Health Services
Indigenous peoples in Central Africa number between 300,000 to 500,000 peoples. They
consist of at least 15 distinct ethnolinguistic groups including the Gyeli, Kola, Baka, Aka, Bon-
go, Efe, Mbuti, western Twa, and eastern Twa. They live in ten central African countries: Angola,
Burundi, Cameroon, Central African Republic, Democratic Republic of Congo, Equatorial Guin-
ea, Gabon, Republic of Congo, Uganda and Rwanda.
18
In general, access to health services is a challenge due to regional overpopulation, poor infra-
structure and indequate personnel. For indigenous peoples, this is even worse as they live in re-
mote areas. In his report following a vist to the Republic of Congo, Professor James Anaya, the
Special Rapporteur on the Rights of Indigenous Peoples noted there is inadequate cultural adap-
tation to the delivery of health services, which appears to create a barrier to the enjoyment of the
right to health by indigenous peoples that goes beyond proximity to the health facility. He noted
that while the government had taken important steps to improve indigenous health, more needs
to be done so that there is equal access to health services especially in remote areas.
19
Indigenous
peoples also reported the challenges they face in accessing health services even where they are
free, such as maternal and child health. Lack of money to pay for prescription drugs and obstetric
services are significant blocks, creating diculties and barriers. Most villages do not have health
facilities, so they are forced to rely on those located in majority Bantu villages which often dis-
criminate against indigenous peoples.
20
Mr. Jean Dominique Dambo, the leader of the indigenous people in Dzaka, a village near Oues-
so, the main town in the Sangha region in northern Congo said, “It is dicult; we don’t have a
health centre, no school, even though we are near the capital”. He further stated, “Over there,
not far from our village, the people are getting free treated mosquito nets and other goods
while we are not informed about it; I am sure they forgot about us”. He also confirmed that
recent health campaigns by the government targeting mothers and children in Ouesso ex-
cluding indigenous peoples in the area.
21
Indigenous peoples rely heavily on traditional med-
icines. This however poses another challenge. The growing inaccessibility to forests and lack
of support by the government is seriously eroding their knowledge and skills in the area of
traditional medicine.
22
A study carried out by the Ministry of Health and the United Nations Populations Fund (UNFPA)
in 2012 indicated that indigenous women are virtually excluded from reproductive health services.
According to the study, while 94 per cent of the Congolese women access antenatal care, only
37 per cent of the indigenous women have access to such services.
23
As a result of this study, the
18
Jackson, D. Implementation on International Commitments on Traditional Forest Related Knowledge: Indigenous peo-
ples’ experiences in Central Africa.
19
A/HRC/18/35/Add.5.
20
A/HRC/18/35/Add.5.
21
http://www.irinnews.org/report/79995/congo-we-remain-marginalised-indigenous-people-say, 2013
22
Report of the Country Visit of the Working Group on Indigenous Populations/Communities to the Republic of Congo,
15-24 March 2010.
23
http://www.irinnews.org/report/97574/in-congo-few-pygmy-women-have-access-to-reproductive-health-services.
016 ξ Chapter 1
State of the World’s Indigenous Peoples
Working Group on Indigenous Populations/Communities made the following recommendations
to governments in regards to health:
1. Provide well-equipped health centres stocked with adequate medicines and endowed
with qualified sta within the communities where indigenous peoples live;
2. Provide training for health personnel from indigenous communities in terms of supervision
and capacity building for traditional birth attendants;
3. Develop targeted sensitization campaigns and initiate community actions to ensure that
the indigenous populations familiarize themselves with: immunization, antenatal and
postnatal controls, HIV/AIDS screening; monitoring of chronic parasitic diseases among
indigenous communities.
24
The Batwa of Uganda
The Batwa are also a vulnerable population. They have limited access to education, a high rate of
alcoholism and poor medical care. They have high child mortality rates and low life expectancy.
As with other indigenous peoples in the African region, there is also a lack of data on their health
status and published research data are rare.
25
Their situation is made worse by loss of land which
they depend on for medicines. Women are also at high risk of getting HIV because of interaction
with neighbouring communities, at risk of rape and having to exchange sex for necessities. Ac-
cess to testing and care and treatment is a challenge, as they have to pay for services, and health
workers do not treat them well.
26
Coordinated action is needed by all sectors to improve the
health of the Batwa peoples. In order for this to happen, the following were recommended:
ɜ Acknowledge the rights of the Batwa as indigenous peoples;
ɜ Increase Batwa participation in developing policies and programs;
ɜ Enforce equal opportunity policies.
Kenya
In Kenya, health facilities are often located in urban centres with almost no mobile health facilities
to cater for nomadic pastoralists and communities in far-flung regions in the north and semi-arid
areas where infrastructure is non-existent. The cost of accessing medical and health facilities in
Kenya is also costly and often beyond the reach of many indigenous communities, who may not
have the means to travel long distances to purchase certain prescribed drugs that are unavailable
in public health facilities. The fact that there are almost no health facilities in close proximity to
most indigenous peoples living in North-Eastern Kenya and remote parts of the Coast province
and Rift Valley means that they have to walk long distances even during an emergency, which
results in poor health outcomes.
24
Report of the Country Visit of the Working Group on Indigenous Populations/Communities to the Republic of Congo,
15-24 March 2010.
25
Social Determinants of Health for Uganda’s Indigenous Batwa: Sherilee Harper: Backgrounder No 32, June 2012.
26
State of the World’s Minorities and Indigenous Peoples. 2013. Minority Rights International. p. 68.
Chapter 1 ξ 017
Indigenous Peoples’ access to Health Services
A report undertaken for the Ministry of Public Health indicated that the IlChamus people, for
example, spend an average of 600 Kenyan shillings ($7) on transport expenses to take pregnant
women in labour for delivery at Marigat district hospital, while the Waata community in Madogo
of Tana River spends an average of 2,000 Kenyan shillings ($24) on transport hire to take their
sick to the provincial hospital in Garissa. It has been reported that most deliveries are conducted
at home because of these challenges.
27
This report included only marginalized peoples and omit-
ted other groups like the Maasai of southern Kenya.
Other factors identified as barriers to health services included:
ɜ Health facilities, where available, are sometimes not operational due to sta shortages;
ɜ Lack of essential drugs and supplies;
ɜ Beliefs in the eectiveness of traditional herbs which are free in the villages, while health
services require payment;
ɜ Lack of awareness of the services available, especially because of low education levels;
ɜ Deliveries occur at home mainly because of the long distances to facilities including the
need to adhere to traditional practices performed at birth. For example, some communi-
ties do not like male health workers assisting women to deliver babies.
ɜ Lack of their own indigenous health sta;
ɜ Language barrier between health workers and indigenous peoples;
ɜ Resistance to family planning services by women because of perceived negative side ef-
fects and lack of support from the men. They feel the need to have many children because
of their populations are small. This is explained by an Ogiek community member:
“Why are we being asked to practice family planning so that other people from
outside the community can come and occupy our land? We do not want to be con-
tinuously referred to as minorities”.
At the Katilu health centre in Turkana south, a community member said:
“Men in our community do not allow women to deliver in the clinic because they want to perform
traditional rituals and apply herbs. The umbilical cord of the male baby is cut using a common
spear in the community, while that of the female baby is cut using a common knife in the com-
munity. They only allow women to go to the hospital two weeks prior to the time of delivery”.
Tanzania
The indigenous peoples of the United Republic of Tanzania include the Maasai, the Barbaig (Da-
toga), Akie, Taturu and Hadzabe. The former two groups are predominantly pastoralists, whereas
the latter comprise forest-dwelling hunter-gatherers. The groups collectively practice pastoral-
ism and hunting-gathering. The Maasai are the most populous, numbering about 450,000. The
27
Nyambedha, E.O., Final Report for Development of Vulnerable and Marginalized Peoples Plans (VMPPS): Ministry of
Public Health and Sanitation, Kenya, 2013.
018 ξ Chapter 1
State of the World’s Indigenous Peoples
Akie number about 5,200, while the Hadzabe population number between 1,000 and 3,000. The
concept of indigenous peoples is not acknowledged in Tanzania, but the government “recognizes
the vulnerability of some of the marginalized communities”.
28
The delivery of health services in
the areas occupied by indigenous peoples is dicult. This is because of poor infrastructure and
also that the communities are sparse and migratory. They have to depend on services provided by
non-governmental organizations, faith-based organizations and other agencies.
A study on the dierences in health between the Datoga/Barabaig and their neighbours indicated
how patterns of health are linked to wider issues of marginalization. The marginalization of the
Datoga/Barabaig includes the lack of access to their traditional homelands where their lands are
being acquired by the government and private interests for non-pastoral commercial use such
as parks, private ranches and commercial wheat estates. Communal lands are being fenced o
resulting in the Datoga/Barabaig being evicted from their traditional lands. The loss of their pas-
ture lands has resulted in the decimation of their herds. The large-scale prairie-type farming has
also resulted in the destruction of trees and other vegetation, aecting rain patterns and soil
erosion. In some areas, water is extremely scarce. The relationship between the Datoga/Barabaig
and the surrounding community has been one of hostility and antagonism. Incidences of abuse
of human rights, the beating and arrest of pastoralists and confiscation of cattle on the pretext
of trespass have been common.
29
Not surprisingly, the Datoga/Barabaig are at a greater risk of
anaemia, maternal mortality and tuberculosis. Infant mortality is also high among the Datoga (20
per cent), while fertility is lower than in neighbouring groups, and pastoral Datoga children show
early growth faltering and little catch-up growth when compared to neighbouring groups.
30
The
pastoralists are also vulnerable to HIV/AIDS due to negative cultural practices and low levels of
literacy. The negative cultural practices are FGM, early sexual debut and early marriages for girls
and the low social status of women.
Botswana
The indigenous peoples of Botswana are collecticvely called the Basarwa, Bakgalagadi or San
and are hunter-gatherers. In his report the Special Rapporteur on the Rights of Indigenous Peo-
ples noted that the government of Botswana has made eorts to address the situation of indige-
nous peoples through the Remote Area Development Policy of 1975, which has been revised over
time in line with new developments.
31
In the revised programme the Government “shall adopt a community-led development approach
which aims to promote participatory processes and community participation in issues aecting
their own development”. The new policy also acknowledges the need for armative measures for
the benefit of communities that have faced intractable disadvantages, either for logistical rea-
sons or because of long standing historical prejudice and subjugation by the dominant groups”.
Such measures will be adopted across a variety of sectors to improve access to education, health,
employment and economic development opportunities, and to develop sociopolitical institu-
28
Country Technical Note on Indigenous Peoples’ Issues: United Republic of Tanzania. Submitted by IWGIA, June 2012.
29
Isa G. Schivji, Globalisation and Popular Resistance (2002) p. 9 .www.caledonia.org.uk/papers/Globalisation%20
and%20Popular%20Resistance.doc.
30
Alyson G. Young, Young Child Health among Eyasi Datoga: Socioeconomic Marginalization, Local Biology, and Infant
Resilience with the Mother Infant Dyad (2008), p. 66.
31
A/HRC/15/37/Add.2.
Chapter 1 ξ 019
Indigenous Peoples’ access to Health Services
tions.
32
The government of Botswana has expressed concern over the diculties faced by provid-
ing a health care system that incorporates and respects both Western and traditional medicines.
In recognition of these challenges the Special Rapporteur on the Rights of Indigenous Peoples
highlighted the need to enhance the understanding of and respect for traditional medicine, which
continues to be practiced among indigenous communities but remains largely excluded from the
government health system.
Namibia
The San, the Himba (Ovatue, Ovatjimba and Ovazemba) satisfy the criteria for indigenous peo-
ples. The loss of their lands, destitution, cultural breakdown and high poverty levels have made
the San the only ethnic group in Namibia whose health status has declined since independence.
Having lost their original source of food, they now depend entirely on government food aid. The
health problems are due mainly to poverty and marginalization. Most of the population has poor
access to health facilities. More than 80 per cent of them live more than 80 kilometres from any
sort of health facilities. These facilities are expensive, and mobile outreach services are irregular
and often ill-equipped to deal with complicated problems. In some cases the sta of the mobile
units cannot speak any of the San languages, giving rise to the likely risk of miscommunication
and wrong diagnoses.
33
Namibia has a high prevalence of HIV/AIDS, and the San are particularly vulnerable due to lack
of information, low standard of living and the unavailability of adequate treatment. The Special
Rapporteur on the Rights of Indigenous Peoples recommended measures to mitigate these
negative eects. These included educating indigenous communities on health issues, which
should be done in all languages in the communities concerned, allocating adequate resources to
indigenous peoples’ health services, including them in medical insurance programmes, capacity-
building, collaboration and coordination, as well as funding organizations that are working
towards the eradication of diseases.
34
South Africa
The Khoi/San peoples of South Africa are among the poorest and most marginalized populations.
There is lack of access to safe water and also high levels of domestic violence. The Special Rap-
porteur on the Rights of Indigenous Peoples also noted that although HIV prevalence was high
in the country, there were no figures for indigenous peoples, and therefore HIV/AIDS should be
considered a serious threat. The Special Rapporteur also made the following recommendations:
ɜ The possibility of establishing a fully equipped clinic in Platfontein to serve the area;
ɜ Health services should target the specifically marginalized indigenous communities;
ɜ Introduction of drinking water to indigenous communities should be considered a priority
in the development plans in the areas where services either do not exist or is insucient.
35
32
A/HRC/15/37/Add.2.
33
Country Report of Research Project by ILO and ACHPR on the Constitution of and legislative protection of rights of
indigenous peoples.
34
Country Report of Research Project by ILO and ACHPR on the Constitution of and legislative protection of rights of
indigenous peoples.
35
E/.CN.4/2006/78/Add.2.
020 ξ Chapter 1
State of the World’s Indigenous Peoples
The pastoralists of North and West Africa
The nomadic pastoralists of the Sahel are geographically and socially marginalized, inhabiting
large regions unsuitable for agriculture and infrastructural development. Human survival in com-
munities in these environments would be virtually impossible without livestock that provides for
basic needs. To pastoralists the well-being of their livestock is important as it is the source of
their livelihoods and a basis for recognition and respect.
36
The close contact between human and
animals and consumption of raw milk contributes to zoonoses like anthrax, Q fever, brucellosis
and echinococcosis.
37
A paper by A. Sheik-Mohamed and J.P. Velema summarized evidence on
the health status of nomadic populations and provided an assessment on the best ways for the
provision of health care.
38
The authors noted that nomadic peoples had poor access to health ser-
vices, were prone to infectious diseases (STIs, guinea worm, leishmaniasis, trachoma, tuberculo-
sis, brucellosis) and had higher rates of maternal and childhood mortality. On the other hand, viral
infections and intestinal parasites were not so common. In the case of helminths, the migratory
lifestyle of the pastoralists minimizes such infections as they move from accumulated dirt and
rubbish. For viral infections, serological surveys on measles undertaken on the Tuareg peoples in
Niger showed that 64.5 per cent of children five years of age were seronegative.
39
This situation
not only makes them susceptible, but it is also an indication that they have not been vaccinated.
Other possible strategies for nomadic pastoralists include moving from areas where there are
health epidemics and avoiding areas which are infested by vectors like mosquitoes and ticks. Their
mobility can also bring disease to an area or cause them to acquire diseases to which they have
no immunity. Obstacles to health service delivery included:
1. Conventional health systems do not reach nomadic pastoralists;
2. Health services are usually in the hands of settled populations who do not relate well to
nomadic pastoralists;
3. Settled populations tend to look down on nomadic pastoralists as uneducated and prim-
itive;
4. There are prohibitive costs for providing health care.
The provision of health care includes:
ɜ Mobile primary health care services that are capable of moving with the nomadic pasto-
ralists;
ɜ Due to the fact that community participation is important in primary health care pro-
grams, it was found that involving nomadic pastoralists was dicult because of their
36
Schelling E., Wyss K., Diguimbaye C. et al. (2008) “Towards integrated and adapted health services for nomadic pasto-
ralists and their animals: a north-south partnership” in Handbook of Transdisciplinary Research. A Proposition by the
Swiss Academies of Arts and Sciences (eds G Hirsch Hadorn, H Homann-Reim, S Biber-Klemm, W Grossenbacher, D
Joye, C Pohl Springer, Heidelberg, pp. 277-291.
37
Schelling E., Diguimbaye C., Daoud S. et al. (2003), “Brucellosis and Q-fever seroprevalences of nomadic pastoralists
and their livestock in Chad”. Preventive Veterinary Medicine 61, pp. 279-293.
38
A. Sheik-Mohamed and J.P. Velema, “Health Care for Nomads in Sub-Saharan Africa”, Tropical Medicine and Interna-
tional Health; Vol 4 No 10, pp. 695-707, October 1999.
39
Measles in a West African Nomadic Community, Loutan, L. and Paillard, S., Bulletin of the World Health Organization ,
Vol. 70, No. 6 1992.
Chapter 1 ξ 021
Indigenous Peoples’ access to Health Services
mistrust of government. Therefore, the provision of essential drugs and supplies was con-
sidered more helpful;
ɜ Having nomadic pastoralist community health workers who can be trained to provide a
mix of essential services, obtain regular medical supplies and refer complicated cases is
likely to be more aordable and sustainable in the long run.
HIV/AIDS and indigenous peoples in the African region
As of December 2012, there were 22 million people living with HIV in sub-Saharan Africa.
40
As most
indigenous peoples live in remote regions, they may be protected by their isolation from HIV/AIDS
and have lower prevalence rates than their neighbours. For example, in Botswana in 2002 it was
found that while the adult prevalence for HIV was 35.3 per cent, it was 21.4 per cent for the San
in Ganzi. However, with settled lifestyles more and more San are exposed to HIV. An increase of
HIV/AIDS was also noted among the indigenous peoples of Cameroon and this was attributed to
the influx of labourers working in the commercial logging industry. In Kenya, the HIV prevalence
in North-Eastern Kenya was less than 0.5 per cent in 2007 compared to the national figure of 7.2
per cent,
41
and rose to 1 per cent in 2008-2009 while the national prevalence decreased to 6.3 per
cent.
42
The current national prevalence is at 5.6 per cent. This area of North-Eastern Kenya was
omitted during the study due to the outbreak of conflict in the region.
In Tanzania, there is awareness that indigenous peoples like the Maasai pastoralists are at in-
creased risk of HIV by nature of their lifestyle.
43
At the same time, data are dicult to find. The
community also has low literacy and there are the usual challenges of language barriers. Some
cultural practices like FGM, early marriages, polygamy and multiple sexual partners also make
women in this community more vulnerable to the infection. The provision of HIV testing, treat-
ment and care services is made dicult by the harsh terrain, long distances to facilities and low
literacy levels. Most of these areas are served by faith-based organizations.
The above information highlights the plight of indigenous peoples in the African region. The sit-
uation globally may not be very dierent; however, there has been some attention at this level to
look more closely at HIV/AIDS and indigenous peoples. For example, United Nations Permanent
Forum theme for the 2009 International Day of the World’s Indigenous Peoples on 9 August 2009
was “Indigenous Peoples and HIV/AIDS”. In his message, the Secretary-General of the United Na-
tions emphasized that it was essential that “indigenous peoples have access to the information
and infrastructure necessary for detection, treatment and protection”. He noted that indigenous
peoples “tend to suer from the low standards of health”, which is perpetuating the gap in many
countries between the recognition of their rights and the actual situation on the ground. He called
on governments and civil society “to act with urgency and determination to close this implemen-
tation gap, in full partnership with indigenous peoples”.
44
40
http://www.afro.who.int/en/rdo/speeches/3732-message-of-the-who-regional-director-for-africa-dr-luis-g-sambo-
on-the-occasion-of-world-aids-day-2012.html.
41
National AIDS and STI Control Programme, Ministry of Health, Kenya. July 2008. Kenya AIDS Indicator Survey, 2007.
Nairobi, Kenya.
42
Kenya National Bureau of Statistics (KNBS) and ICF Macro. 2010. Kenya Demographic and Health Survey, 2008-2009.
Calverton, Maryland: KNBS and ICF Macro.
43
Hilde Basstanie and Rafael Ole Moono Ngorongoro District HIV/AIDS Programme Formulation Report, 2004.
44
http://www.unaids.org/en/Resources/PressCentre/Featurestories/2009/August/20090811IntDayWorldsIndigenous/.
022 ξ Chapter 1
State of the World’s Indigenous Peoples
Indigenous peoples face a higher vulnerability to HIV due to a range of factors including stigma-
tization, structural racism and discrimination and individual/community disempowerment. Health
Canada in collaboration with UNAIDS and Public Health Agency Canada hosted an International
policy dialogue on HIV/AIDS and indigenous peoples. This dialogue provided a platform to discuss
the impact of HIV/AIDS on indigenous peoples and to explore a way forward in terms of research,
policy and program development.
Report findings of the dialogue included:
ɜ Relationship between HIV/AIDS and indigenous peoples has not received due interna-
tional attention despite them being vulnerable;
ɜ It clearly identified patterns of transmission for indigenous men and women including a
higher proportion of new HIV diagnoses among indigenous peoples;
ɜ It noted high rates of HIV transmission among indigenous women, particularly in devel-
oping countries;
ɜ It noted a younger age of HIV infection of indigenous peoples compared with the non-
indigenous population in some countries.
As a result of the above, the participants:
ɜ Called for the identification of indigenous peoples as a priority group;
ɜ Called for countries to develop national strategies for HIV and indigenous peoples;
ɜ Advocated for AIDS service organizations to develop culturally appropriate services for
indigenous peoples in partnership with indigenous communities’ representatives;
ɜ Noted how indigenous people are often invisible in reported statistics;
ɜ Discussed how best to leverage international policy instruments, such as the UN Declara-
tion on the Rights of indigenous peoples (UNDRIP) and ILO Convention 169;
ɜ Welcomed the creation of the International indigenous peoples Working Group on HIV/
AIDS (IIHAWG).
Traditional medicine
Traditional medicine is the sum total of knowledge, skills and practices based on the theories,
beliefs and experiences used by indigenous peoples or dierent cultures to maintain health and
prevent, diagnose and improve or treat physical and mental illness.
45
Africans have relied on traditional medicine for generations before the advent of western medi-
cine. The art was passed from generation to generation and sometimes from father to son. In Af-
rica the cause of disease is not perceived in the same way as western medicine. Causes of illness
and death are rooted in beliefs of witchcraft, sorcery and superhuman forces.
46
45
WHO 2002, Traditional Medicine Strategy 2002-2005.
46
Rödlach, A. (2006). Witches, Westerners, and HIV: AIDS and Cultures of Blame in Africa. Walnut Creek: Left Coast
Press pp. 101-104.
Chapter 1 ξ 023
Indigenous Peoples’ access to Health Services
In the present day, indigenous Africans rely on traditional medicine and practitioners as they have
done for generations. Compared to western medicine practitioners, traditional medicine prac-
titioners are more readily available, less expensive and more acceptable. It is estimated that in
Malawi 80 per cent of the 12 million people make use of traditional medicine for their needs.
47
In
2000, there were approximately 4500 traditional healers in Zimbabwe and only 1400 doctors.
48
Generally, in sub-Saharan Africa the ratio of traditional healers to the population is 1:500, while
doctors trained in western medicine it is 1:40,000.
49
As indigenous peoples have always lived in
harmony with their environment and learned the important plants which can be used as medi-
cines, they resort to this method of healing before seeking treatment in orthodox medicine. For a
long time there has been little eort to understand traditional medicine as it was considered to be
shrouded in mystery. Some governments tried to suppress indigenous medicine, which then went
underground and continued to thrive.
50
Most African countries have the tolerant model of health
system where western medicine is practiced but other forms are tolerated.
51
The World Health
Organization estimates that up to 80 per cent of people in the African region use traditional
medicine and that the widespread use is due to its aordability.
52
Moreover, it is popular because
it is firmly embedded in the wider belief system. Traditional medicine is also said to be more eec-
tive in the treatment of psychic and psychosomatic conditions. This is because the healers have
knowledge of the patient’s background while conserving African culture.
53
Some African countries have made eorts to integrate traditional medicine into the health system.
There are countries where traditional medicine practitioners have been registered and have asso-
ciations. In South Africa, for instance, traditional healers are recognized and regulated by law.
54
However, caution is required in advocating for blanket use of traditional medicine because further
research is needed to ascertain the ecacy of certain medicinal plants and treatments used.
Eects of sedentarization on indigenous peoples
The world is changing rapidly, and the lifestyles of indigenous peoples are also changing and will
continue to change. This means that their previously active lifestyle and dietary habits will change.
While indigenous peoples have a higher burden of infectious diseases, non-communicable diseases
are also emerging. Living in settled areas with higher population densities predisposes them to
infectious diseases. Increased population density in settled areas facilitates the transmission of
density-dependent diseases such as malaria. At the same time, pathogenic organisms may be
47
Peltzer 1988, “The role of faith healers in primary mental health care: A South African perspective”, Curare:11.207-210).
48
UNAIDS (2000). Report of the Inter-regional Workshop on Intellectual Property Rights in the Context of Traditional
Medicine, Bangkok, Thailand.
49
Richter, 2004, PEP for rape survivors in South Africa: Reflecting on the process to get to government policy: Interna-
tional Conference on AIDS.
50
Green, E.C., Engaging indigenous African healers in the prevention of AIDS and STDs in Anthropology in Public Health:
Bridging dierences in culture and society, Edited by Robert A Hahn, Oxford University Press Inc. New York 1999.
51
WHO 2002, Traditional Medicine Strategy 2002-2005; Anfom ,E.E 1986: Traditional Medicine in Ghana; J.B. Danquoh
memorial lectures.
52
WHO 2002, Traditional Medicine Strategy 2002-2005.
53
Steinglass M., “It Takes a Village Healer - Anthropologists Believe Traditional Medicines Can Remedy Africa’s AIDS
Crisis. Are They Right?” Lingua Franca April 2002, p. 32.
54
E/CN.4/2006/78/Add.2 of 15/12/05.
024 ξ Chapter 1
State of the World’s Indigenous Peoples
introduced by the number of people moving into, and establishing themselves in settled areas.
Further, the intrusion of people into previously unsettled areas may also expose them to new
disease hazards.
55
Barkey found that settled Turkana men reported severe complaints and higher
rates of infectious diseases than the nomads, including a significantly higher frequency of cold with
cough, eye infection, and chest infection than the nomads. They also had higher body mass index.
56
Children of pastoralists also experience malnutrition when they live in settlements as their diets
change from dairy products to starches and sugars. Comparing settled and nomadic Rendille
children in Kenya and Nathan found that sedentary children under six years had significantly
higher levels of malnutrition and anaemia than nomadic children.
57
This was attributed to the
consumption of three times more milk by the nomadic children. Indigenous peoples need to be
made aware of the consequences of change in lifestyle and what they need to do to mitigate
the negative eects.
Best practices in delivering health services
This section provides examples of best practices and innovations that have been used to reach
indigenous peoples in remote regions.
Outreach services
Mobile outreach clinics or strategically placed health posts have been used to reach remote areas.
The challenge has been for these entities to provide services on a regular basis and the fact that
they may not be able to deal with emergencies. They are also expensive and dicult to sustain.
In many instances, sta do not speak indigenous languages, therefore creating another barrier.
Providing a culturally sensitive health service
Indigenous peoples in the African region, apart from having poor access to quality health ser-
vices, also find the available services are not friendly. At most times the health workers look
down upon them as “backward and primitive” peoples. Indigenous peoples also have the prob-
lem of language barriers and therefore use health facilities only when their conditions are ad-
vanced. As previously stated, cultural sensitivity is important if available health services are to
be utilized. Also taking into account traditional knowledge which indigenous communities have
relied on for thousands of years is extremely important. In South Africa, Ngomane et al. found
that pregnant women in rural districts delayed visiting clinics, preferring instead to be looked
after by traditional healers in order to protect their unborn infants from harm.
58
They also shied
away from delivery in hospitals because of the harsh treatment they received from the nurses.
55
Sheik-Mohamed, A.,Velema, J.P. “Where Health Has no access; the nomadic populations of sub-Saharan Africa” Tropi-
cal Medicine and International Health, Vol. 4 No pp. 695-707, Oct 1999.
56
Barkey, N.L., Campbell, B.C. and Leslie, P.W. (2001), “A Comparison of Health Complaints of Settled and Nomadic Turka-
na Men”. Medical Anthropology Quarterly, 15:391-408. doi:10.1525/maq.2001.15.3.391.
57
Nathan M., Fratkin E., Roth E. “Sedentism and child health among Rendille pastoralists of Northern Ken-
ya”, Social Science and Medicine Vol 43, Issue 4, August 1996. http://www.sciencedirect.com/science/article/
pii/0277953695004289.
58
Ngomane, S., Mulaudzi, F.M., “Indigenous beliefs and practices that influence the delayed attendance of antenatal
clinics by women in the Bohlabelo district in Limpopo, South Africa”. Midwifery (2010), doi:10.1016/j.midw.2010.11.002.
Chapter 1 ξ 025
Indigenous Peoples’ access to Health Services
According to Ngomane et al., indigenous women made the following comments about their
treatment in the hospital:
ɜ “The kneeling position is not allowed in hospital and nurses give you instructions and
won’t listen to you”.
ɜ “If you air your views or your opinion, they laugh at you and ridicule you”.
ɜ “They make you feel small and useless“.
ɜ “The nurses give you instructions and will not listen to you”.
The women also indicated that their rationale for going to clinics and hospitals is often motivated
by fear of complications or maternal death and complications that could cause them to lose their
infants:
ɜ “I came to the clinic to put my name on their books, in case I have a dicult delivery”.
ɜ “My sister was saved by the hospital as the baby was delivered by an operation”.
It is important that there is dialogue between the community and the health sector. The
similarities and dierences between the two must be identified in order to reach consensus on
issues pertaining to improved antenatal attendance. This will create a feeling of empowerment
and awareness in the community, which will assist members of the community to utilize their
resources and antenatal care services optimally.
Innovation in delivery of health services
When studies of Chadian pastoralists and their livestock revealed that the vaccination status was
higher in the animals than in children
59
,
60
authorities decided to conduct joint campaigns bringing
together veterinarians and public health workers. These campaigns not only demonstrated the
feasibility of working across sectors, but were also 15 per cent cheaper than separate campaigns.
For such eorts to succeed however there is need for community participation at all stages and
multi-stakeholder engagement.
Other innovations which are being used by countries are maternity shelters in remote areas. These
shelters are in the hospital compound and encourage pregnant women to come and stay there
towards the end of their pregnancies. For example, one such shelter is found in Garissa in the
North-Eastern part of Kenya. In this area, the maternal mortality rates in 2003 were estimated be-
tween 1,000-1,300 per 100,000 live births against a national figure of 410 per 100,000 live births.
61
59
Zinsstag J., Schelling E., Daoud S. et al. (2002) “Serum retinol of Chadian nomadic pastoralist women in relation to their
livestocks’ milk retinol and beta-carotene content”, International Journal for Vitamin and Nutrition Research 72, 221-228.
60
Schelling E., Diguimbaye C., Daoud S. et al. (2003) “Brucellosis and Q-fever seroprevalences of nomadic pastoralists
and their livestock in Chad”. Preventive Veterinary Medicine 61, 279-293.
61
Central Bureau of Statistics (CBS) [Kenya], Ministry of Health (MOH) [Kenya], and ORC Macro. 2004. Kenya Demo-
graphic and Health Survey 2003. Calverton, Maryland: CBS, MOH, and ORC Macro.
026 ξ Chapter 1
State of the World’s Indigenous Peoples
Case Study: Maternal Shelters Save lives
Case The maternal shelter is a waiting home where women who live far and those with high-
risk pregnancies stay for monitoring and quick access to the provincial hospital, which saves
the lives of both mothers and newborns. The facility was established with support of UNICEF
to address maternal and newborn health in hard-to-reach areas.
“Had my wife not come to the shelter to deliver at this hospital, she could have died”, said
Mr. Mohamed“. The two previous deliveries were dicult and she almost died from excessive
bleeding”. He was therefore happy to make the 800 km journey to the shelter where his wife
stayed. She had a Caesarean section and required a transfusion, which saved her life.
62
The use of maternal homes was also introduced in Eritrea in 2007 to reduce maternal mortality in
remote areas. This led to a 56 per cent increase in facility deliveries and no maternal deaths in the
20 months since the introduction of the concept.
63
The Kenya Ministry of Health also has a strategy to deliver services to the household through the
Community Strategy.
64
In this strategy community health workers are trained in various maternal,
newborn and child health services and deployed in the community. It is envisaged that they will
be able to provide integrated community case management of pneumonia, diarrhoea, malaria and
malnutrition starting in hard-to-reach, underresourced areas.
Another innovative way of delivering services is the concept of the tuberculosis (TB) Manyatta.
This was devised by Dr. Tonelli,
65
a Catholic nun working in a remote district in North-Eastern
Kenya in 1976. The pastoralists living there had a high default rate for TB treatment. As a result,
she urged them to construct small dwellings next to the health facility where the patient could
receive observed treatment for four months, supported by a family member. As this concept was
very successful, TB Manyattas were set up in remote areas for nomadic pastoralists.
66
In Namibia,
the treatment of TB for the San has been improved by educating family members on TB treat-
ment.
67
South Africa and Rwanda have also started health insurance for their populations, and it
is hoped this will trickle down to indigenous peoples.
Addressing the data gaps
Information on the health status of indigenous peoples in the African region is not adequate.
Health systems in many African countries have challenges in collecting, collating and analysing
data for their populations.
62
http://www.unicef.org/infobycountry/Kenya 62635.html.
63
http://www.unicef.org/esaro/5479_maternal_newborn_health.html.
64
Taking the Essential Package of Health to the Community: A Strategy for the Delivery of Level One Services: MOH,
Kenya 2006.
65
http://annalenatrust.org/index.php?option=com_content&view=article&id=46&Itemid=53.
66
WHO: A Brief Hisory of Tuberculosis Control in Kenya: 2008 sourced from http://whqlibdoc.who.int/
publications/2009/9789241596923_eng.pdf.
67
State of the World’s Minorities and Indigenous Peoples 2013, Events of 2012, Minorities Rights Groups International.
Chapter 1 ξ 027
Indigenous Peoples’ access to Health Services
This challenge becomes more evident in data for indigenous peoples because:
ɜ Indigenous peoples have not yet been fully recognized in many States as such, therefore,
no provision has been made to collect data. For example, the concept of indigenous peo-
ples is not acknowledged in Tanzania but the government “recognizes the vulnerability of
some of the marginalized communities”.
68
ɜ Indigenous peoples in the African region are usually lumped together as marginalized
groups. This lack of recognition makes it dicult to take bold steps to put strategies in
place to collect disaggregated data according to ethnicity.
ɜ States may also be hesitant to collect ethnic-specific data as a way to discourage tribal-
ism and promote national unity and cohesiveness.
ɜ Indigenous peoples often live in remote and hard-to-reach areas where collecting data is
considered dicult and expensive and since the population is small, it will not have a ma-
jor impact on the overall results. An example of this is Kenya, where three demographic
and health surveys in 1989, 1993 and 1998, omitted northern Kenya, which is inhabited by
nomadic pastoralists because the population was less than 4 per cent. The 2003 demo-
graphic survey indicated that the national under-five mortality rate was 115 per 1,000 live
births, while it was 163 per 1,000 in North-Eastern Kenya.
69
ɜ Challenges in data collection included language barriers between data collectors and
respondents.
ɜ As most of indigenous African communities have low literacy levels, the data are collected
by people who do not speak the language or understand the culture. Therefore, obtaining
accurate demographic data is dicult. Among the Maasai community obtaining accurate
data on maternal and infant deaths is a challenge, as they may never be reported. Further,
among the Maasai it is dicult to know which woman has never had a child because the
practice is for every married woman to be called the mother of a child. Therefore, in cases
where a woman has no child, she is given one by a family member to raise as her own.
ɜ Another significant gap is the lack of adequate research on indigenous peoples’ health
issues in the African region.
During the International consultation of indigenous peoples’ health between 23 and 26 Novem-
ber 1999 the objective was amongst others to provide key elements for the development of World
Health Organization policies, strategies and recommendations for the protection of and promotion
of the right to health of indigenous peoples. The following recommendations were made to WHO;
ɜ Promote the systematic collection and reporting of statistics disaggregated by ethnicity
by member states. This will require the development of working criteria or definitions of
ethnicity and the development of indicators that are able to measure what constitutes a
positive health outcome in indigenous peoples’ terms.
ɜ Develop, in close consultation with the informal advisory group, a comprehensive re-
search agenda which places emphasis on the broad determinants of health.
70
68
Country technical notes on Indigenous peoples issues, United Republic of Tanzania June 2012 and submitted by IWGIA
69
Central Bureau of Statistics (CBS) [Kenya], Ministry of Health (MOH) [Kenya], and ORC Macro. 2004. Kenya Demo-
graphic and Health Survey 2003. Calverton, Maryland: CBS, MOH, and ORC Macro.
70
WHO/HSD/00.1.
028 ξ Chapter 1
State of the World’s Indigenous Peoples
It is clear that there are significant data gaps in the health of indigenous peoples in the African
region. These can be addressed at the very outset by states recognizing indigenous peoples. This
can then set the stage for strengthening health systems in data collection, disaggregating data
according to ethnicity, and empowering the communities themselves by increasing access to ed-
ucation. Having indigenous peoples collecting data will increase accuracy of the data.
Armative action and training of indigenous health care workers
Indigenous peoples often live in rural and remote areas where access to health services is reduced
or simply not available. At the same time, where there are health facilities, sta are not able to
communicate in indigenous languages, creating a further barrier. Training health workers from
indigenous communities could address this challenge. At the same time, many of these communi-
ties have poor access to education, which makes it harder to target students for medical training
colleges. Improving education and armative action for bright indigenous students to undertake
bridging courses in order to enter training institutions is a possible solution. Another strategy is
to have more rural-based training schools and tuition support for indigenous students. Increas-
ing the proportion of medical students who come from rural backgrounds provides positive rural
learning experiences in medical school. Further, specific rural residency/vocational training pro-
grammes will increase the number of graduating physicians who possess interest, knowledge and
skills for rural practice. Recruiting and retaining physicians in rural practice requires attention
to the environment, health system, financial constraints and other factors.
71
Another strategy to
attract and retain health care workers in rural and remote areas is to improve the working environ-
ment in these areas. A study undertaken in Zambia indicated that nurses considered satisfactory
accommodation, access to continued education and motivation to work as important non-mone-
tary incentives for working in remote areas.
72
Development of responsive health policies
The foundation of having best practices in delivering health care to indigenous peoples is for
states to embrace multicultural health systems. The World Health Organization asserts that all
people have the right to health. During the fiftieth anniversary celebration of the Universal Dec-
laration on Human Rights on 8 December 1998 in Paris, the WHO Director General Dr. Gro Harlem
Brundtland said:
“It is no coincidence that the idea to establish a world health organization emerged from
the same process that identified the universal value of human rights. The WHO constitution
states the enjoyment of the highest attainable standard of health is one of the fundamental
rights of every human being without distinction of race, religion, and political beliefs, eco-
nomic or social condition”.
In most state health systems cultures and views of indigenous peoples are ignored or dismissed
as health systems are based exclusively on western medicine. This approach marginalizes indige-
71
Bulletin of the World Health Organization 2010;88:395-396. doi: 10.2471/BLT.09.073072.
72
http://wiredspace.wits.ac.za/handle/10539/9082.
Chapter 1 ξ 029
Indigenous Peoples’ access to Health Services
nous peoples, denying them access to basic health services and devaluing their traditional health
systems. Most health systems can be defined as monocultural, multicultural or intercultural.
73
Monocultural: This is based on the concept of society being homogenous and privilege the domi-
nant national culture over all other cultures. Though there maybe some acknowledgement of eth-
nic or linguistic or cultural diversity, it is not reflected in policies and resource allocation. Further,
data collection does not take into account any ethnic or cultural dierences.
Multicultural: This system welcomes and promotes dierent cultures in society. It is still insu-
cient if it fails to ensure equality among cultures.
Intercultural: This goes beyond mere recognition to seeking exchange and reciprocity in a mutual
relationship, as well as in solidarity among the dierent ways of life.
There are four fundamental prerequisites that must be present in order for an intercultural health
system to exist. These are:
1. Fundamental respect for human rights as codified in international human rights instru-
ments and international law.
2. Recognition of indigenous peoples because if states do not acknowledge the existence of
indigenous peoples, it is not possible to develop policies that respond to their health ca-
pacities and needs. Often indigenous peoples are included in broader categories such as
“vulnerable groups” or “the poor”, obscuring the particularities of their situation. Further-
more, this recognition entails the structural reforms necessary to exercise self-determi-
nation, which in the case of health, corresponds to supporting the development of in-
digenous health systems while also ensuring full and eective participation in the health
services oered by the state.
3. Political will, since the mere existence of policies aimed at improving the health of indige-
nous peoples is insucient if they are not successfully implemented.
4. Conscious decision on the part of the national society to engage in an exchange and shar-
ing of knowledge, values and customs which, if practiced on a daily basis, would overcome
monoculturalist structures.
Taking into account the above prerequisites in view of the African situation, challenges are evi-
dent because many countries have not ratified ILO 169 Convention.
74
Conclusion
Indigenous peoples of Africa have inadequate access to health services. This is due to the lack
of recognition of indigenous peoples rights and the fact that health indicators are poor, educa-
tion levels are low and access to other social services is lacking. The general lack of data is also
a concern that makes it dicult to address the problems and target solutions. Loss of their lands
73
Chapter 5, State of the World’s Indigenous Peoples, United Nations, 2009.
74
ILO 168 sourced from:
http://www.ilo.org/wcmsp5/groups/public/---ed_norm/---normes/documents/publication/wcms_100897.pdf.
030 ξ Chapter 1
State of the World’s Indigenous Peoples
has made indigenous peoples vulnerable as they cannot access the healing medicines and tra-
ditional food as they did in the past. Improving indigenous peoples’ situation needs their active
participation in the design and implementation of health services. Legal recognition by states will
help to pave the way for documenting and tackling the current challenges in health care. Adopt-
ing targeted intervention and conducting research will also go towards meeting the health care
challenges, including the need to increase the level of accessible and responsive health services,
document and preserve traditional medicine practices which are eective, improve education sta-
tus and train indigenous health workers. Indigenous peoples’ resource and knowledge must not
be discarded, otherwise Africa will be poorer.
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tive-health-services.
www.caledonia.org.uk/papers/Globalisation%20and%20Popular%20Resistance.doc.
UN Photo/Broddi Sigurdarson
Chapter 2 ξ 033
Indigenous Peoples’ access to Health Services
Chapter Two
Access to Health Services
by Indigenous Peoples
in Asia
Dr. Mukta Lama
UN Photo/Broddi Sigurdarson
034 ξ Chapter 2
State of the World’s Indigenous Peoples
Chapter Two
Access to Health Services by
Indigenous Peoples in Asia
Dr. Mukta Lama
Introduction
Indigenous peoples living in Asia have limited access to appropriate health care services. As a
consequence of this and other health determinants, they suer the worst health of identifiable
groups in the Asian region. Indigenous peoples in Asia die younger, have higher rates of malnu-
trition, child mortality, and carry high burden of “diseases of the poor” namely undernutrition and
infectious diseases. A number of explanations account for the disparities in access to health ser-
vices experienced by the indigenous peoples. The health of indigenous peoples is often not a pri-
ority of the national governments, thus health care needs remain unheard in health care planning
with no or weak representation of the indigenous peoples in the government system. The general
health care services in most cases do not arrive in the remote regions of the country where most
indigenous peoples live, and even when they do arrive, they are often not appropriate to address
the needs of indigenous peoples and often do not accommodate the belief systems and process-
es for improving health and well-being. There is an urgent need to address disparity and deficits
in indigenous health in Asia, which is a challenge for democratic governance in the region.
The UN Special Rapporteur on the right to health noted that the right to health and right to survive
are two of the most basic human rights. This is aligned with the provision of International Cove-
nant on Economic, Social and Cultural Rights (ICESCR), in which Article 12 recognizes “the right
of everyone to the enjoyment of the highest attainable standard of physical and mental health”.
Further, the General Comment No. 14 of the UN Committee on Economic, Social and Cultural
Rights, elaborates that the right to health, “is the right to the enjoyment of a variety of facilities,
goods, services and conditions necessary for the realization of the highest attainable standard
of health.… [The right includes both] timely and appropriate health care … [and] the underlying
determinants of health, including access to safe and potable water, and adequate sanitation, an
adequate supply of safe food, nutrition and housing, healthy occupational and environmental
conditions, and access to health-related education and information, including on sexual and re-
productive health”. In this context, morbidity and mortality of children and poor health of indig-
enous peoples is a matter of pressing social justice inequality for which governments and other
actors must be held accountable. Despite the impressive improvements in poverty reduction and
social development in a number of Asian countries over the past decades, the persistence prob-
lems of poor indigenous health remain a major issue in the Asian region.
One of the major challenges in addressing the issue of indigenous health deficit is the invisibility
or obscured visibility of the issue from the national discourse in many states. Little is known in the
rest of the world about their struggle for equality and their profound disparities in health status
and/or access to health services. The majority of countries in the Asian region do not have any
Chapter 2 ξ 035
Indigenous Peoples’ access to Health Services
structural capacity for collecting health information disaggregated for indigenous peoples from
within the larger non-indigenous populations. Some governments intentionally avoid collecting
the disaggregated data by indigenous ethnicity in their eort to portray national unity or discour-
age dierentiation within their citizenry. Many Asian countries lack capacity to acknowledge the
relevancy of indigenous-specific data in part due to competition for resources and lack of incen-
tives for institutions to support the creation of an evidence base for an indigenous peoples’ health
information system. The United Nations has repeatedly called for nation states to gather baseline
disaggregated information specific to indigenous peoples, and in some situations this is gradually
beginning to occur. Nevertheless, in Asia, unlike other parts of the world like the Americas and
Australia, an additional complexity, coined the “Asian controversy”, relates to the definition of
precisely who is indigenous. Deprived of clear client identification of membership in indigenous
population groups and/or tribes, the task of collecting data and the subsequent use in planning,
implementing and monitoring health initiatives are not simply possible.
In practice, dierent countries with specific historic and contextual relationships to the state and
the dominant population, indigenous peoples in Asia have been identified and referred to by dif-
ferent names such as “minority nationalities”, “schedule tribes”, “ethnic minorities”, “hill tribes”, “cul-
tural communities”, “adivasi”, “janajati”, and others. Some of the Asian states ocially recognize
the term “indigenous peoples” to identify those people who have distinct cultural tradition and
history. Countries such as Philippines, China (Taiwan), Malaysia, Nepal and, more recently, Japan
have embraced the term following the United Nations Declaration on Rights of the Indigenous
Peoples (UNDRIP) and ILO Convention No. 169 on Indigenous and Tribal Peoples. While countries
such as China, India and Bangladesh, for example, resist the recognition due to contentions in the
definition, they have adopted various armative action and special measures for the peoples by
adopting specific labels in their specific country context.
75
Notwithstanding the diverse country-specific stance in formally recognizing the category “indig-
enous peoples”, the majority of the Asian countries engage with the distinct group of populations
in their legal, administrative and political uses ranging from the purpose of armative action to
assimilation and discrimination. China for example, in its 2000 census enumerates 55 ocially
recognized terms for minority nationalities or minzu who reside in five autonomous geograph-
ic regions. For instance, the identification of China’s minzu emphasizes the social, cultural, eco-
nomic conditions, customs, traditions, language and geographic concentrations that distinguish
indigenous peoples from other sections of national community.
76
Despite not ocially adopting
the term “indigenous”, identification of China’s minority nationalities largely corresponds to the
definition developed by ILO Convention No. 169 and the World Bank.
77
China’s case echoes that in
other countries in Asia, including, for example, India, Malaysia and other countries. Scholars have
debated both for and against the adoption of the term but they appear to agree that the defini-
tion in the Asian setting should be broad enough to encompass the plurality of indigenous groups
in question with respect to their historic and country-specific contexts. The category “indigenous
peoples”, supplemented by the assertion of the peoples who wish to self-identify themselves by
75
Kingsbury 1998; Erni 2008.
76
Minority Aairs Editorial Department. Working Handbook of Minority Nationalities [CHN: Minzu Gongzuo Shouce].
Kunming (CHN): Yunnan People’s Publishing House; 1985.
77
Chee-Beng 2008; Li 2008.
036 ξ Chapter 2
State of the World’s Indigenous Peoples
the term has increasingly become a social reality in Asia,
78
thus is the term “indigenous” is being
used interchangeably with the other more specific terminology contained in this chapter.
Who are indigenous peoples in Asia?
Asia includes a vast geographically diverse area of about 12 million square kilometres that is cul-
turally and ecologically divided into five subregions. The distribution of indigenous peoples into
very dierent geographic subregions and the degree of engagement in indigenous issues by the
various nations’ actors and the dierences within the concerned indigenous peoples themselves
diers substantially. For example, the knowledge about indigenous peoples in dierent coun-
tries within subregions varies greatly. Five subregions are conventionally categorized as western,
south-eastern, southern eastern and central Asian subregion.
The following table shows the distribution of countries with the subregions:
Table 1: Subregions and countries in Asia
Central Asia
Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, Uzbekistan
Eastern Asia
China, China (Taiwan), Democratic People’s Republic of Korea, Japan, Mongolia,
Republic of Korea
Southern Asia
Afghanistan, Bangladesh, Bhutan, India, Iran (Islamic Republic of), Maldives, Nepal,
Pakistan, Sri Lanka
South-Eastern Asia
Brunei Darussalam, Cambodia, Indonesia, Lao People’s Democratic Republic, Malaysia,
Myanmar, Philippines, Singapore, Thailand, Timor-Leste, Viet Nam
Western Asia
Armenia, Azerbaijan, Bahrain, Cyprus, Georgia, Iraq, Israel, Jordan, Kuwait, Lebanon,
Oman, Qatar, Saudi Arabia, State of Palestine, Syrian Arab Republic, Turkey,
United Arab Emirates, Yemen
Source: DESA.
The Asian subregions are culturally diverse in their ecology, geography and physical features. The
regions include a multitude of indigenous groups who comprise 70 per cent of the estimated 350
million indigenous peoples worldwide. As mentioned earlier in the report, comprehensive data on
the demographic status of the indigenous peoples in the Asian region are incomplete or not avail-
able. Information on indigenous peoples in Central and Western Asia, in particular, is so scarce it is
very dicult to draw even a rough profile of the population. The data available within subregions
78
Baviskar 2007; Hathaway 2010.
Chapter 2 ξ 037
Indigenous Peoples’ access to Health Services
on the population of indigenous peoples are also limited for various reasons. An estimate oered
by the International Working Group on Indigenous Aairs (IWGIA) in 2008 with a subsequent
edition by Hall and Patrinos (2012) is an often cited source for understanding the distribution of
the indigenous peoples is in the subregions of Asian continent. The following figure shows the
approximate distribution of the population in the four subregions:
Figure 1: Indigenous Population in Asia (million)
Source: Compiled from IWGIA (2008) in Hall and Patrinos (2012)
15.41
29.81
94.9
105.23
0
20
40
60
80
100
120
Western Asia
(Arabia)
Southeast Asia
South Asia
East Asia
(China, Japan)
Indigenous Population in Asia
(million)
Sowip 2_Figure 1 (page 47).xlsx
Source: Compiled from IWGIA (2008) in Hall and Patrinos (2012).
China has largest share of indigenous population in the world estimated to be about 105 million
indigenous peoples. In Japan, according to Figure 1, there are some 230,000 indigenous peoples.
There are 84.3 million indigenous peoples in India which makes India the second largest in terms
of the absolute concentration of indigenous peoples. As the above figure shows, the South Asian
region as a whole includes an indigenous population of 95 million peoples. The share of indigenous
population in South-East Asia is about 30 million while western Asia has only about 15 million.
Despite the ocial data, assimilation to promote commonality by absorption into the dominant
communities and within the States where indigenous peoples live, the reality is that indigenous
societies themselves are conspicuous by their immense plurality. Within indigenous societies,
there is vast diversity in terms of language, customs, dress, tradition and social and political or-
ganization. There is no reliable information available to determine the exact number of cultural
or linguistic groups within the indigenous communities in dierent countries. A rough estimate
shows that South Asia alone may have more than 750 groups identified, although not all are rec-
ognized as so. For example, the Indian Constitution enlists 461 ethnic groups as Scheduled Tribes,
but studies estimate more than 635 groups exist in the country.
An important point is that for countries like India where the constitution has guaranteed certain
rights as Schedule Tribes, this translates into better information on socioeconomic and health
situation than other countries which have no such policies. But even in the Indian situation the
number of groups recognized formally may dier substantially from the number of groups that
actually exists or are self-defined by the groups themselves as being indigenous. The government
of Nepal recognized 59 groups as indigenous nationalities, but is in the process of revising the
038 ξ Chapter 2
State of the World’s Indigenous Peoples
list to include other self-defined indigenous groups. A similar scenario is also true for other South
Asian counties. Although the names of each specific group are dicult to list with the current
state of the information collected and access to it, the following table gives an idea of the major
groups until relatively better data can be collected on the subcontinent:
Table 2: Names of indigenous groups in South Asia
Country Commonly
referred names
Major indigenous groups Approximate
population
Bangladesh Tribal, upajati,
indigenous hill
tribe, Jumma,
indigenous hill
men, aboriginal
tribes
Bawm, Chak, Chakma, Khumi,
Khyang, Lushai, Marma, Mro, Pangkhua,
Tanchangya Tripura and others collec-
tively known as Jumma and Adivasi in
plain, including Santal, Banais, Bhuiyas,
Bhumijies, Dalus, Garos, Gonds, Hadis,
Hajangs, Hos, Kharias, Kharwars, Kochs,
Koras, Maghs (Bakarganj District), Mal
Paharias, Oraons, Maches, Mundas, San-
thals, Sauria Paharias, Turis and others
1.7-3.7 million
(1.2-2.5 per cent)
Bhutan Sarchops, Khengs, Adivasi, Birmi, Brok-
pa, Doya, Lepcha, Toktop and others
Approximately
10 per cent of
the total popu-
lation
India Scheduled
Tribes or Adivasi
(original inhabi-
tants);
461 groups recognized; major groups
include Gond, Oraon, Khond, Bhil, Mina,
Onge, Jarawa, Nagas and others
84.3 million, they
comprise 8.2 per
cent of the total
population
Nepal Indigenous
Nationalities
(Adivasi
Janajati)
Magar, Tharu, Tamang, Newar, Rai, Gu-
rung, Limbu and others
8.4 million peo-
ple, or 37.19 per
cent of the total
population
Pakistan Pashtun, Sindhis, Baluchs, Kihals and
Mors, Buzdar, Kailasha and others
Not available
Sri Lanka Vyadha (“huntsmen/archers”) or Vadda 1,229 and 4,510
people,
Source: IWGIA 2008.
Table 3 shows major groups in the East and South-Eastern regions of Asia. In South-East Asia the
Ethnic Minority Classification Project carried out from 1953 to 1979 in China identified 55 ethnic
minority groups but there were more than 400 names of nationalities registered ocially with
the government during early post-liberation years For example, the Philippines have three major
groups, but within them are various other indigenous groups. The same pattern is true for several
other countries in South-Eastern Asia.
Chapter 2 ξ 039
Indigenous Peoples’ access to Health Services
Table 3: Indigenous peoples in East and South-East Asia
Country Commonly
referred names
Major indigenous groups Approximate
population
China Minority
nationality, minzu
55 groups recognized, which include
Zhuang, Manchu, Hui, Miao, Uygur, Yi,
Tujia, Mongolian, Tibetan, Bouyei, Dong,
Yao, Korean, Bai, Hani, Li, Kazakh, Dai,
She, Lisu, Gelao, Lahu, Dongxiang, Wa,
Shui, Naxi, Qiang, Tu, Xibe, Mulam, Kir-
giz, Daur, Jingpo, Salar, Bulang, Maonan,
Tajik, Pumi, Achang, Nu, Ewenki, Jing,
Jino, De’ang, Uzbek, Russian, Yugur,
Bonan, Menba, Oroqin, Drung, Tatar,
Hezhen, Gaoshan, Lhoba (not all may
self-identify as indigenous)
105,226,114 (8.47
per cent of the
total population
of China)
Japan Indigenous
peoples
Ainu, Okinawans or Ryukyuan Ainu (28,782),
Ryukuans (1.3
million)
Philippines Indigenous peo-
ples and indig-
enous cultural
communities;
Major seven collective names include
Mindanao Lumad, Cordillera Peoples;
Caraballo Tribes, Mangyan, Negrito/
Aeta, Palawan hill tribes and Visayan
12-15 million (10-
20 per cent of
the total popula-
tion)
Cambodia chuncheat daoem
pheak tech, which
means literally
“minority original
ethnicity”.
17 groups recognized; major groups
include Brao, Chong or Khmer Daoem,
Jarai, Kachak, Kanchruk, Kavet, Khaonh,
Kraol, Kreung, Kui, Lun, Mil (Mel), Por
(Poar, Pear), Phnong (Punong), Rhade
(Ede), R’ong, S’och (Saoch), Stieng, Suoy,
Thmon, Tumpuon.
101,000 (1 per
cent of the total
population of
Cambodia)
Indonesia masyarakat adat
(communities
governed by cus-
tom)
Masyarakat adat communities, includ-
ing groups such as the Dayak Benuaq,
the Orang Tengger and the Orang Badui
30-40 million
estimate
Lao Ethnic minorities
and non-ethnic
Lao
49 groups ocially recognized, speak-
ers of Mon-Khmer, Sino-Tibetan and
Hmong-lu Mien language families
Malaysia Aborigines and
natives
Orang Asli (original peoples) of penin-
sular Malaysia, the Bukitans, Bisayahs,
Dusuns, Sea Dayaks, Land Dayaks
groups of Sarawak and the natives of
Sabah
12 per cent of the
total population
of Malaysia
040 ξ Chapter 2
State of the World’s Indigenous Peoples
Country Commonly
referred names
Major indigenous groups Approximate
population
Myanmar Ethnic nation-
alities, national
races
Shan, Karen, Rakhine, Karenni, Chin,
Kachin, Kayah, Mon
32 per cent of
the total popu-
lation
Thailand Chao-Khao or hill
tribes
Chao-Khao or hill tribes include
Hmong,Karen,Lisu, Mien,Akha,Lahu,
Lua,ThinandKhamu; indigenous fisher
communities chao-ley, and hunter gath-
ers group Mani people
923,257 (not in-
cluding people in
south and north)
Viet Nam Ethnic minorities
(dan toc thieu so,
dan toc it nguoi)
53 groups identified including Tay, Thai,
Nung, Hmong, Dao and Khmer
14 per cent of the
total population
Source: IWGIA 2008.
Colonialism, especially of European origin is regarded as less applicable to Asia in defining the
context of indigenous peoples’ history. The past and present dispossession of the land and re-
sources, as well as loss of political autonomy and culture of the indigenous groups in Asia, how-
ever, is comparable to the situation in white settler colonies.
Indigenous peoples in Asia are subject to political domination, cultural discrimination, economic
exploitation and dispossession in the hands of the dominant national society as equal to their
counterparts in settler colonies in the past. Discrimination against indigenous peoples, based
on language, race, culture and identity, is rampant across the Asian states. Indigenous activists
in Asia often term this phenomenon of dispossession and domination a process of internal col-
onization, to a large extent distinct to the Asian situation. They carry and suer from negative
impact and trauma induced by past and continuing discrimination. The harm such discrimination
inflicts upon the physical and mental health of the indigenous children, women and men are least
researched and often remain most invisible or misrecognized.
Indigenous health status
Identification of groups as indigenous peoples is paramount to the knowledge development
about the status of the indigenous peoples’ health. Measuring indigenous health that takes into
consideration the indigenous concept of health is an even more complex task. The current data
available on the indigenous status tend to be framed by generic biomedical measurement and
illness. While this may partially capture the status of indigenous health, understanding of indige-
nous health requires a broader approach. The description of the indigenous concept of health that
goes beyond the biomedical approach is given by the World Health Organization’s Committee on
Indigenous Health (1999):
79
79
Committee on Indigenous Health, The Geneva Declaration on the Health and Survival of Indigenous Peoples, WHO,
Geneva, WHO/HSD/00.1 (1999).
Chapter 2 ξ 041
Indigenous Peoples’ access to Health Services
Indigenous peoples’ concept of health and survival is both a collective and an individual in-
tergenerational continuum encompassing a holistic perspective incorporating four distinct
shared dimensions of life. These dimensions are the spiritual, the intellectual, physical, and
emotional. Linking these four fundamental dimensions, health and survival manifests itself
on multiple levels where the past, present, and future coexist simultaneously.
The above description clearly shows the need for broader approach to collecting information to
document the present health status of indigenous peoples to contribute to the development
of appropriate strategies and programmes. Baseline data on a broad range of health indicators
are urgently needed to compare health indicators, and improve health standards by developing
health goals between dierent groups of indigenous and non-indigenous peoples, as well as to
study what interventions can improve the health of indigenous peoples over time.
Current health information, even when available, does not generate a comprehensive picture for
the Asian region as a whole nor does it permit comparisons among indigenous peoples and be-
tween them and their non-indigenous mainstream counterparts. This section presents some ba-
sic indicators available from government and academic sources to highlight the health status of
indigenous peoples in Asia.
The most commonly used health indicators in the National Census and Demographic and Health
Surveys carried by the governments are infant mortality, mortality of children aged 0-5 years,
child nutrition, incidence or prevalence of diseases and their risk factors, and life expectancy at
birth. As has been indicated earlier, the scope for comparison across the country is limited as vari-
ations in the approach taken by the specific countries exist.
Health-related Millennium Development Goals include: 1) eradicate extreme hunger and poverty;
2) reduce child mortality; 3) improve maternal health; and 4) combat HIV/AIDS, malaria and other
diseases. Data produced for measuring the progress of the MDGs unfortunately do not require
disaggregation by ethnicity and are geared towards the aggregate national average. This data
capture problem has made the situation of indigenous peoples’ invisible and gives the impression
of a distorted picture, where the nested and unseen data that could describe the most vulnerable
minorities of indigenous peoples are getting worse, while the non-indigenous majority may be
improving. This is important because the remedy needs to be targeted to alleviate the greatest
needs especially if they are the poorest minorities with little power and influence.
In the design of population-based studies this is an easy detail to fix, because in many cases data
are limited simply due to absence of an ethnicity or language variable. Even when the health data
are generated by ethnicity omission of the variable in analysis means no disaggregated profiles
specific to indigenous peoples or minorities as a whole.
The quality of data collected is clinically orientated towards statistical markers that give no in-
dication of broader issues of physical wellness or social well-being. Indicators that use mortality
rates measure the worst outcomes causing death thus mask co-morbidity. More comprehensive
indicators and indices of health and wellness, the presence or absence of disease or risk factors,
and long-term outcomes need to be developed with due consideration of the interaction with
indigenous concepts of health and how to improve it.
Narrowing the indigenous to mainstream population health gap is a particular concern as some of
the countries in Asia especially China, India and Viet Nam have achieved considerable progress in
health including that of indigenous peoples. Epidemiologic and biostatistics evidence on indige-
042 ξ Chapter 2
State of the World’s Indigenous Peoples
nous health based on a review of the literature clearly shows that there is a systematic gap across
the Asian states. The clear message coming from these data is that if the indigenous health gap
is left unattended, then the disparities gap will expand. Hence, in the coming decades, the Asian
indigenous peoples will experience even poorer health due to lower education and employment in
a vicious cycle created by extreme poverty.
The case of China can be illustrative of the health situation of the indigenous peoples. An analysis
of the trends in infant/child mortality and life expectancy in indigenous populations in Yunnan
using the population census of the China from 1953 through 2000 and data obtained from Yun-
nan Provincial Health Department shows that the minority nationalities have lower rates in key
health indicators. For example, the weighted average life expectancy at birth in 2000 for minority
nationalities was 64.5 whereas the total Chinese population was 71.4. The variance between the
majority Han population and minority nationalities within autonomous provinces where minority
population are concentrated, however, is slightly less. For example, life expectancy of the Han
population in Yunnan was 68.8, which shows a dierence between Han and minority nationalities
of only about 4.4 years.
80
Although a considerable heterogeneity between the dierent minority
populations is to be noted, the pattern of data on the life expectancy can give an important indi-
cation of the poor situation of the population concerned.
Figure 2: Gap in life expectancy: comparing indigenous and non-indigenous populations, with
states in order of 2009 HDI rating
Source: Das 2012.
20
11
7
6
10
13
20
0
5
10
15
20
25
New Zealand
Canada
Mexico
Panama
Guatemala
Nepal
Australia
Gap in Life expectancy: Comparing Indigenous and
Non-Indigenous Populations, with States in Order of 2009 HDI Rating
Gap in Life Expectancy
Sowip 2_Figure 2 (page 64).xlsx
Source: MacIntosh, 2012:76.
Life expectancy is one of the key indicators of Human Development Index (HDI). Available data
show a remarkable gap in life expectancy between indigenous and non-indigenous populations
living within the same state. Comparing high-income to low- and middle-income counties shows
that the gap for indigenous peoples is observed in diverse nations. While Australia had the high-
80
Li, 2008.
Chapter 2 ξ 043
Indigenous Peoples’ access to Health Services
est recorded gap in life expectancy--20 years--between indigenous and non-indigenous, it was
comparable to that of low-income Nepal, as shown in Figure 3.
81
Nepal falls at 157th in HDI ranking.
Comparison between indigenous and non-indigenous groups in dierent countries depicts similar
picture on infant and child mortality rate. Analysis of the health data made above by Jianghong Li
(2008) for China, for example, shows that the weighted average mortality rate under age 1 for the
sample minority nationalities was 77.8 deaths per 1,000 live births versus 53.6 for the Han Chinese
in 2000. India shows a similar picture according to the 2005-2006 National Family Health Survey
(NFHS-3) which provides estimates of important indicators on family welfare, maternal and child
health, and nutrition according to social groups. Infant mortality rate for the Scheduled Tribe (ST)
was recorded to be 62.1 against the rate of 57.0 per 1,000 live births for the total population in In-
dia.
82
The data also show that the highest morality rates are concentrated in the regions with indig-
enous populations, especially in rural areas. Similar to Yunnan in China, where a higher rate of the
infant mortality exists, in India infant mortality is concentrated in the regions of Madhya Pradesh and
Arunachal Pradesh, where significant indigenous population live. The pattern is clear; for provinces
where indigenous peoples are in higher concentration, the mortality rates are correspondingly higher.
Figure 3: Infant mortality rate: indigenous versus mainstream by country (per 1,000 births)
Infant Mortality Rate (per 1,000 births)
Sources: Li 2008, Mohindra and Labonté 2010, Bennett and Dahal 2008, Dang 2012.
7 7. 8
62.1
59
30.4
53.6
57
55
23.9
0
10
20
30
40
50
60
70
80
90
China India Nepal Vietnam
Indigenous
All pop.
Sowip 2_Figure 3 (page 56).xlsx
Sources: Li 2008, Mohindra and Labonté 2010, Bennett and Dahal 2008, Dang 2012.
Nepal and Viet Nam display a similar picture. For example, according to NDHS , in 2006 the infant
mortality average in Nepal for indigenous peoples was 55 deaths per 1,000 live births while the
national average was 59.
83
Viet Nam appears to be doing better in terms of reducing the infant
mortality rate, but it has not been successful in reducing the disparity between its vulnerable
ethnic minorities and the majority population. Viet Nam for example, has 30.4 infant deaths per
1,000 live births for ethnic minorities while national average is only 23.9.
84
The table above shows
a comparative scenario on the infant mortality of the four dierent Asian countries.
81
Cunningham, 2009; MacIntosh, 2013.
82
Ministry of Tribal Aairs 2010.
83
Bennett, Dahal, et al. 2008.
84
Dang, 2012.
044 ξ Chapter 2
State of the World’s Indigenous Peoples
The case for child mortality and under-five mortality is also very similar in terms of the disparity
between indigenous and non-indigenous populations in the Asian countries. Given the highly vari-
able information availability we have information on the indicators for only few countries. In South
Asia, for example, Nepal provides a glimpse of the situation in all three aspects of child mortality
based on the further analysis of the national data. For India, Mohindra and Labonté (2010) have
analysed the time trend information from the National Family and Health Survey (NFHS-1), 1992-
1993; NFHS-2, 1998-1999; NFHS-3, 2005-2006. Bennett and Dahal (2008) did same for Nepal
using the data set generated from National Demographic and Health Survey 2006. We draw from
analysis of VHLSS by Dang (2012) for Viet Nam on the mortality rates. The following table shows
the comparative picture of three countries in Asia disaggregated for indigenous population com-
pared to the total population of the country.
Table 4: Infant, child and under-five mortality in selected Asian countries
Mortality
Nepal NDHS, 2006
India, NFHS
2005-2006
Viet Nam, VHLSS 2006
Indigenous
nationality
All
pop.
Scheduled
Tribe
All
pop.
Ethnic
minority
Ethnic
majority
Infant mortality 59 55 62.1 57 30 23
Child mortality 22 13 95.7 74.3 NA NA
Under-five mortality. 80 68 35.8 18.4 41 28
Source: Bennett and Dahal, et al. 2008; Mohindra and Labonté 2010; and Dang 2012.
Data on child mortality are sparse in other countries that do not disaggregate by ethnicity. In the
countries where data are collected using the geographic area as unit of analysis, proxy indicators are
the means to generate some understanding of indigenous health to see the dierence between the
remote regions where indigenous peoples predominantly live compared with the other provinces with
fewer indigenous peoples. In Pakistan, for example, Balochistan in the North-West Frontier Province
(NWFP) and Federally Administered Tribal Areas (FATA) are the predominantly tribal areas. They are
also the least developed provinces and have highest levels of infant mortality rate from 70 to 129 per
1,000 live births. Unfortunately, the majority of infant deaths were caused by preventable causes such
as diarrhoea, respiratory infection, tetanus and others.
85
Thus, improving living conditions and access
to health services would result in rapid improvements for child health in these regions.
Minority Rights Group International (MRG) Report 2013 shows that Baluchistan also experience
highest level of maternal mortality ratio with 758 per 100,000 live births. This is indeed a shocking
figure when the national maternal mortality rate has declined from 400 per 100,000 in 2004-
2005 to 276 in 2006-2007. If Pakistan is to meet the MDG target of reducing the maternal
mortality to 140 per 100,000 also for its tribal population, it will certainly require substantial
restructuring of the state policies and programmes. We do not have access to ocial figures on
maternal mortality in Myanmar, but research estimates reveal that the maternal mortality rate for
the indigenous peoples is “triple that of the country as a whole, making this statistically among
85
Walker, 2013.
Chapter 2 ξ 045
Indigenous Peoples’ access to Health Services
the most dangerous places in the world to be a pregnant woman”.
86
It is estimated that “one third
of these deaths occur due to postpartum haemorrhage, a condition that can be prevented with
the provision of basic health care services”.
87
Child nutrition is another major indicator used to assess the health status of the population.
The available data reveal that a number of Asian countries have shown improvement in child
nutrition over the last two decades. Astonishingly, despite such improvements, changes in the
nutritional status of the children in indigenous communities are much slower in pace than their
non-indigenous counterparts. A study by Ouyang and Pinstrup-Andersen (2012:1456) on health
inequality between ethnic minorities and the Han populations in China states, “Health and
nutrition status in terms of height-for-age and weight-for-age actually improved for both the
Han group and the minority group, but the improvement is much smaller for the minorities, and
hence the growing health gap”. Another study conducted in China has made similar conclusions
and suggested that stunting, wasting and being underweight were distinct indicators of the
nutritional status of children and chronic growth retardation is the major type of child protein-
energy malnutrition in poor rural minority areas of Yunnan Province, China.
88
In Cambodia, more than 20 per cent of indigenous children under five children suer from mal-
nutrition and 52 per cent are classified as underweight and stunted in growth (Health Unlimited
2002). The country has a small population of indigenous peoples, approximately 100,000 with
most concentrated in two provinces in one of the world’s poorest countries with low human devel-
opment index (UNDP 2004). The prevalence of malnutrition in Indonesia is similarly high at 24.6
per cent of children under five years old as of 2000. Indigenous Adat populations suer greater
risk of child mortality. Human development levels among the Philippines indigenous groups in re-
gion of Cordillera and specifically Manabo households vary, showing that the Manabo households
had a much higher rate of under-five mortality at 96 deaths per 1,000 live births, which is higher
than national average of 42 per 1,000.
89
In Bangladesh indigenous peoples are largely concentrated in Chittagong Hill Tract (CHT) where
approximately 600,000 indigenous Jumma peoples live. CHT, being one of the country’s most
deprived areas, suers particularly extreme rates of ill health. Immunization coverage in CHT is
recorded to be considerably low, with full immunization coverage by age 12 months at 51 per cent
compared to 71 per cent overall in Bangladesh.
90
The case of India corroborates the findings in China and other Asian countries and shows that nu-
tritional status of the Scheduled Tribes (ST) children falls behind the national average compared
with the mainstream or dominant communities. The mortality rate of ST children is worse and im-
provement is slower than for other communities in the country. Adequate nutrition and access to
vaccination are key determinants in child growth and mortality, thus both are depicted in Figure 4
and Figure 5, which show time trends in the child nutrition status and access to vaccination over
the period from 1992-1993 to 2005-2006 in India:
86
Walker 2013:145.
87
http://www.unpo.org/article/11087#sthash.Zc7ut7Jr.dpuf.
88
Li, Guo et al., 1999.
89
Macdonald, 2012.
90
Minsitry of Health and Family Welfare, 2011.
046 ξ Chapter 2
State of the World’s Indigenous Peoples
Figure 4: Scheduled Tribe, malnutrition and vaccination, India
56.8
55.9
54.5
24.8
26.4
31.3
0
10
20
30
40
50
60
1992-93 1998-99 2005-06
% of children undernourished % of children with full immunization
53.4
47
42.5
35.4
42
43.5
0
10
20
30
40
50
60
1992-93 1998-99 2005-06
% of children undernourished
% of children with full immunization
Total Population,
Malnutrition and Vaccination, India
Sowip 2_Figure 4 (page 59).xlsx
Scheduled Tribe,
Malnutrition and Vaccination, India
Total population, malnutrition and vaccination, India
56.8
55.9
54.5
24.8
26.4
31.3
0
10
20
30
40
50
60
1992-93 1998-99 2005-06
% of children undernourished % of children with full immunization
53.4
47
42.5
35.4
42
43.5
0
10
20
30
40
50
60
1992-93 1998-99 2005-06
% of children undernourished
% of children with full immunization
Total Population,
Malnutrition and Vaccination, India
Sowip 2_Figure 4 (page 59).xlsx
Scheduled Tribe,
Malnutrition and Vaccination, India
Source: Statistical Profile of Schedule Tribes in India 2010, Ministry of Tribal Aairs.
Immunization coverage is generally assessed using two indicators: breadth or coverage (percent-
age receiving any basic vaccination) and intensity or quality of coverage (percentage receiving
all basic vaccinations). Analysis of NFHS data in India suggests that there have been substantial
improvements between 1992 and 2005, especially among Scheduled Tribes.
91
However, a disag-
gregated analysis reveals that, despite the gains made, immunization rates among STs remained
consistently below those recorded for other groups including the Scheduled Castes and Other
Backward Classes (OBCs), for all types of vaccinations. This is attributed to the extremely poor
immunization policy and coverage for ST children on the part of the government service delivery.
The following table shows the vaccination coverage of ethnic minorities in Viet Nam:
91
Das and Hall, 2012.
Chapter 2 ξ 047
Indigenous Peoples’ access to Health Services
Figure 5: Children with full vaccination, Viet Nam 2002 (per cent)
Source: Dang 2012.
82.3
48.3
68.1
38.1
93.4
72.4
76.1
83.2
6 7.1
100806040200
BCG
DPT (three doses)
Polio (three doses)
Measles
All (BCG, DPT, Polio, Measles)
Children with Full Vaccination, Vietnam 2002 (per cent)
All Pop Ethnic Minority
58.3
Sowip 2_Figure 5 (page 59).xlsx
Source: Dang, 2012.
Access to vaccination in other Asian countries also shows that there have been improvements in
the coverage, but the available data show that the ethnic minorities remain below the national
average. The situation calls for proactive health policies of the government to reach indigenous
peoples in the regions where they live. The disparity in access to vaccinations by the children in
Viet Nam illustrates how indigenous peoples are constantly falling behind the dominant commu-
nities. As figure 5 shows the percentage of indigenous children who have received full immuniza-
tion is 38.1 while the national average is 67.1 per cent.
Diseases and determinants of the health of indigenous peoples
Nutritional deficiency of indigenous peoples caused by the massive changes induced through
colonization and state intervention in their ways of living has resulted in higher rate and complex
form of disease patterns of indigenous peoples. Colonization, market expansion and state inter-
ventions have blocked indigenous peoples’ access to their forest, river and other natural resourc-
es. The traditional ways of farming, food-gathering, hunting, or fishing places and practices has
been destroyed and indigenous peoples become increasingly dependent upon the outside world
for foods that are unfamiliar and low in nutrient quality. A study on determinants and disease
patterns of indigenous peoples describes the nutritional deficiencies of indigenous peoples in the
following words:
Besides hunger and general inadequacy of food and dietary energy (calories), specific de-
ficiencies of various nutrients are widespread. Examples are iron deficiency, which can be
caused by dietary inadequacy or secondary to blood loss, intestinal parasites, or malaria;
048 ξ Chapter 2
State of the World’s Indigenous Peoples
hypothyroidism, shortness of iodine aects hundreds of millions of people; poor vitamin
intake (e.g., vitamins A and D, folic acid); and heavy metals, such as zinc. These deficiencies
and any underlying causes, including poverty and inadequate food, should be corrected to
reach satisfactory outcomes for those aected.
92
Table 5: Major health problems of indigenous peoples
ɜ High infant and young child mortality
ɜ High maternal morbidity and mortality
ɜ Heavy infectious disease burdens
ɜ Malnutrition and retarded growth
ɜ Shortened life expectancy at birth
ɜ Diseases and deaths associated with cigarette smoking
ɜ Social problems, illnesses and deaths linked to misuse of alcohol and other drugs
ɜ Accidents, poisonings, interpersonal violence, homicide and suicide
ɜ Obesity, diabetes, hypertension, cardiovascular disease and chronic renal disease (life-
style diseases)
ɜ Diseases caused by environmental contamination (e.g., heavy metals, industrial gases,
and euent wastes) and infectious diseases caused by faecal contamination
Source: Gracey and King 2009:66.
Contemporary indigenous health issues in Asia are strikingly similar in many aspects to prob-
lems of indigenous peoples worldwide. Although the gap is gradually being narrowed in health
status of indigenous and non-indigenous populations substantially over the last few decades in
the region, there is a significant burden of disease for the indigenous population as compared
to general population. The studies show that indigenous peoples in Asia “bear a triple burden of
persisting infectious diseases, increasing chronic conditions, and a growing recognition of injuries
and violence”.
93
It further states that incomplete demographic transitions, greater risks of com-
municable diseases including HIV and AIDS, massive unplanned urbanization and a host of social
determinants of health compound these problems. Thus poor health is caused by a number of
factors: a high level of undernourishment, poor hygiene and sanitation, overcrowded living space,
lack of clean drinking water, environmental contaminations and a high degree of poverty. In ana-
lysing the disease patterns of the indigenous peoples across the globe, Gracey and King (2009)
summarized the major health problem of the indigenous peoples as per table above:
Generalization across the indigenous peoples in Asia with regard to their health status may be
problematic as the extent of the disparities varies between the indigenous and non-indigenous
population, as well as within the indigenous groups. There are also specific historical and local
contextual factors in dierent Asia countries that aect the health of the indigenous peoples in
particular location. For example, studies show that there is prevalence of malaria in particular
parts of the Bangladesh, India and Indonesia aecting certain indigenous groups more than oth-
92
Gracey and King, 2009:66.
93
Rakić, 2008:728.
Chapter 2 ξ 049
Indigenous Peoples’ access to Health Services
ers. Similarly, the problem of sexually transmitted diseases associated with the tracking of girls
and migration may be of higher severity in Thailand, Myanmar, India, Nepal and Indonesia.
94
Conflict related injuries are also an important factor that comes into purview when describing
indigenous health. Lao People’s Democratic Republic for example still suers from landmine ex-
plosion that takes lives of more than 100 people each year. Philippines and Myanmar are equally
aected by conflict and related injuries which, among the indigenous peoples are a considerable
problem. Indigenous peoples are also less prepared for the disaster related health problems such
as the devastating typhoon experienced recently in Philippines.
The health deficit for indigenous women is greater than their male counterparts. The health dis-
crepancy faced by the indigenous peoples of Peninsular Malaysia’s diverse indigenous peoples,
collectively known as Orang Asli, is an illustrative example for such situation. A report by the
Women’s Aid Organisation (WAO) which examined Malaysia’s progress on gender equality point-
ed out that Orang Asli women have a lower life expectancy than men. They run a greater risk of
malnutrition and have high rates of post-partum haemorrhage and puerperal sepsis. In a number
of countries in Asia, indigenous women face the highest level of vulnerability of violence in conflict
situations, tracking and sexually transmitted diseases in addition to other burdens of disease.
Asia experiences higher incidents of infectious diseases such as tuberculosis and rheumatic fever
which are quite uncommon among non-indigenous peoples. The indigenous populations are also
suering increasingly from the lifestyle diseases including obesity, heart diseases, cancer, type 2
diabetes, as well as physical, social and mental disorders.
95
Such disorders are often linked to mis-
use of alcohol and of other drugs which result from identity loss, disorientations in the collective
cultural life world and indigenous identities.
96
Inaccessibility to proper health care services, inad-
equate clinical care and health promotion, and poor disease prevention services on the part of the
State aggravate this situation because preventable conditions are not adequately addressed by
the health care delivery systems.
Indigenous peoples’ access to health services
Lack of access to adequate and culturally appropriate health care services is one of the prima-
ry experiences of the indigenous peoples in Asia and a key reason for indigenous health deficit.
Compared to their non-indigenous counterparts, indigenous peoples have limited health care in-
frastructure and ability to utilize existing health services. Data coming from various countries on
the group dierence with respect to access indicate that indigenous groups, especially indigenous
females, are most likely to report being in bad health, have the highest incidence of temporary
health problems and are less likely to receive or seek treatment when ill. The systematic charac-
ter of the health gap is related to the lack of general state capacity to provide health services to
indigenous peoples. Restructuring of the existing preventive and curative health care services are
at the heart of the indigenous peoples right to health and well-being.
94
Macdonald, 2012.
95
Anderson and White, 2008
96
King, Smith, et al., 2009.
050 ξ Chapter 2
State of the World’s Indigenous Peoples
There are several other factors that impede indigenous access to health services besides the state
capacity and willingness to provide necessary support for improving indigenous health. Unfortu-
nately, only limited disaggregated information is available on utilization of existing health care
services for indigenous peoples. One exception and a key indicator for assessing the utilization
of the health care services by the population has been the visit of pregnant women to a health
facility prior, during and after delivery. The data generated from national surveys in selected Asian
countries show that a considerable disparity exist between the indigenous and non-indigenous
population on access and utilization of such maternal-child services. For example, in China 73
per cent of the pregnant women in non-autonomous prefectures had antenatal examination but
only 51 per cent of the mothers from autonomous prefectures with larger population of minority
nationality made such visits.
97
Other countries depict similar picture on health care service to mothers. Viet Nam shows that
ethnic minority people are 16 per cent less likely to visit hospital when they are ill.
98
In Bangladesh,
districts in Chittagong Hill Tracts (CHT), where the majority of Bangladeshi indigenous peoples
live, antenatal care visits, assistance during delivery by medically trained personnel and post-
natal care for mothers were lower than that of national figures. For example, the Khagrachhari
district in CHT has recorded rate of 30 per cent antenatal, and 6.6 per cent post natal care visits
which is lower than national average of 47.6 and 16.1 per cent, respectively.
99
Further analysis of
demographic and health information for a 2005-2006 survey in Nepal shows that 34 per cent of
mothers from indigenous nationalities receive antenatal care from a skilled birth attendants as
compared to 44 per cent for average population. The disparity appears wider still when comparing
access to antenatal care with hill Brahman community, where 76 per cent of mothers receive such
assistance. The Indian situation is not very dierent as the only one third of women belonging to
Scheduled Tribes receive antenatal care as compared to the population average of about one half
(49 per cent) for the mainstream. It even indicates the worst case scenario as the proportion of
Scheduled Tribe women to have received such care actually declined from 35 per cent in 1998 to
32 per cent in 2006 (Das and Hall 2012).
Another measure to assess the access of health institutions and facilities by the population has
also been through identifying the place of birth or delivery. Asian countries have varying records
of delivery, but on the whole, the majority of indigenous mothers tend to give birth in their homes.
In India for example, only about 29 per cent of mothers from the indigenous population had
delivery in the health facilities indirectly, which means that some 71 per cent give birth in their
own homes without any assistance from skilled birth attendants. The situation of the non-ST
communities was better than of the STs, with 49 per cent of the mothers having access to health
facilities for delivery. The following table shows the place of delivery in India for indigenous and
non-indigenous population:
97
Li, 2008.
98
Dang, 2012.
99
Ministry of Health and Family Welfare, 2004.
Chapter 2 ξ 051
Indigenous Peoples’ access to Health Services
Figure 6: Place of delivery (access to health institutions and facilities), India
Source: Das 2012.
11.6
5.8
70.9
1 7. 7
18
20.2
51.3
38.7
0
20
40
60
80
Public Sector
Private Sector
Own home Delivery through
health facility
Place of Delivery (acces on Health Institution and Facilities), India
National Average Scheduled Tribe
Sowip 2_Figure 6 (page 64).xlsx
Source: Das, 2012.
Indigenous peoples’ access to health services utilization information
Whereas some countries in Asia are improving indigenous access to health information, in general
most countries are substantially lagging behind due to multiple reasons. Viet Nam, for example
shows that knowledge about HIV/AIDS among never-married women is recorded to be at the
rate of about 95 percent. There is, however, dierence in knowledge about HIV/AIDS for dierent
ethnic groups. Women belonging to ethnic minority groups are 12 per cent less likely to ever hear
about the HIV/AIDS, and 18 per cent less likely have correct perception about it and significantly
less likely to know about correct ways about how they could prevent themselves from contracting
HIV/AIDS. In India, 60.9 per cent of mainstream population has heard about HIV/AIDS, compared
to only 38.6 per cent of women from Scheduled Tribes who have received such information. The
situations of Bangladesh and Nepal are also similar as 46 per cent of the population has ever
heard of HIV/AIDS and only 13 per cent of women have complete information on transmission of
the disease in Bangladesh. Disparity between the indigenous and non-indigenous peoples in Ne-
pal with regard to knowledge about HIV/AIDS remains a cause of concern as the only 60 per cent
of women among the indigenous peoples living in southern plains of Nepal known as Tarai have
heard about HIV/AIDS compared to national average of 73 per cent. Indigenous women lack direct
links and access to public information and mass media, and most importantly it is not communi-
cated in their mother tongue.
There are several reasons that indigenous peoples in Asian countries have limited access to health
care services and information. The first and often-cited reason is the distance to the health facil-
ities. As most indigenous peoples in Asia live in remote parts of the country where government
has not invested in the health infrastructure, thus leaving the majority of indigenous populations
to rely on the traditional medicines and methods for health care. Nor has there been eort in rec-
ognizing and promoting the complementary indigenous knowledge and practices on health care
and well-being. As the following figure shows, even when health care infrastructure does exist,
the availability of drugs and quality health advice is lacking for indigenous groups.
052 ξ Chapter 2
State of the World’s Indigenous Peoples
Figure 7: Problems in accessing medical advice or treatment (per cent), India
Problems in accesing medical advice or treatment (%), India
Source: Statistical Prole of Schedule Tribes in India 2010, Ministry of Tribal Aairs
41
35.8
67
25.2
22.9
46.6
80706050403020100
National Average
Scheduled Tribes
At least one problem in
accessinghealth care
Problems in accessing medical
advice or treatment (%), India
Distance to
health facility
Sowip 2_Figure 7 (page 65).xlsx
Source: Statistical Profile of Schedule Tribes in India 2010, Ministry of Tribal Aairs.
Reducing language barriers is critical for improving indigenous peoples’ access to health care,
and other services provided by the State. In the majority of the Asian countries, language of the
dominant communities is being adopted as ocial language. Unfortunately, indigenous popula-
tion often cannot speak a language other than their own mother tongue except in the condition
of cultural assimilation. Thailand is a representative case in Asia. More than 100,000 indigenous
peoples in Thailand ocially referred to as hill tribes had no access to the public health system.
The National Commission on Human Rights of Thailand noted that for the hill tribes who have not
yet received legal status, the public health service is elusive. Referring to the question of linguistic
barriers, the Committee on the Elimination of Racial Discrimination in its concluding observations
stated that “the Committee is concerned about the inadequate access to social welfare and pub-
lic services by certain ethnic groups because of language barriers and the limited availability of
such services where these groups live”.
100
A great number of indigenous peoples have attributed their inability to access health services to
aordability. In Nepal for example, 43 per cent of indigenous women have reported that they are
unable to receive the health care services due to lack of money. Despite the fact that poverty has
been drastically reduced in Asian countries over the past few decades, including for indigenous
peoples, available data show that indigenous peoples have a higher poverty rate in the region.
The exception is China, where the poverty gap between indigenous and non-indigenous popula-
tion is stable, while the poverty gap is widening in most Asian countries.
101
Finally, access to health care services by indigenous peoples is hampered by lack of represen-
tation of the indigenous peoples in the health management system. There are very few health
professional and workers trained from among the indigenous populations who can be involved in
management of health care. The investment in the training of indigenous persons in the health
100
Walker, 2013:161.
101
Hall and Patrinos, 2012.
Chapter 2 ξ 053
Indigenous Peoples’ access to Health Services
work force is substantially behind in almost all countries. Indigenous representation and partici-
pation in decision-making with regards to health policies, planning and evaluation at the national
level and their right to participate in decision-making in local health facility management are
critical to improving indigenous access to health services.
Indigenous health and post-2015 development framework
The above analysis of the available data from dierent Asian countries on the health status of the
indigenous peoples shows a systematic deficit in the indigenous health and access to health ser-
vices from the government. Indigenous peoples seems to fall behind in all major health indicators
employed by the existing mainstream health policies and programmes even when the state has
made significant progress in economic growth and social development. Irrespective of the HDI of
the country and growth rate, indigenous peoples have a lower rate of life expectancy, higher infant
and child mortality, poorer maternal health outcomes and lower levels of access to health services
provided by the government, including development of and access to information on indigenous
health and health services. Persistent and ever-growing inequality between indigenous and non-in-
digenous peoples living in the same State is intertwined with the question of human rights violation.
The health deficit and persistent social inequalities result from the combined eects of social
determinants of health and the indigenous specific factors related to colonization and history.
The WHO Commission on Social Determinants of Health and the 1986 Ottawa Charter for Health
Promotion (WHO 1986) identified income, education, employment, living conditions, social sup-
port and access to health services as the key social determinants of poor health.
102
These factors
certainly apply to the indigenous peoples, as poverty and other disadvantages are dispropor-
tionately concentrated in the indigenous areas alongside a generic lack of government support.
The general socioeconomic factors of indigenous health inequalities arise from historically and
culturally specific factors particular to the peoples aected. Thus Indigenous health is aected by
the colonial and intergenerational dispossession, structure of racial discrimination, loss of iden-
tity, culture, language and land, as well as spiritual, emotional and mental disconnectedness.
103
The Millennium Development Goals (MDGs) have achieved a significant progress towards reduction
of poverty, child death, infectious diseases such as malaria, tuberculosis and HIV/AIDS and increase
in school enrolment and employment over the past. While the MDGs are making a real dierence in
people’s lives, the changes for the indigenous peoples, however, have not been equal to their non-
indigenous counterparts. The MDGs have some major deficiencies with regard to indigenous peoples.
The first is that MDGs rely on national aggregate results and remains blind to the need of social
groups such as indigenous peoples with specific conditions of disadvantages. The progress in the
national average technically can be attained without any improvements in the minority indigenous
peoples’ health situation or can even be accomplished at the cost of ethnic minority by diverting
programs though priority investing of resources in easily accessible (urban and semi-urban) areas
where higher populations are concentrated, thus driving statistics on improvement at the national
level. Such a situation can only begin to be addressed by improvement on the lack of disaggregated
data for indigenous peoples. The lack of data seriously hampers the State’s ability to plan and monitor
102
Nettleton, Napolitano, et al. 2007.
103
Cunningham, 2009.
054 ξ Chapter 2
State of the World’s Indigenous Peoples
the progress on MDGs with visibility of the specific ethnic groups. The second critique of the MDGs
has been its lack of reference to the principles of human rights for attaining these goals.
Another major weakness of the conventional approach, including that of the MDGs, has been
to target general health application population health initiatives where the exclusive focus has
been on non-indigenous notions of health primarily consisting of biomedical perspectives on
disease and treatment. The mainstream health strategies have not yet taken into consideration
the relational and holistic concept of indigenous health that defines health and well-being in
broader terms than the absence of disease and physical health. Indigenous health embraces
spiritual, emotional and mental aspects together with physical health in their understanding of
well-being and health. The indigenous concept of health also goes beyond the individual and
considers the collectivity and harmonious relationship with other members of the community
and nature as intricate part of the well-being.
The United Nations is currently engaged in the process of devising a new global development
plan for the post-2015 period, when the MDG program will conclude. There is a wide range of
agreement that the new global development framework that will replace the MDG should situate
inequality and human rights central to it strategy. Such an approach is crucial not only because
inequality has negative impact on growth and creates tension between communities but also un-
dermines democracy. Indigenous peoples have called for post-2015 framework to be based on a
foundation of human rights. This is highly relevant as the right to life is broadly interpreted as not
just protection from arbitrary killing, but also as creating material conditions where food, clean
water, and medicine are available to all. With regard to indigenous peoples, ILO Convention No.
169 on Indigenous and Tribal Peoples, which has been key reference for indigenous peoples world-
wide, recognizes the health related rights specifically in Article 25.
104
This provision complements
with the similar health rights armed in UNDRIP 2007, Article 21 (1) which recognizes the rights of
indigenous peoples to the improvement of their economic and social conditions “in the areas of
education… housing, sanitation, health and social security”.
The report of the High Level Panel on the Post-2015 Development Agenda recommended five big
transformative shifts; one of them is stated as “Leave no one behind”. This recommendation rec-
ognizes the issue of inequality and discrimination as central ones and calls for further work on the
MDG achievements. It states that; “We must keep faith with the original promise of the MDGs, and
now finish the job. … We should ensure that no person—regardless of ethnicity, gender, geography,
disability, race or other status—is denied universal human rights and basic economic opportu-
nities”. This indicates the necessity to emphasize the task of removing both direct and indirect
discrimination faced by the aected communities for achieving equity in health. As elsewhere,
indigenous peoples in Asia face direct discrimination as manifested in a range of spheres, from
104
ILO C 169, Article 25 1) governments shall ensure that adequate health services are made available to the peoples
concerned, or shall provide them with resources to allow them to design and deliver such services under their own
responsibility and control, so that they may enjoy the highest attainable standard of physical and mental health; 2)
health services shall, to the extent possible, be community-based. These services shall be planned and administrat-
ed in co-operation with the peoples concerned and take into account their economic, geographic, social and cultural
conditions as well as their traditional preventive care, healing practices and medicines; 3) the health care system shall
give preference to the training and employment of local community health workers, and focus on primary health care
while maintaining strong links with other levels of health care services; and 4) the provision of such health services
shall be coordinated with other social, economic and cultural measures in the country.
Chapter 2 ξ 055
Indigenous Peoples’ access to Health Services
access to health facilities and the delivery of health services. They are also adversely aected by
the underlying determinants of health, such as access to safe drinking water, sanitation, adequate
housing and nutrition. Additionally, health practitioners may give lower-quality diagnoses, med-
ication and care and may even show neglect towards those discriminated against. Indirect dis-
crimination that indigenous peoples experience may on the surface appear neutral, but it has the
eect of discrimination. One prime example of indirect discrimination includes providing health
information and services only in the dominant language or in accordance with dominant cultural
practices, which results in the de facto exclusion of indigenous peoples.
The report also calls for a “data revolution” to improve the quality of statistics and information
available to citizens. In the Asian region, as in other parts of the world, indigenous peoples have
spoken clearly on this issue stating that such a data revolution should include the collecting dis-
aggregated information on key indicators for both baseline and progress tracking. A number of
Asian countries have already begun collecting the information disaggregated to create profiles
for specific to indigenous peoples on key health indicators such as life expectancy, child mortality
and others. The post-2015 framework should intensify the task and collect quantitative data on
dierent types of health facilities, locations and their users disaggregated by ethnicity. Similarly,
disaggregated data on health practitioners, patient-health worker ratios, sta recruitment would
be crucial in planning inclusion of the indigenous professionals into the health workforce. Finally,
quantitative and qualitative data on the burden of preventable and treatable disease, disability
and premature death and their determinants among indigenous peoples should also include in
such a data revolution envisioned in post-2015 development framework. This would be in line with
the High Level Panel’s call for designing “goals that focus on reaching excluded groups by making
sure we track progress at all levels of income, and by providing social protection to help people
build resilience to life’s uncertainties”.
Conclusion
Several common health problems that indigenous peoples share with other excluded populations
may be addressed through general health initiatives. Indigenous peoples however, further, face
distinct set of complex issues that require initiatives specific to indigenous peoples. Indigenous
peoples, for example, suer from political marginalization and loss of autonomy. In order to re-
verse the eect of colonization and political marginalization the recognition of indigenous peo-
ples’ right to self-determination is regarded as an appropriate mechanism. Through the exercise
of the right to self-determination, indigenous peoples can revive and reclaim their cultural tradi-
tions and indigenous identity and self-esteem based on a positive image that is crucial for overall
health and well-being of the people. Such autonomy would also involve empowering indigenous
peoples to preserve and develop their own solutions and plans to improve their health rather than
imposing solutions upon them. Article 24.1 of the UNDRIP is illustrative of such an autonomy. It
states, “Indigenous peoples have the right to their traditional medicines and maintain their health
practices, including the conservation of their vital medicinal plants, animals and minerals”.
The dispossession that indigenous peoples suered from both through colonial and contemporary
processes of dispossession has left a legacy of impoverished indigenous communities which has
resulted in a detrimental eect on indigenous peoples’ health. The process has displaced them from
their lands and alienated them from their natural resources. The land and territory for indigenous
peoples is deeply linked to their identity, culture, spirituality and overall health of the community.
056 ξ Chapter 2
State of the World’s Indigenous Peoples
Indigenous language is also central to identity, cultural expressions and collective living. It is
especially important as a fundamental cultural expression of indigenous knowledge on health,
medicine and spirituality and thus for well-being. Indigenous languages, however, are being lost
rapidly and with them is the loss of valuable knowledge on medicinal plants, healing and indig-
enous identity. The post-2015 development agenda should consider revitalization of the indige-
nous languages as an important strategy connected to disease prevention and health promotion.
Finally, improving equity in health for indigenous peoples is linked to fulfilling their right to
participate in decision-making. The participation of the population in all health-related decisions
from community, national and international levels is an important dimension of the human
right to health. Consultation processes have began for the post-2015 development agenda and
has oered important opportunity for participation of the indigenous peoples in formulating a
new global partnership for eradicating poverty and transform economies through sustainable
development to promote improved indigenous health and well-being to levels comparable to
non-indigenous groups.
References
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London, Elsevier.
Baviskar, A. (2007). Indian Indigeneities: Adivasi Engagements with Hindu Nationalism in India.
Indigenous experience today. M. d. l. Cadena and O. Starn. Oxford, Berg. Wenner-Gren Interna-
tional Symposium series: 275-303.
Bennett, L., D. R. Dahal, et al. (2008). Caste, Ethnic and Regional Identity in Nepal: Further
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Dang, H.-A. (2012). Viet Nam: A Widening Poverty Gap for Ethnic Minorities. Indigenous peoples,
poverty, and development. G. Hall and H. A. Patrinos. New York, Cambridge University Press.
Das, M. B. and G. Hall (2012). India: The Scheduled Tribes. Indigenous peoples, poverty, and
development. G. Hall and H. A. Patrinos. New York, Cambridge University Press.
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Gracey, M. and M. King (2009). “Indigenous health part 1: determinants and disease patterns”. The
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Hall, G. and H. A. Patrinos (2012). Indigenous peoples, poverty, and development. New York,
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Indigenous Peoples’ access to Health Services
Hathaway, M. (2010). “The emergence of Indigeneity: Public intellectuals and an indigenous
space in Southwest China”. Cultural Anthropology 25(2): 301-333.
International Work Group for Indigenous Aairs (IWGIA) (2008). The Indigenous World 2008.
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King, M., A. Smith, et al. (2009). “Indigenous Health Part 2: The Underlying Causes of the Health
Gap”. The Lancet 374: 76-85.
Kingsbury, B. (1998). “”Indigenous Peoples” in International Law: A Constructivist Approach to
the Asian Controversy”. The American Journal of International Law 92(3): 414-457.
Li, J. (2008). “Trends in infant/child mortality and life expectancy in indigenous population in
Yunnan Province, China”. Australian and New Zealand Journal of Public Health 32(3): 216-223.
Li, Y., G. Guo, et al. (1999). “Prevalance and coorelates of malnutrition among children in rurual
minority area of China”. Pediatrics International 41(549-556).
Macdonald, K. (2012). Indigenous Peoples and Development Goals: A Global Snapshot. Indige-
nous peoples, poverty, and development. G. Hall and H. A. Patrinos. New York, Cambridge
University Press.
MacIntosh, C. (2013). “The Role of Law in Ameliorating Global Inequalities in Indiegnous Health”.
Journal of Law, Medicine and Ethics Spring: 74-88.
Ministry of Health and Family Welfare, G. o. t. P. s. R. o. B. (2004). Social Assessment and Tribal
Health Nutrition and Population Plan for the HNP Sector Program (2005 to 2010).
Ministry of Tribal Aairs, G. o. I. (2010). Statistical Profile of Scheduled Tribes in India 2010.
Minsitry of Health and Family Welfare, G. o. t. P. s. R. o. B. (2011). Tribal/Ethnic Health Popula-
tion and Nutrition Plan for the Health, Population and Nutrition Sector Development Program
(HPNSDP) 2011 to 2016.
Mohindra, K. and R. Labonté (2010). “A systematic review of population health interventions and
Scheduled Tribes in India”. BMC Public Health 10(438): 1-10.
Nettleton, C., D. A. Napolitano, et al. (2007). An overview of current knowledge of the social de-
terminants of indigenous health (Commission on Social Determinants of Health, Working Paper).
Geneva, World Health Organization.
Ouyang, Y. and P. Pinstrup-Andersen (2012). “Health Inequality between ethnic Minority and Han
Populations in China”. World Development 40(7): 1452-1468.
Rakić, J. G. (2008). Indigenous Health, Asian. Encyclopedia of Public Health. W. Kirch, Springer:
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(Accessed December 20, 2013).
UN Photo/Broddi Sigurdarson
Chapter 3 ξ 059
Indigenous Peoples’ access to Health Services
Chapter Three
Access to Health Services
by Indigenous Peoples
in the Arctic Region
Ketil Lenert Hansen, PhD
UN Photo/Broddi Sigurdarson
060 ξ Chapter 3
State of the World’s Indigenous Peoples
Chapter Three
Access to Health Services by
Indigenous Peoples in the
Arctic Region
Ketil Lenert Hansen, PhD
105
Introduction
The focus in this chapter is on access and utilization of quality health care services for the indige-
nous peoples from the northern regions of Fennoscandia and the Inuit (the Kalaallit) in Greenland.
Indigenous peoples in many parts of the world are described as among the most vulnerable mi-
nority groups, with the poorest health status; they receive a poorer quality of care than their
majority peers. Indigenous peoples struggle to access health services in relation to their needs
and face health service disparities when compared to the majority population.
106
These disparities
are superimposed on the higher cost and logistics of communications, transportation and rapidly
changing extreme weather related to delivering timely health care to people living in northern,
often remote communities.
“One of the major constraints to delivering good quality health care in the North has been the
allocation of financial and human resources. Another of particular significance is a problem
related to communication and transportation infrastructure that links regional and peripheral
facilities with central or national referral centres. In addition, the harsh climatic conditions and
the special needs of the indigenous populations pose significant challenges”.
107
In several circumpolar northern countries, health professional shortages and service delivery
challenges exist. Many patients live in rural areas, often remote and isolated, thus far away from
the health care service providers. Consequently people living in these locations face long journeys
and high costs to obtain health care.
108
Childbirth in Greenland is an example of the challenge of
obtaining health care support in the North. Women are required to leave their local communities
during pregnancy, as a consequence of new policies and guidelines in Greenland.
109
105
Ketil Lenert Hansen, who has a Ph.D. in public health, is a researcher at the Arctic University of Norway.
106
MRG, 2013, p. 188.
107
Ikaheimo, 2010, p. 414.
108
Vuori, Kylanen and Tritter, 2010, p. 513.
109
R. A. Montgomery-Andersen, Willen and Borup, 2010, pp. 301-303.
Chapter 3 ξ 061
Indigenous Peoples’ access to Health Services
Several health and living condition indicators demonstrate that indigenous peoples living in the
far northern countries face increased risks for health problems compared to mainstream national
population statistics. Indigenous peoples in the north tend to have higher rates of chronic condi-
tions and disease including but not limited to hypertension,obesity and type 2 diabetes.
110
Discrimination is associated with poorer physical and mental health and health services inequity.
It is important to understand the historical context of indigenous peoples’ rapid social and cultur-
al change and how current health conditions are thought to emanate from colonization aecting
the health status of indigenous peoples in the past and present.
111
Too often those issues are not
taken into account when designing health interventions.
This chapter will focus on the health care challenges for indigenous peoples living in the Arctic
and how indigenous peoples face these challenges. The particular focus is on the Sami living in
Norway, Sweden, Finland and Russia and the Inuit in Greenland.
Indigenous and total populations in Norway, Sweden, Finland, Russia and Greenland
In Northern Norway (Nordland, Troms and Finmark) the total population is 470,000
112
(2011). In
Northern Sweden (Norrbotten, Västerbotten) the total population is 520,000.
113
In Finland (Oulu,
Lappi) the total population is 650,000, and in the Komi Republic (Russian Federation) the total
population is 1,050,000. In Greenland the total population is 56,000, including 50,000 born in
Greenland, (2013).
114
In sum, the total population estimation for the four countries is 2,750,000.
The Sami include several subgroups stratified according to geographical location and dialect. The
size of the Sami population is approximately 70,000-100,000, but estimates vary in accordance with
criteria used such as genetic heritage,
115
mother tongue and the personal sense of ethnicity.
116
The
largest proportion of Sami is believed to reside in Norway (60,000), followed by Sweden (36,000)
and Finland (10,000), with the lowest proportion residing on the Russian Kola Peninsula (2,000).
117
Accurate population estimates are dicult to assess because there are no current standards for
routinely measuring demographic numbers to indicate the scope and magnitude of the Sami popu-
lation, due to a lack of information on race and ethnicity in indicators contained within public regis-
ters. Sami population estimates may be far less than true population counts. For example, based on
numbers from several register data, there are about 40,000-50,000 Sami in Sweden alone.
118
The Sami are the indigenous peoples living in the Nordic countries and they reside in the northern
regions of Fennoscandia in what today comprises the northern areas of Norway, Sweden, Finland
110
P. M. D. Bjerregaard and Young, 2008, pp. 3-17.
111
Marrone, 2007, p. 189.
112
K. Young, 2008, p. 27.
113
K. Young, 2008.
114
T. K. Young, Rawat, and Dallmann, 2012, p. 27.
115
Slaastad, 2012, pp. 3-78.
116
Ketil Lenert Hansen, 2011, pp. 19-22.
117
Slaastad, 2012, pp. 3-78.
118
Sven Hassler, Sjölander and Ericsson, 2004, pp. 384-388.
062 ξ Chapter 3
State of the World’s Indigenous Peoples
and Russia’s Kola Peninsula, as depicted on Map 1.
119
They belong to the Finno-Ugric language
group. The Sami language consists of several dialects and distinct written languages.
The Kildin (Kola) Sami population was 1,991 persons in the 2002 Russian Census, 89 per cent of
whom resided in Murmansk Oblast. According to the 2002 Census, about 38 per cent of Sami live
in towns and cities, a higher proportion than the average 28 per cent for indigenous peoples of
northern Russia. The number of Sami over the age of 60 years has reduced sharply as a result of
high mortality rate particularly among Sami males. A low birth rate and a high death rate among
the Kola Sami may lead to a sharp population decline in the near future.
120
Map 1: Greenland and Sápmi. Home of the Sami, stretches over four countries: Norway, Sweden,
Finland and Russia’s Kola Peninsula. Sami flags are superimposed over the regions where Sami
live.
Illustration: Ketil Lenert Hansen.
119
Kulonen, Pulkkinen and Seurujärvi-Kari, 2005.
120
Kozlov in P. M. D. Bjerregaard and Young, 2008, pp. 163-165.
Chapter 3 ξ 063
Indigenous Peoples’ access to Health Services
The Beginnings of political transformation for Sami peoples
During the last three decades, Sami society has undergone an ethnic and cultural revival.
121
Their po-
litical situation has also improved. In Norway, Sweden and Finland the Sami have been recognized
as the original inhabitants of northern Scandinavia.
122
However, it is only the Norwegian Govern-
ment that has ratified the ILO-Convention No. 169 in recognition of the Sami as indigenous peoples.
The National Sami Parliament has been established in each of the three countries.
123
However, these
parliaments often do not have the strength, national legislative authority and social structures of
an extensive bureaucracy to adequately articulate the international rights and needs of the Sami.
124
Sami are engaged in a variety of livelihoods, including farming, fishing, trapping and sheep and
reindeer breeding and herding. Although considered as “traditional” and a cultural marker of the
Sami, reindeer herding was of relatively recent vintage, developed during the sixteenth century.
In both Norway and Sweden, but not in Finland; semi-nomadic reindeer herding is, by law, an
occupation strictly reserved for the Sami. Data from 2009 found that only a minority (3,010 in-
dividuals) of the Sami in Norway; were actively engaged in reindeer herding with slightly more
men than women.
125
Many Sami live in the large urban cities, especially: Tromsø, Umeå, Rovaniemi,
Stockholm and Oslo, and are involved in all the modern professions, occupations, and trades.
126
Today the challenges facing the Sami peoples consists of conserving traditional knowledge, val-
ues and culture traits, while adapting to the local communities and indeed a world that continues
to change. Many Sami people find themselves in a transitional state where it is important to adapt
to a changing new world without losing sight of the values of the Sami traditional world view.
127
In Greenland, about 90 per cent of the population is Inuit and the remainder are mainly Danish.
128
The 17 small towns and 60 villages in the country are isolated from one another and can be reached
only by boat or plane. The majority of the approximately 56,000 inhabitants live on the south
and central west coast. The largest town is the capital, called Nuuk, which has 15,000 inhabitants.
Around 20 per cent of the population lives in villages with between 300 and 500 inhabitants.
The Inuit culture is distinct, although influenced by relations with Danish, European and other
cultures and societies around the globe. Language and diet are central markers of Greenlandic
culture. A majority of the population speaks Kalaallisut (West Greenlandic), which has led to its
status as the ocial “Greenlandic” language. Hunting and fishing have always been an important
aspect of the Greenland Inuit culture, and most Greenlanders still hunt at least part-time to sup-
plement their diet. Today, local food makes up approximately 20 per cent of the diets; the spec-
trum of food items is much narrower, usually consisting of meat and blubber of marine mammals
(seals in particular), birds, fish, caribou and musk.
129
Greenland’s economy since World War Two
121
P. Pedersen, Høgmo and Solbakk, 2012.
122
Kulonen, et al., 2005.
123
Sjolander, 2011, pp. 1-2.
124
Sjolander, 2011, p. 2.
125
Slaastad, 2012.
126
P. Pedersen, et al., 2012.
127
P. M. D. Bjerregaard and Young, 2008, p. 15.
128
Niclasen and Mulvad, 2010.
129
P. M. D. Bjerregaard and Young, 2008, p. 30.
064 ξ Chapter 3
State of the World’s Indigenous Peoples
has increasingly become dependent upon commercial fishing, which represents 90 per cent of the
region’s export income. The economy is however dependent upon subsidies from Denmark which
amounts to approximately 50 per cent of public spending in Greenland.
130
The influence of colonialism
The Sami people in Sápmi and the Inuit in Greenland have a common history with colonization.
Greenlandic social anthropologist Aviâja Egede Lynge has stated: “We have always been taught
that we were one of the best colonies in the world. No slavery, no killing … so why, then should
we have had a reason to de-colonize? And why should we have a reason to ask questions about
250 years of colonial presence?”
131
Today, Greenland has achieved greater self-determination with
the home rule, however, Greenlanders still feel ruled by Denmark. Despite the fact that the mem-
bers of the home rule government are native Greenlanders, most leading positions are still in the
hands of the Danish population who have strong influences on decision-making processes.
In Norway, the process of assimilation, frequently referred to as “Norwegianization”, lasted from
1850 to approximately 1980. According to the Land Act of 1902, property could be transferred
only to Norwegian citizens (i.e., persons able to speak, read and write Norwegian), and proficiency
in the Norwegian language continued to be a criterion for buying or leasing state land until the
1940s. For almost a century, the Sami language was prohibited in Norwegian schools, from 1860
to 1959. Residential schools were important arenas for the assimilation of Sami children into the
dominant cultures assisted by individual experiences of stigmatization and discrimination.
132
Although the overt policies of assimilation may be a thing of the past in terms of Nordic society
and politics, the negative consequences have been projected into the present and, indeed, will in-
form relations in the future. It takes time to fundamentally change general frameworks in politics,
legislation and ordinances, as well as myths and attitudes, to appropriately redress and reclaim
Sami culture, language, traditions and social needs; including equitable access to health care,
education and employment and other determinants of health. Many people remain influenced by
past assimilation policies despite the ocial legislation and policies having been reversed. Sim-
ply put, “being dierent” is often the source of discrimination and harassment, and, as a minority
population, the Samis and Inuit are particularly vulnerable. Studies conducted abroad reveal dis-
crimination against indigenous peoples tends to be closely associated with health issues. Dis-
crimination has been found to be associated with negative mental and physical health outcomes,
negative health behaviours and increased mortality.
133
Centuries of colonial contact have irrevo-
cably damaged the cultural traditions and practicesof indigenous Sami and Inuitpopulations,
and have also had a lasting, negative impact on generations of Sami and Inuit youth.
130
Niclasen and Mulvad, 2010, p. 438.
131
Lynge, 2006. http://www.rethinking-nordic-colonialism.org/files/pdf/ACT2/ESSAYS/Lynge.pdf.
132
Minde, 2005, p. 6.
133
Williams and Mohammed, 2009, pp. 20-47.
Chapter 3 ξ 065
Indigenous Peoples’ access to Health Services
The right to health care for indigenous peoples
Everyone has the right to access health facilities, goods and services without discrimination.
134
This means non-discrimination both in access to health care and in enjoyment of the underlying
determinates of health. One key contextual barrier for indigenous peoples to access health care is
the continuing impact of colonization. Even though the health status of indigenous peoples has
improved in the last decades, significant health disparities continue to exist, for example, increas-
ing rates of diabetes, cardiovascular diseases and cancers among the Inuit in Greenland.
135
In countries where indigenous peoples were significantly impacted by colonization, it is import-
ant to understand the cultural and biological consequences of colonization and how these have
aected the health status of indigenous peoples historically and currently.
136
One possible way
to approach this issue is to investigate present dierences in health care access and utilization
between the indigenous peoples and the majority populations. This may assist in the eort to
understand how ethnic, cultural and racial factors influence access and utilization. Specifically,
this could be a way to study barriers to health care such as communication, cultural sensitivity,
socioeconomic status, trust in the health care system and the level of satisfaction by the indige-
nous peoples who use the services.
Health status of Sami peoples
Past research on Sami peoples’ health has revealed a uniquely positive situation compared to
other indigenous peoples of the circumpolar regions of Greenland and Arctic Russia.
137
Life ex-
pectancy and mortality rates of the Norwegian and Swedish Sami and their non-Sami neigh-
bours were quite similar.
138
Many of the health problems that indigenous peoples in the cir-
cumpolar region and elsewhere face are not as prevalent among the Sami, such as dramatic
elevated risk for diabetes, cardiovascular disease, lung cancer and various infectious diseases.
There are generally small dierences in risk for the major diseases and causes of death.
139
At
the same time, the knowledge of the health conditions of the Sami is not available, particularly
regarding the condition of Russian Sami. However, the situation has improved over the last few
years. An increasing number of articles on Sami health have been published in the Scandinavian
countries, particularly in Norway and Sweden where a number of specific health problems have
been identified. For example, among the Swedish reindeer-herding men a significantly higher
risk of fatal accidents, work-related stress and suicide have been identified.
140
The increased risk
of suicide among Sami men is also found in Norway and Finland.
141
The health problems of the
Sami peoples are thought to be associated with discrimination and marginalization and lack
of knowledge of the Sami identity and culture.
142
Several studies consider discrimination as an
134
ICESCR and International Convention on the Elimination of all forms of Racial Discrimination, ICERD, Article 5.e. iv.
135
P. M. D. Bjerregaard and Young, 2008, pp. 31-34.
136
Marrone, 2007, p. 189.
137
Ketil Lenert Hansen, 2011, p. 54.
138
Brustad, Pettersen, Melhus and Lund, 2009; S. Hassler, Johansson, Sjolander, Gronberg and Damber, 2005.
139
Hassler in P. M. D. Bjerregaard and Young, 2008, pp. 158-161.
140
S. Hassler, et al., 2005; Kaiser, Sjolander, Liljegren, Jacobsson and Renberg, 2010.
141
Silviken, Haldorsen and Kvernmo, 2006; Soininen and Pukkola, 2008.
142
Sjolander, 2011, p. 9.
066 ξ Chapter 3
State of the World’s Indigenous Peoples
important risk factor for poor health. The Sami people in Scandinavia, as the Inuit in Greenland,
have a long history of suering discrimination and racism. A large proportion of Norwegian Sami
peoples experience discrimination based on their background.
143
There are also similar findings
among the Sami youth in the Nordic countries.
144
Furthermore, the results demonstrate that dis-
crimination is associated with inferior self-perceived health and psychological distress,
145
which
is supported by several other studies across multiple population groups in a wide range of
cultural and national contexts,
146
including indigenous communities in the circumpolar north.
147
These findings suggest that perceived discrimination is an important emerging risk factor lead-
ing to negative health outcomes.
Among the most vulnerable groups in Russia are the indigenous peoples. There is no unified sys-
tem of health monitoring of indigenous peoples, although some general trends show significantly
lower than average health outcomes compared the majority Russian population. According to
the 2002 Census the average life expectancy of Russian indigenous peoples was 15 years below
the Russian average.
148
Among the Sami in Russia, smoking and alcohol use are very common.
In a survey of 15-to 18-year-old Sami in Lovozero in the Kola Peninsula, 59 per cent identified as
regular or episodic smokers. Girls tended to smoke more heavily than boys. Alcohol consumption
in Murmansk Oblast was among the worst in Russia. A survey found that half of Sami teens,
ages 15 to 18 years old, reported having used alcohol.
149
Studies demonstrate that alcohol abuse
in the Russian north is linked to a range of social and economic factors.
150
Also the isolation of
the parents from their children, who are away at boarding schools, and the stressful, eect of
“modernization” are among the factors that often lead to alcohol dependency. The steady growth
of suicides and violent behaviour among the indigenous peoples in the Russian north is another
alarming trend. Suicide rates are up to four times the Russian average. Also a significantly higher
level of emotional distress and psychological tension are found in indigenous children, and the
prevalence of these conditions is increasing.
151
Health status in the Inuit population in Greenland
Life expectancy in Greenland at the beginning of the twenty-first century was at the level of
countries like India, Mongolia and Russia. Suicide and tobacco-related diseases are the main rea-
sons for the low life expectancy in Greenland.
152
Infant mortality was around 10 per 1,000 in 2000-
2004, compared to 4.2 per 1,000 in Norway in 2004.
The causes of mortality and morbidity in Greenland are all higher than Denmark and other Nordic
countries. This includes a high infant mortality rate, high death rate due to unnatural causes, like
143
Ketil Lenert Hansen, 2011; K. L. Hansen, Melhus, Hogmo and Lund, 2008.
144
Omma, 2013; Turi, 2011.
145
K. L. Hansen, Melhus and Lund, 2010; K. L. Hansen and Sorlie, 2012.
146
Williams and Mohammed, 2009.
147
P. M. D. Bjerregaard and Young, 2008.
148
MRG, 2013, p. 186.
149
Kozlov in P. M. D. Bjerregaard and Young, 2008, p. 162.
150
P. M. D. Bjerregaard and Young, 2008, pp. 95-99.
151
MRG), 2013, pp. 188-189.
152
Bjerregaard and Stensgaard 2008 Greenland in P. M. D. Bjerregaard and Young, 2008, pp. 31-34.
Chapter 3 ξ 067
Indigenous Peoples’ access to Health Services
suicides and accidents, which result in the life expectancy to be lower. Greenland has an increas-
ing rate of diabetes, infectious disease and cardiovascular diseases and cancer, due to smoking
and other lifestyle factors. Other health challenges are child abuse, abortion, violence, sexually
transmitted diseases, substance abuse, low oral health, stressors of mental health and the eects
of contamination of the traditional diet.
153
“Greenland experienced a major health transition during the twentieth century and especially
during the latter half of the century. In 1950, mortality was high and the main causes of death
were tuberculosis and acute infectious diseases, During the 1950s, the importance of these
diseases as causes of death diminished sharply and total mortality decreased. However, as
mortality from infections, heart diseases and accidents continued to decrease, new causes of
death gained importance, particularly cancer and suicide”.
Health care organization, expenditures and financing—a comparison between Norway,
Sweden, Finland, Greenland and Russia
Norway, Sweden, Greenland and Finland generally have very similar health care systems. The Nor-
dic model is characterized by significant decentralization, down to the municipality level, with a
high degree of both political and fiscal autonomy, and largely free health care has been in place
for decades.
Norway, Sweden, Greenland and Finland are similar in their sources of health care financing,
which entails taxation from dierent levels of government, grants from the central government,
health insurance funded by employer and employee contributions, and user charges for specific
services. A private sector exists, accounting for about 15 per cent in Norway and Sweden and 25
per cent in Finland.
154
In Norway, the delivery of primary health care and public health services is the responsibility
of municipalities, whereas “specialized health services” (including general and psychiatric hospi-
tals, ambulances, substance abuse treatment and patient transportation) are provide by regional
health authorities. The Swedish system diers slightly from this model in that municipalities are
responsible for long-term care and home care only, whereas public health, hospitals and primary
care are the responsibility of 18 county councils.
Northern-Finnish patients have limited access to health care services in circumpolar areas across
the Nordic countries for two reasons. First, health professionals in Norway and Sweden do not
speak Finnish, which presents a language barrier. Second, the Social Insurance Institution of Fin-
land does not cover the expenditures of travel or the costs of medicine. In addition, it seems
that in circumpolar areas, the density of Finnish service providers is greater than Swedish ones,
causing many Swedish citizens to transfer to Finnish health care providers every year.
155
However,
153
P. M. D. Bjerregaard and Young, 2008, p. 33.
154
T. K. Young, et al., 2012, pp. 158-161.
155
Vuori, et al., 2010, pp. 512-514.
068 ξ Chapter 3
State of the World’s Indigenous Peoples
studies have found that long distances to medical care or Sami ethnicity have no influence on the
cancer patient survival in Northern Finland.
156
The Greenland government has a separate and independent health care system from that of Den-
mark, although much of the bureaucracy is staed by Danish people. The Ministry of Health (De-
partementet for Sundhed/Peqqissutsimut Naalakkersuisoqarfik) has overall responsibility for all
health services, from the operation of the tertiary care Queen Ingrid Hospital in Nuuk to health
centres and rural hospitals in towns and villages. Greenland is organized into 16 health districts.
Danish is the dominant language spoken because a large proportion of the medical sta is re-
cruited from Denmark.
Since the 1990s, health reforms in Russia have focused on financing and decentralization. The
regions are key players in health care provision and the impact of reform varies widely across the
country. The remoteness and small size of indigenous settlements aects access to, and the ex-
pense of medical care. All indigenous peoples of Russia are entitled to free medical care coverage,
which includes a compulsory annual check-up at state and municipal health care facilities. Yet
federal and regional health care programs do not always provide medical brigades to visit remote
areas. Medical personnel often lack modern, mobile equipment that allows them to go out and
examine indigenous peoples in remote settlements, such as reindeer herding camps. Nomadic
reindeer herding is the traditional livelihood of many indigenous peoples in the Russian north.
Working with indigenous peoples out in the tundra is complicated due to the practical diculties
of carrying out examinations in the constantly moving reindeer herding camps, as well as di-
culties with controlling the prescribed treatment. Poorly equipped health care facilities and lack
of investment means that it is extremely dicult to retain medical sta and attract specialists to
come and work in rural hospitals.
157
A major challenge in international comparison of health care systems is that dierent countries
have dierent health care systems with dierent financial management practices. However, a ba-
sic measure in the international comparison of health care systems is health care expenditures. It
provides a glimpse of the health care resources available to, and used by the various health care
agencies. Conversely, there is international agreement on the inclusion criteria and classification
of types of expenditures in the form of the System of Health Accounts (SHA) developed by the
organization for Economic Cooperation and Development (OECD).
158
,
159
The Nordic countries, all
have similar levels of per capita health expenditures, with health care accounting for 8-10 per cent
of GDP.
160
In Russia, health care expenditure accounts for 5 per cent of GDP, while in the Komi Re-
public, the per capita expenditures are 15 per cent higher than the national average. In northern
Norway, the per capita expenditures are 25-30 per cent higher than the national average, whereas
in northern Sweden and Finland the dierence is less than 10 per cent. Greenland reports a lower
level of per capita health expenditure than Denmark, the only instance where expenditures in the
north are lower than in the south.
156
Soininen and Pukkola, 2008, p. 33.
157
MRG), 2013, pp. 186-188.
158
Further details are available from the SHA manual. Available from: http://www.oecd.org/health/healthdata.
159
T. Kue Young (2008) Circumpolar Health Indicators: Sources, Data and Maps. Supplements 3. International Journal of
Circumpolar Health. pp. 115-126.
160
OECD health Data from 2 periodes; 2000-2004 and 2005-2007 and Russian data from WHO.
Chapter 3 ξ 069
Indigenous Peoples’ access to Health Services
Hospital and primary care
Hospital services are core to any health care system. A variety of hospitals are located in the cir-
cumpolar regions, from highly specialized ones such as the university hospitals in Tromsø, Umeå
and Oulu, to small ones in the remote towns of Greenland. The rate of hospital beds per 100,000
is the most commonly available indicator, which is more or less comparable across dierent ju-
risdiction.
161
In northern Norway there were 337 hospital beds per 100,000. The same numbers for
Northern Sweden were 308, Finland 226, Greenland 185 (Nuuk), and Komi Republic 977.40 The
Russian region have the highest bed availability, with around 1,000 hospital beds per 100,000.
162
Use of health care in the main Sami areas of Norway
In 2011 a study investigating the current health expenditures in somatic hospital and specialist
service in the Sami municipalities found that “the overall public hospital expenditure rate in Sami
municipalities is above the national average and equivalent to corresponding municipalities in
the same geographical area. However, there was a considerable variation among the Sami mu-
nicipalities. The age groups 35-49 and 50-64 in all Sami municipalities have higher expenditure
rates than the national average regarding outpatient contacts and hospitalizations, while the
expenditure rate on the elderly (80 years or older) is below the national average in most Sami mu-
nicipalities”.
163
However, this study did not indicate how the Sami patients experience the quality
of care in the patient-physician relationship.
Health care delivery for the Sami peoples
The Norwegian government was the very first State to ratify the United Nations International
Labour Organization (ILO) Convention No. 169 on the rights of indigenous peoples in 1990 (Swe-
den and Finland have not ratified this Convention), which further strengthened the rights of the
Norwegian Sami. Today the Sami have their own jurisdiction area where Sami and Norwegian lan-
guages are granted equal status as ocial languages. The Sami peoples of Norway have the legal
right to all public services in their own language, including health services.
Sweden recognized the Sami as indigenous peoples in 1977.
164
As such, the Sami enjoy special pro-
tection and are granted innate rights pertaining to cultural and linguistic rights, protected under
Swedish law, as well as through international conventions and declarations. However, has thus far
refrained from ratifying ILO Convention No. 169 on the rights of indigenous peoples.
165
Better health care service for Sami people has been raised on the political and health professional
agenda for many years and from numerous sides. Health care, with dierences in health gradients
between the northernmost county of Norway (Finnmark), where many Sami live, and the
counties farther south in Norway, government actions has been implemented since the 1960s to
161
T. K. Young, et al., 2012, pp. 161-163.
162
K. Young, 2008, p. 123.
163
M. Gaski, Melhus, Deraas and Forde, 2011, pp. 8-9.
164
Swedish Government, 1999, p. 16.
165
Swedish Government, 1999.
070 ξ Chapter 3
State of the World’s Indigenous Peoples
strengthen the Sami peoples.
166
Since 1980, problems of underutilization of health services and
communication between health workers and Sami patients were brought into focus, and the result
was that the first outpatient psychiatric clinic was funded in the Sami core area of Karasjok with
Sami-speaking therapists. Several years later, an outpatient clinic with Sami clinicians provided
services in internal medicine, rheumatology, and other specialties.
In 2002, the Sami Centre for Mental Health (SANKS) was established. It is a multi-professional
training centre for Sami mental health workers, and many of the therapists are Sami speaking.
SANKS oers psychiatric treatment and assessment to patients in addition to counselling,
teaching and research.
167
Treatment modalities include various outpatient treatments as well
as treatment at psychiatric wards for adult, youth and families. Due to long distance between
Sami municipalities, small branches have been established in some other regions, where the Sami
people reside and telecommunications is frequently used.
168
“Norway is the only country that has a specific Sami focus on public health for the Sami pop-
ulation, acknowledging the need for culturally and linguistically adapted health services. Al-
though health and social services for the Sami had been established in the 1980s, the first
national plan for health and social services for the Sami population was made in 1995 (NOU
1995: 6 Plan for helse- og sosialtjenester til den samiske befolkning i Norge). Where the Swed-
ish and Finnish health care system and public health policies are concerned, the Sami seem to
be nothing less than fully assimilated. A main reason that Norway is a leading country can be
explain by the considerable number of Sami health and social services workers compared with
the other Nordic countries who advocated for an ethnic-specific health service.”
169
However, many Sami peoples claim that the Norwegian health services do not ensure the needs of
Sami patients.
170
Also, it is likely that the issue of health services is similar and even worse in the
other Nordic countries. While some studies have been conducted,
171
the existence of health ser-
vices research particularly investigating health care utilization among Sami in Norway, Sweden,
Finland and Russia need more attention.
172
Patient satisfaction
Health care systems are designed to serve consumers (users, clients, patients). Part of the as-
sessment of the quality of services provided is the level of satisfaction by those who have used
the services. There are some studies of Sami patients and their providers. In a study by Turi et al.
(2009)
173
there is an attempt to measure the frequency in the use of health services. In the study
166
Margrete Gaski, 2011.
167
www.sanks.no.
168
Baarnhielm, Javo and Mosko, 2013, pp. 40-55.
169
Hassler, Kvernmo and Kozlov in P. M. D. Bjerregaard and Young, 2008, pp. 166-167.
170
Norge Sosial- og helsedepartementet, 1999.
171
Margrete Gaski, 2011; Lund et al., 2007; Turi, 2011.
172
P.M.D. Bjerregaard and Young, 2008, pp. 166-167.
173
Turi, 2011, pp. 1-10.
Chapter 3 ξ 071
Indigenous Peoples’ access to Health Services
of Sami adolescents (15-16 years old) and their non-indigenous peers it was found that Sami
and non-Sami youth use health services with equal frequency. In another study of mental health
care,
174
Sami patients showed less satisfaction with all investigated treatment parameters than
their Norwegian peers, including contact with sta and treatment alliance. In another study by
Nystad et al. (2008),
175
Sami-speaking patients expressed that they are less satisfied with the mu-
nicipality general practitioner service than the Norwegian speakers and that misunderstandings
between physician and patient due to language barriers were more frequent.
Sami children and adolescents
In the Nordic countries today, Sami youth come of age in a society in which their personal values,
culture and language have a completely dierent status compared to the conditions under which
their parents were raised. Young people who are proficient in the Sami language and culture enjoy
a more liberated and less politicized definition of “Saminess” than did the preceding generation.
Many adolescent Sami express a complex identity including Norwegian, Swedish or Finnish and
Sami culture and language; some identify themselves with another ethnicity as well. Many of the
younger Sami are from families where their parents’ and grandparents’ generations were the tar-
gets of force assimilation policies. This experience has encouraged discussion between the Sami
generations, particular when individuals of similar backgrounds choose dierent solutions in or-
der to form their identity. A recent report published by the Nordic Ombudsmen for Children
176
in-
dicated that Sami children are still bullied due to their ethnicity. However, most of them are proud
of their Sami identity. At the same time, it is often dicult for some Sami children and adolescents
to be honest about their Sami background. There is a need to place more focus on discrimination,
health and well-being of Sami children and adolescents, to understand how colonization and
Sami identity interact to influence health care access and utilization by Sami peoples.
Elderly Sami health and well-being
Today many elderly Sami, especially outside the defined Sami core areas, have lived their lives in
a world of tension trying to strike a balance between assimilation, revitalization, and ambiguity,
when it comes to their Sami identity and culture. Considering the history of assimilation, stig-
matization, and discrimination, it seems reasonable to assume that a Sami heritage contested
throughout a lifespan might have a significance impact on health and well-being in old age.
177
Postcolonial theory provides a framework for understanding how indigenous peoples’ health is
closely related to historical, social, political, and economic factors and forces. There seems to be a
wide consensus regarding the significance of cultural competence in interactions between health
care providers and indigenous patients. Theories on cultural competence ask for “culturally based
care knowledge, acts, and decisions used in sensitive and knowledgeable ways to appropriately
and meaningfully fit the cultural values, beliefs, and lifeways of clients”.
178
Eorts are made to
find cultural-specific features of the Sami experience of well-being to develop appropriate and
174
Sorlie and Nergard, 2005, pp. 304-310.
175
Nystad, Melhus and Lund, 2008.
176
In Norwegian, Barneombudene i Norden, 2008.
177
Blix, Hamran and Normann, 2013, pp. 264-265.
178
Leininger and McFarland, 2006, p. 15.
072 ξ Chapter 3
State of the World’s Indigenous Peoples
culturally safe social and health care services.
179
Traditional Sami cultural aspects, such as Sami
language, traditional Sami foods, spirituality and way of life, are important aspects that are being
emphasized in the care of elderly Sami, especially those suering from dementia.
There has been very little attention paid to the needs of elderly Sami peoples in the health care
system and this area requires strengthening in the future, especially when it comes to cultural-
specific features in health care services. The development of cultural competent standards of care
for health providers is a necessary pre-condition to achieve this goal.
Use of traditional medicine
Integrating traditional healing within health services for indigenous peoples has currently taken
on a much stronger focus. Traditional healing is a part of traditional knowledge among indigenous
peoples. Knowledge traditions and world views constitute the context for the health care system
of a society. In recent studies in the Arctic region it was found that the therapist showed little
awareness of their client’s use of traditional healers. While over a third of the Sami clients had
used traditional healers in relation to their current health problems, less than half reported that
this was given any consideration during the hospital stays.
180
Other studies found that some Sami users were giving greater importance to religion and spiri-
tuality and were less satisfied with the public psychiatric services than those Sami patients who
had not used traditional or complementary treatments. Studies suggest that dierent aspects
of traditional healing within the health services to the Sami community should be given greater
consideration.
181
It is likely that the issues regarding the use of traditional medicine is similar and relevant to cir-
cumstances among the indigenous peoples in the other Nordic countries and among the Inuit in
Greenland, but this is an area that needs to be a higher priority area for health services research.
Health status and health care delivery in Greenland
Greenland is a Danish colony, and in the last few decades, the home rule government has been
given extensive powers to govern. The future goal is to attain full independence. The conditions
for health care in Greenland dier in a number of ways from the Sami in the Nordic countries, be-
cause of geographic and climatic conditions. The health care system is obligated to deliver equal
care to all citizens regardless of their place of residence. This requires a large number of small,
cost-eective health centres capable of providing acute care because the expenses for transport
of patients and sta are very high.
182
Due to their small size and isolation, towns and villages in
Greenland often need to be self-sucient and are very vulnerable to external factors.
183
No pri-
vate providers of health care services exist in Greenland, but private dental care, physiotherapy,
psychotherapy and treatment for alcohol and drug abuse are available in Nuuk.
179
Tervo, Muller-Wille and Nikkonen, 2003, p. 120.
180
Sorlie and Nergard, 2005.
181
Sexton and Sorlie, 2008, pp. 135-146.
182
Bjerregaard and Stensgaard 2008 Greenland in P. M. D. Bjerregaard and Young, 2008, pp. 34-37.
183
Niclasen and Mulvad, 2010, p. 438.
Chapter 3 ξ 073
Indigenous Peoples’ access to Health Services
In the last 50 years, Greenland as well as other indigenous societies in the circumpolar regions has
undergone rapid social, environmental and economic changes, which have influenced all aspects
of their life, impacting on living conditions and health care. In the past, perinatal complications,
acute and chronic infectious diseases and injuries dominated as the leading causes of morbidi-
ty.
184
Recently, chronic and lifestyle diseases and disabilities dominate morbidity concerns despite
the fact that the “old” diseases have not decreased to the same low levels found in Western coun-
tries. Furthermore, the burden of poor health related to social conditions does not appear to be
decreasing.
185
Specific health care access study shows that 83 per cent of the population in Greenland had been
in contact with a primary health care centre within the last year (2011). Females were more frequent
users than males. Personal contact was the most frequent type of consultation (75.8 per cent),
followed by telephone (14.8 per cent) and e-mail (9.8 per cent) consultations. Musculoskeletal
symptoms accounted for the most frequent basis for diagnoses.
186
Self-rated health (SRH) is a relevant variable in primary health care and in general public health
assessments and monitoring. In a recent study with Inuit and Sami youth from Norway, poor SRH
was reported to be three times higher among Inuit than Sami. A cause of great concern is that In-
uit female youth were reported with the poorest SRH. Suicidal thoughts and risk were associated
with poor SRH.
187
Another study shows that aggregate acculturation
188
is a strong risk factor for
substandard SRH among the Inuit of Greenland.
189
Mental problems are thus increased in parallel with the societal change and development. The
suicide rate in Greenland, especially among men, is among the highest in the world. The highest
incidence is found among males aged 15-24 years. The highest suicide rate is in the capital, Nuuk,
and in Eastern Greenland. However, the incidence of attempted suicide using medicine was high in
the Nuuk, especially among females. The highest incidence of suicide attempts using medication
was observed among females in the age group 15-19 years, who, as mentioned earlier, had the
lowest self-rated health. Together this reflects considerable risk and psychosocial vulnerability
among young people in Greenland.
190
Today, a major threat to the Greenlandic health care system is the lack of sta on all professional
levels and their rapid turnover, especially for the small towns and remote villages.
191
This reduc-
es health care in several ways, “especially to continuity in care, the surveillance of health and
services and preventive or health promotion eorts”. In 2007 the first public health program in
Greenland, Inuuneritta (“let us have a good life) was proposed. The goal of the program is to meet
184
P. M. D. Bjerregaard and Young, 2008, pp. 15-16.
185
Niclasen and Mulvad, 2010, pp. 439-440.
186
M. L. Pedersen, Rolskov, Jacobsen and Lynge, 2012, p. 1.
187
Spein et al., 2013, p. 1.
188
Acculturation for indigenous peoples is related to the process of colonization over centuries as well as the ongoing
social transition experienced in the Arctic today. Changing living conditions and lifestyle aect health in numerous
ways in Arctic indigenous peoples.
189
Eliassen, Braaten, Melhus, Hansen and Broderstad, 2012, pp. 4-6.
190
Bloch, Drachmann and Pedersen, 2013, pp. 2-3.
191
Niclasen and Mulvad, 2010, p. 442.
074 ξ Chapter 3
State of the World’s Indigenous Peoples
the health challenges among the Inuit in Greenland. Inuuneritta focuses on diet, physical activity,
alcohol and drug abuse, smoking, violence and sexual health. It also includes programs on suicide
prevention, early interventions for the health and development of children and dental health.
192
In 2008, a new plan for reorganization of the health care system was proposed. Researchers
Niclasen and Mulvvad (2010) describe the important issues of the plan as follows:
“A fundamental component of the structural reorganization is tying all parts of the health
care system together through telemedicine and in the future with a joint electronic patient
file. The rapid epidemiological changes make surveillance and monitoring of health particu-
larly important, and data on core indicators of health and health care are urgently needed.
Furthermore, better steering instruments on resource allocation and quality, and securing
best clinical practice are areas where focus in the future is needed”.
In order to attract students, the nursing education has been extended to include a university-
based bachelor’s degree, and to meet the needs for high-quality health care in the small villages,
a specialized training program to qualify nurses to work without direct supervision by a medical
doctor is planned. Also medical doctors are oered a one-year specialization in Arctic health, for
working in the rural areas in Greenland.
Giving birth in Greenland
In 2001-2003, new policies and guidelines for pregnancy and childbearing were introduced, which
led to an increase in the proportion of deliveries at the Queen Ingrid´s Hospital in Nuuk. However,
these changes were met with some public criticism.
193
The guidelines for transfer and visitation were
set into motion in 2002, and females are referred for birth either in their own community or, in the
case of at-risk pregnancy, sent to the national referral hospital during the last trimester. However,
the new national health policy (2009) not only transfers females in the case of at risk pregnancy, but
also consolidates low-risk pregnancies in clusters at regional hospitals. It is estimated that 40-50
per cent of the pregnant females will be transferred out of their local communities during the last
two to four weeks of pregnancy and then come back one to two weeks after birth.
194
Inuit childbirth is the women’s own personal act, and the unborn child is a living part of
the community. …in other indigenous cultures where birth is not only considered a personal
event, but is also one of the ways that the child and family are linked to the community.
195
The new policies and guidelines for pregnancy have changed the focus on birth as a personal and
community act to birth within the private and political arena. Between 1953 and 1992 women in
Greenland gave birth in their local communities and as late as 2000, it was still uncommon for
women to leave their communities to give birth. Females often feel isolated when they have to
go to the larger cities, where hospital nurses and doctors do not speak Greenlandic. Greenlandic
perinatal policy did not include economic support for women desiring to have family with them
192
Niclasen and Mulvad, 2010, p. 443.
193
P. Bjerregaard and Olesen, 2010, pp. 480-485.
194
R. Montgomery-Andersen, Douglas and Borup, 2013, p. 80.
195
R. Montgomery-Andersen, et al., 2013, p. 80.
Chapter 3 ξ 075
Indigenous Peoples’ access to Health Services
when they were transferred for birth; this was up to the individual families.
196
In a country with
its own unique culture and cultural norms, it is important that when changing policy that women
and their families are a part of the dialogue around change. This has not happened in Greenland,
because decisions regarding birth setting have been made by policymakers, health and govern-
ment ocials and were fashioned after the Danish system, where the Inuit females and families
themselves were often not a part of the dialogue.
Gender-based violence among Inuit in Greenland
In the international literature, Gender Based Violence (GBV) is applied to a broad range of relat-
ed life events. The World Health Organization (WHO) defines violence as a health problem. “The
intentional use of physical force or power, threatened or actual, against oneself, another person,
or against a group or community that either result in or has a high likelihood of resulting in injury,
death, psychological harm, mal development, or deprivation”.
197
Violence as a public health problem
has traditionally focused on violence that occurs in public space and assessed as a cause of injuries.
The more recent definition stated above, broadens the potential harmful eect to include not only
physical injuries. The United Nations definition is often applied when addressing the specific form
of violence which women are subjected to: “Any act of gender-based violence that result in, or is
likely to result in, physical, sexual or psychological harm or suering to women, including threats of
such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or private life”.
198
Few studies have been written by indigenous peoples in the Arctic region. One study has com-
pared reported violence in Greenland and Denmark, where a health survey addressed the same
questions to both women and men. The overall prevalence of reported violence was higher in
Greenland than Denmark and the gender focuses of violence diered. In Greenland, women re-
ported the same high level of severe violence as men, whereas in Denmark the men reported
violence, rather than women. However, the types of violence reported by women in Greenland
diered from the types reported by men, as women were more often sexually abused and abused
as children. To date, no studies have been undertaken that have addressed gender-based vio-
lence among Sami peoples. However, a recent study began in Norway on Gender-Based Violence,
Ethnicity and Mental Health. There is also a subproject in the Population-based Study on Health
and Living Conditions in Areas with Mixed Sami and Norwegian Settlements, titled the SAMINOR
Questionnaire Study.
199
It is known that the elderly in northern Norway (where most Sami reside)
are more likely to be exposed to family violence than seniors in general, living in South Norway.
200
Linguistic barriers in health care setting
Eective communication between a patient and the provider is paramount in a health care set-
ting. Therefore, language barriers present a formidable obstacle to accessing adequate health
care. Language dierences have been shown to be a serious barrier among various cultural and
196
R. A. Montgomery-Andersen, et al., 2010, p. 301.
197
Krug, 2002.
198
United Nations General Assembly Declaration on the Elimination of Violence Against Women, 1993.
199
http://uit.no/prosjekter/prosjekt?p_document_id=261008.
200
Sited from: http://www.nordlys.no/nyheter/article6915937.ece.
076 ξ Chapter 3
State of the World’s Indigenous Peoples
ethnic groups.
201
A study carried out in 1980 concluded that linguistic and cultural barriers pre-
vented Sami patients from going to the doctor, leading to an inferior health service for Sami
people.
202
In Norway (as well in Sweden and Finland) all municipalities and counties with Sami
peoples are responsible for solving language barriers associated with services, so that the basic
user rights can be met. Research indicates that Sami patients experience linguistic and cultural
barriers in the meeting with the health services.
203
For many Sami, it is important to be able to use
their mother tongue in conversations with their doctor, nurse, social worker and other health care
personnel. Language barriers can lead to inadequate health care and treatment for Sami patient.
Sami patients often do not receive health services in their own language, because only a few
health workers can speak Sami. Further, interpreter services are poorly developed in the rural Sami
areas. Many Samis are also reluctant to admit that they do not understand the majority language
or are in need of interpretation. Some Sami therefore fail to seek health care services, even when
they have significant care needs.
204
Surveys have indicated that there is severely limited use of
interpreters in health and child welfare services.
Today, children under school age and elderly Sami are completely monolingual in the Sami lan-
guage. At the same time, bilingual Sami have diculty communicating in Norwegian, especially
when they are seeking health care.
In the report titled “Discrimination of the Sami—the rights of the Sami from a discrimination per-
spective” (2008), by the Ombudsman against Ethnic Discrimination (DO) in Sweden, reported
that many Sami are met with discrimination and prejudice when they seek medical care for their
Sami-speaking children:
“In their contact with the DO, parents of Sami-speaking children describe that when they
seek medical care, they feel insulted by medical sta. Several parents have experienced sit-
uations where doctors, nurses and speech therapists have commented on the fact that the
child and his/her parent speak Sami with each other. Examples of such comments include
“Speak Swedish. We live in Sweden”. “Can the child only speak Sami?” and “When is this child
going to learn Swedish?” The perceived insinuation is that the child is not fully functional
because he or she speaks his/her mother’s tongue better than Swedish”.
205
Cultural barriers in health care settings
Indigenous peoples often hold dierent priorities and perception of health than their mainstream
majority peers. This can stem from traditional cultural or religious beliefs about health and
well-being, dierent customary practices around health care, or living in distinct locations with
unique health challenges. In order to achieve better equity in health outcomes, these dierent
viewpoints must be taken into consideration in policy development and service delivery.
206
201
Marrone, 2007, pp. 192-193.
202
Fugelli, 1991.
203
Nystad, et al., 2008, pp. 119-120.
204
NorwegianHealthAuthorities, 2009.
205
Pikkarainen and Brodin, 2008, p. 30.
206
MRG, 2013, p. 18.
Chapter 3 ξ 077
Indigenous Peoples’ access to Health Services
“In the discourse about health services for Sami patients in Norway the last few years, at-
tention is given to cases where the health services is accused of not taking care of the needs
of Sami patients. The system do not allow for neither language nor cross-cultural communi-
cation or the patients view of health”.
207
The lack of language and cultural understanding can lead to symptoms of disease being misinter-
preted and treatment not provided all of which can have serious consequences. There are indica-
tions that there is an underreporting of disease in the Sami community, particularly in relation to
somatic and mental health, medical care at birth and chronic diseases.
208
Dental health care and dental treatment
Dental health is an important aspect of general health and well-being for both children and
adults. In Norway, reports from the National Bureau of Statistics have consistently reported a
lower oral health status in the three northernmost counties, the worst being the northernmost
county (Finnmark), especially in some of the communities with a large proportion of indigenous
Sami population.
209
By oering free dental examinations, the scientists at the Arctic University of
Norway will be able find out why people in the Sami municipalities (in Finnmark) have lower oral
health than the national average.
210
In Greenland, dental carries burden is high in children compared to the other Nordic countries,
and the strengthening of oral health promotion and disease prevention is urgently needed.
211
In a
study by Koposova et al. (2013), dental prevalence was higher among the Russian children than
the Norwegian children.
212
Environmental factors aecting health for indigenous people
There have been concerns about pollutants in marine foods and reindeer meat; however, recent
research does not give any reason to believe that the consumption of marine foods and reindeer
meat presents a high health risk for the Sami and Inuit peoples.
213
Radioactive contamination
resulting from the Chernobyl accident in Russia has aected south-Sami peoples in central Nor-
way and Sweden. Radioactive exposure was largely food borne in reindeer because radioactive
pollutions from Chernobyl were carried by wind and spring rain patterns in high concentrations to
central Sweden and Norway. Most detrimental was the contamination of lichen, the main winter
staple of Scandinavia’s reindeer. Many reindeer had to be destroyed, because of high level of ra-
dioactive pollutions.
214
The Chernobyl accident has had a major impact on the psychosocial health
of the South Sami reindeer herds in Norway and Sweden. The Samis are still concerned about the
207
Margrete Gaski, 2011, p. 9.
208
NorwegianHealthAuthorities, 2009.
209
Adekoya, 2012, pp. 31-38.
210
http://uit.no/nyheter/artikkel?p_document_id=353106&p_dim=88108.
211
Petersen and Christensen, 2006, pp. 35-44.
212
Koposova et al., 2013, pp. 3-11.
213
Symon and Wilson, 2009.
214
Bloch, et al., 2013.
078 ξ Chapter 3
State of the World’s Indigenous Peoples
impact from the nuclear accident that may aect their health and future prospects for reindeer
husbandry.
215
The Sami and Inuit peoples in the Arctic are primarily exposed to pollutants through traditional
food and water, but also through the air. Pollutants are particularly a problem for indigenous
peoples, who mainly live on traditional diets. Although the largest emissions of pollutants do
not happen in the Nordic countries and in Greenland, the air currents which transport airborne
contaminants to the Arctic are particularly worrisome. Therefore, this is an issue for the Sami and
Inuit peoples. Long-range pollution seems to have shown a downward trend in recent years, but
local pollution from industries could be a problem for indigenous health and the environment.
216
Recently, in northern Sweden there has been a mining dispute where hundreds of Sami and other
activist have protested against iron mining plans in the Sami traditional reindeer herding lands
in Kallak. According to Swedish law, the Sami peoples cannot claim ownership of the land where
they have lived for nearly 9,000 years, but have the right to use it for herding. The mining dispute
has led to renewed calls for the government to adopt changes that recognize Sami ownership
rights over the land. “Legally, Sweden has a long way to go to take full responsibility for the Sami
people”, said Christina Allard, an associate professor at Lulea University. Sweden, unlike Norway
and many other countries has yet to sign legally binding international conventions that protect
the rights of indigenous peoples.
217
In the future, local pollution from new industries in the Arctic
area will have a major impact on the living conditions and psychosocial health of the indigenous
peoples living in the circumpolar areas.
Conclusion
The delivery of high-quality health care to indigenous peoples in the circumpolar areas poses
significant challenges. These include the need to develop culturally sensitive health services for
the indigenous Sami and the Inuit peoples taking into account language barriers, cross-cultural
misunderstandings and racial discrimination. The goal is for health and social services to be of the
same quality that is provided for the rest of the population. Entering into the health care system
(access to care) and receiving appropriate health care and for the services to be eective (quality
of care) are key factors in ensuring good health outcomes. Often the health and social services
practitioners are perceived as representatives of majority cultural values and norms that have,
throughout history oppressed indigenous peoples, resulting in a deeply felt mistrust of health
care institutions. Current health policies and practices favour western standardized health care
systems, where the voices of indigenous peoples are often absent. Circumpolar health care sys-
tems must take into account the influence of indigenous peoples’ view of health and well-being
and to develop specific interventions to increase access and utilization among indigenous peo-
ples. This requires health providers to critically reflect on whether policies and practices promote
or compromise indigenous health and well-being. Indigenous peoples should not be a passive
consumer of health care, but rather an active partner in the development of high quality of care,
that ensure good health outcomes for indigenous peoples in the circumpolar areas.
215
Sjolander, 2011.
216
Symon and Wilson, 2009.
217
AP News – Sweden’s Indigenous Sami in fight against miners by Malin Rising. Aug. 29. 2013.
Chapter 3 ξ 079
Indigenous Peoples’ access to Health Services
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State of the World’s Indigenous Peoples
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UN Photo/Broddi Sigurdarson
Chapter 4 ξ 083
Indigenous Peoples’ access to Health Services
Chapter Four
Access to Health Services by
Indigenous Peoples in
Central, South America
and the Caribbean Region
Dr. Myriam de Rocio Conejo Maldonado
UN Photo/Broddi Sigurdarson
084 ξ Chapter 4
State of the World’s Indigenous Peoples
Chapter Four
Access to Health Services
by Indigenous Peoples
in Central, South America
and the Caribbean Region
Dr. Myriam de Rocio Conejo Maldonado
Introduction
Central, South America and the Caribbean region have vibrant and politically active indigenous
populations that comprises between 45 and 50 million peoples who belong to almost 600 indige-
nous groups.
218
The highest numbers of indigenous peoples are found in Mexico, Peru, Guatemala,
Bolivia and Ecuador. According to World Bank figures, 12.76 per cent of the entire population and
approximately 40 per cent of the rural population is indigenous.
219
Indigenous peoples represent a
disproportionate number of the poorest, in a region that has the world’s greatest income dispari-
ty. Indigenous peoples live in a range of diverse settings, from tropical forest villages to mountain
towns and in the largest cities. Many have strong attachments to their traditional territories which
are located in the rural areas however, more and more indigenous peoples are either migrating or
being displaced to regions or countries that are long distances from their communities. The num-
ber of indigenous peoples living in urban areas has also increased where there is dependency on
urban clusters for their livelihood.
220
Over the past two centuries, colonialism has influenced indigenous communities, resulting in highly
mixed populations in the Caribbean, linked to the importation of slaves from Africa to the almost
destruction of indigenous groups such as the Taino in Cuba, Puerto Rico, the Dominican Republic
and Jamaica. While some indigenous groups were able to remain in isolation, others were forced
into cities and towns or settled in less hospitable lands or pushed o their lands altogether. In many
cases, indigenous peoples were to be incorporated, voluntarily or involuntarily, into the mainstream
population where they might or might not self-identify as indigenous peoples. While they could
live and work in the same way as their non-indigenous neighbours, many were forced into the worst
socioeconomic roles. For example, many indigenous peoples of mixed descent in Mexico left their
homes, crossing state and national borders to take up marginalized labour roles, especially in the
United States as agricultural labourers, construction workers and domestic workers.
221
218
http://www.iwgia.org/regions/latin-america/indigenous-peoples-in-latin-america.
219
It should be noted there is a lack of specific information on indigenous peoples’ health the Caribbean region.
220
http://www.iwgia.org/regions/latin-america/indigenous-peoples-in-latin-america.
221
Raul Montenegro and Carolyn Stephens “Indigenous health in Latin America and the Caribbean”
www.thelancet.com, Vol 367, June 3, 2006.
Chapter 4 ξ 085
Indigenous Peoples’ access to Health Services
Despite State subjugation policies aimed at their destruction, indigenous peoples are still man-
aging to uphold and rebuild their identity, language and culture, as well as their traditional social,
legal and political systems, or a large part thereof. Central America, South America and the Ca-
ribbean’s history and very essence are rooted in the cultural and social foundations of indigenous
peoples. Throughout history, indigenous peoples have developed dierent forms of resistance
and currently, having gained strength, indigenous movements are reclaiming their land rights,
respect for their cultural values, languages, customs and institutions and the right to decide their
development priorities. Indigenous movements in Central America, South America and the Carib-
bean have grown markedly in recent decades and have increased their organizational capacity as
political actors, demanding increasingly higher levels of participation.
222
International legal framework for intercultural health
There are a number of the legally binding instruments on the right to health that have relevance
to indigenous peoples. These include the Universal Declaration of Human Rights;
223
International
Covenant on Economic, Social and Cultural Rights;
224
Convention on the Rights of the Child;
225
Convention on the Elimination of all Forms of Discrimination against Women;
226
and the Millenni-
um Summit Declaration.
227
Other instruments include:
The International Convention on the Elimination of All Forms of Racial Discrimination (CERD,
1965) is a legal mechanism that obliges all Member States of the United Nations to eliminate ra-
cial discrimination, as well as to act against racism. U.N. Committee on the Elimination of Racial
Discrimination CERD) has emphasized that:
[I]n many regions of the world indigenous peoples have been, and are still being, discrim-
inated against and deprived of their human rights and fundamental freedoms and in par-
ticular that they have lost their land and resources to colonists, commercial companies and
State enterprises. Consequently, the preservation of their culture and their historical identi-
ty has been and still is jeopardized.
228
The International Labor Organization Convention No. 169 (ILO, 1989) on indigenous and tribal peo-
ples, which has been ratified in Latin America by Mexico, Guatemala, Honduras, Nicaragua, Costa
Rica, Colombia, Ecuador, Peru, Bolivia, Paraguay, Chile, Brazil, Uruguay and Argentina, defines, inter
alia, the rights of indigenous peoples to ownership and possession of land, recognition of their val-
ues and practices, making decisions about their own priorities, customary law, social security and
health, equality regarding contracts and conditions of employment, and education at all levels.
222
http://www.ilo.org/indigenous/Activitiesbyregion/LatinAmerica/lang--en/index.htm.
223
The Universal Declaration of Human Rights http://www.un.org/en/documents/udhr/.
224
International Covenant on Economic, Social and Cultural Rights
http://www.ohchr.org/EN/ProfessionalInterest/Pages/CESCR.aspx.
225
Convention on the Rights of the Child http://www.ohchr.org/en/professionalinterest/pages/crc.aspx.
226
Convention on the Elimination of all Forms of Discrimination against Women
http://www.ohchr.org/Documents/ProfessionalInterest/cedaw.pdf.
227
Millennium Summit Declaration http://www.un.org/millennium/declaration/ares552e.htm.
228
U.N. Committee on the Elimination of Racial Discrimination (CERD), General Recommendation XXIII: Indigenous Peoples,
U.N. Doc. CERD/C/51/misc 13/Rev 4, at 3 (1997) [hereinafter CERD General Recommendation on Indigenous Peoples].
086 ξ Chapter 4
State of the World’s Indigenous Peoples
In Article 5, of ILO Convention 169 states that in applying the provisions of this Convention:
a. the social, cultural, religious and spiritual values and practices of these peoples shall be
recognized and protected, and due account shall be taken of the nature of the problems
which face them both as groups and as individuals;
b. the integrity of the values, practices and institutions of these peoples shall be respected;
c. policies aimed at mitigating the diculties experienced by these peoples in facing new
conditions of life and work shall be adopted, with the participation and co-operation of
the peoples aected.
Article 25 of ILO Convention 169 states:
1. Governments shall ensure that adequate health services are made available to the peo-
ples concerned, or shall provide them with resources to allow them to design and deliver
such services under their own responsibility and control, so that they may enjoy the high-
est attainable standard of physical and mental health.
2. Health services shall, to the extent possible, be community-based. These services shall be
planned and administered in co-operation with the peoples concerned and take into ac-
count their economic, geographic, social and cultural conditions as well as their traditional
preventive care, healing practices and medicines.
3. The health care system shall give preference to the training and employment of local com-
munity health workers, and focus on primary health care while maintaining strong links
with other levels of health care services.
4. The provision of such health services shall be coordinated with other social, economic and
cultural measures in the country.
The Declaration and Program of Action of Vienna (1993) recognizes the significance of both the
participation and the contribution of indigenous populations in social and economic develop-
ment, and calls upon states to guarantee the fulfilment of the rights and fundamental freedoms
of indigenous populations, as well as to recognize and respect cultural diversity and their systems
for social organization.
The Declaration and Program of Action of Durban (2001) rearms the need to fulfil human rights
and fundamental freedoms of indigenous peoples and the need to combat racism, racial discrim-
ination, xenophobia, and related intolerance that aects them.
The United Nations Declaration on the Rights of Indigenous Peoples (2007) commits, as does ILO
Convention 169, all subscribing States to respect the cultural expressions of indigenous groups in
all fields, including health. The UN Declaration states in Article 24:
1. Indigenous peoples have the right to their traditional medicines and to maintain their
health practices, including the conservation of their vital medicinal plants, animals and
minerals. Indigenous individuals also have the right to access, without any discrimination,
to all social and health services.
2. Indigenous individuals have an equal right to the enjoyment of the highest attainable
standard of physical and mental health. States shall take the necessary steps with a view
to achieving progressively the full realization of this right.
Chapter 4 ξ 087
Indigenous Peoples’ access to Health Services
The Inter-American instruments ensuring the right to health and other human rights of indige-
nous peoples include:
ɜ American Declaration on the Rights and Duties of Man
ɜ American Convention on Human Rights
ɜ Additional Protocol to the American Convention on Human Rights
ɜ Inter-American Convention on Prevention of Violence Against Women (“Belem Do Para”)
ɜ Inter-American Convention to Prevent Torture
ɜ Inter-American Convention on the Elimination of All Forms of Discrimination Against Per-
sons with Disabilities
These are, inter alia, some international mechanisms that have the mandate to address the health
rights of indigenous peoples in the Central, South America and the Caribbean region such as:
ɜ The United Nations Permanent Forum on Indigenous Issues was created in 2000 and has
made recommendations urging all Member States to include the intercultural perspective
within their health policies, programs and services, with special reference to reproductive
health, as well as to reassess the role played by healers and midwives as agents for the
exchange between ancestral medicine and western medicine.
ɜ Resolutions CD37.R5 (1993), CD40.R6 (1997), and CD.47.R13 (2006) of the Pan American
Health Organization (PAHO) establishes guidelines to address health with an integrat-
ed and intercultural approach, and the incorporation of indigenous wisdom, knowledge
about medicines and therapies for health care, in relation to the geopolitical and social
context of indigenous peoples, the promotion of health and the renewed primary health
care strategy (PHC-R).
ɜ Resolutions of the Meetings of Health Ministers of the Andean Subregion (REMSA) ad-
dress dierent questions. REMSA XVII/296 (1993) made health care a priority for the in-
digenous populations in the subregion, and REMSA XXVII/417 (2006) and REMSA XX-
VIII/438 (2007) allowed the creation of the Andean Commission for Intercultural Health,
as well as the elaboration of the Andean Intercultural Health Plan as a response to those
initiatives oriented to provide health services with an intercultural approach for the coun-
tries in the Andean subregion.
The legal norms and international mechanisms mentioned above relate to the need to respect the
health rights of indigenous peoples; establish laws, policies and programs to diminish or combat
inequality in the area of access to health care; and guaranteeing health with the provision of
culturally appropriate health services. Further, there must be interaction between traditional/
ancestral medicine and conventional medicine in order for them to complement each other.
Indigenous peoples must be able to participate in the development and planning of health
services on equal terms in order to improve their own health situation.
Health issues in Central America, South America and the Caribbean
Many indigenous peoples in Central America, South America and the Caribbean still live in isolated
environments where conditions are harsh. People living within natural ecosystems are exposed to
many health hazards produced mostly by the exacting environment. In the past, health risks were
088 ξ Chapter 4
State of the World’s Indigenous Peoples
linked to basic access to foods, water and shelter and, in many contexts, risks from predators.
229
Health and well-being prior to colonization was closely related to sophisticated knowledge and
use of the local ecosystems. The early period of colonialism brought new diseases that were
especially lethal for communities in the coastal areas.
230
Current-day problems still have a major
impact on indigenous peoples’ lives in the region. The security of indigenous peoples’ lands,
territories and resources has become a competition between the governments of the region in the
areas of agricultural, mining and energy generation initiatives particularly in Argentina, Bolivia,
Brazil, Chile, Guatemala, Honduras, Mexico, Panama and Peru. This has had negative impacts on
indigenous peoples, particularly for indigenous peoples living in remote areas and forest zones,
including those living in voluntary isolation in the Amazon rain forest.
Indigenous peoples and their communities in most Central and some South American States con-
tinue to face limited economic opportunities, poor access to social services, high levels of public
insecurity and the strong influence of organized criminal enterprises. All of these challenges are ex-
aggerated by the generally weak state presence in remote geographical zones, as well as by fragile
institutions, uneven justice administration, politicized judicial systems, and continuing high levels of
corruption and impunity particularly in Central and South America.
231
This situation has resulted in
major inequalities between indigenous peoples and their non-indigenous counterparts. Indigenous
peoples experience the worst social conditions and thus health profiles include the highest rates of
morbidity and mortality and the least access to health services compared to the rest of the pop-
ulation. According to unpublished data, in 2003 the average rate for infant mortality in Colombia
was 19 per 1,000 infants, but for the Wayuu indigenous group the infant mortality rate was 111 per
1,000.
232
In terms of morbidity rates in Bolivia, the Guaraní, with a population of 153,483 have a prev-
alence of tuberculosis five to eight times that of the national average.
233
Indigenous peoples are
more likely to suer from substance abuse, depression and other mental disorders that are obsta-
cles to the enjoyment of the right to the highest attainable standard of physical and mental health.
HIV/AIDS and other sexually transmitted diseases are also spreading in indigenous communities. At
the same time, indigenous communities are faced with economic exploitation of indigenous women
and lack of information about physical and mental health.
234
The right to life for indigenous peoples in the region is frequently at risk due to higher mortality
and morbidity rates compared to the general population. The health and personal integrity of
indigenous peoples is at risk throughout their lives—from infancy where there are high mortality
rates, and throughout life where there is a great prevalence of disease and death at early age.
Among the Maya in Guatemala, life expectancy for indigenous peoples is 17 years shorter than for
229
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Minorities Rights Group International State of the World’s Minorities and Indigenous Peoples 2012, p. 90.
232
Raul Montenegro and Carolyn Stephens, “Indigenous health in Latin America and the Caribbean”
www.thelancet.com, Vol 367, June 3, 2006.
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Raul Montenegro and Carolyn Stephens, “Indigenous health in Latin America and the Caribbean”
www.thelancet.com, Vol 367, June 3, 2006.
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Pan American Health Organization (PAHO), “Human Rights and Health: Indigenous Peoples” 2008, p. 2.
Chapter 4 ξ 089
Indigenous Peoples’ access to Health Services
the non-indigenous population.
235
In Bolivia, 9 per cent of Guaraní peoples have access to safe
drinking water which impacts on the enjoyment of the right to health. Lack of infrastructure and
medical services also impact on indigenous peoples’ right to health, particularly in physically iso-
lated communities.
236
The other major concerns include the general lack of disaggregated data by ethnicity and gender
in most of the countries in the regions. This makes it dicult to obtain a precise picture of the
overall health situation of indigenous peoples. On the other hand, there are data available on
the current health of indigenous peoples but it is scattered, depending on individual groups of
scientists and their studies, but it is not available on government databases. Some countries such
as Brazil have made eorts to gather data, and even have a specific indigenous oce within the
government that is tasked with obtaining information on groups in isolation.
237
Indigenous peoples make up to 40 per cent of the rural population in the region, where there is of-
ten little or no access to conventional health services. As a result, at least 80 per cent of indigenous
peoples depend mainly on traditional therapists for medical assistance”.
238
The infant mortality rate
is 54 per 1,000 live births
239
expressed as profound and disturbing disparity; “infant mortality rates
among indigenous children are 60 per cent higher than among non-indigenous children”.
240
The indigenous population in Mexico is estimated to be 12.6 per cent of the wider population and
80.6 per cent of the indigenous population are considered to be extremely poor. Maternal mor-
tality rates in the states of Guerrero, Chiapas and Oaxaca are 103.2, 82.7 and 80.6 per 100,000,
241
respectively. In the rural areas of these three states the probability of death due to preventable
diseases is 181 per cent higher than the probability in the urban centres of the same states.
242
In
the case of Guatemala indigenous peoples are 42.8 per cent of the total population and 86.6 per
cent
243
of this indigenous population live in poverty. The maternal mortality rate has reached 211
per 100,000.
244
The infant mortality rate has reached 51.1 per 1,000 live births.
235
Pan American Health Organization (PAHO), “Human Rights and Health: Indigenous Peoples” 2008, p. 2.
236
“State Policy: From Custody to the Policy of Rights—a Solved Issue?” in: Indigenous Peoples in Voluntary isolation and
initial contact, Antenor Vaz, IWGIA, Copenhagen, 2013, p. 12.
237
Raul Montenegro and Carolyn Stephens, “Indigenous health in Latin America and the Caribbean” www.thelancet.com,
Vol 367, June 3, 2006.
238
Cevallos, Rodrigo, “Prestación de servicios de salud en zonas con pueblos indígenas”, http://www2.paho.org/hq/
dmdocuments/2009/servicios%20salud%20zonas%20indigenas.pdf, p. 19.
239
“Mortalidad infantil y en la niñez de pueblos indígenas y afrodescendientes de América Latina: inequidades estruc-
turales, patrones diversos y evidencia de derechos no cumplidos”, CEPAL y CELADE, Naciones Unidas, Santiago de
Chile 2010http://www.eclac.cl/Celade/publica/bol62/BD6206.html.
240
“Mortalidad infantil y en la niñez de pueblos indígenas y afrodescendientes de América Latina: inequidades estruc-
turales, patrones diversos y evidencia de derechos no cumplidos”, CELADE-CEPAL http://www.eclac.cl/publicaciones/
xml/1/41581/LCW.348Oct_2010.pdf.
241
http://www.ipsnoticias.net/2011/10/mexico-muerte-materna-destino-fatal-de-campesinas-e-indigenas/.
242
La salud de la población indígena en México, José Luis Torres, Renata Villoro, Teresita Ramírez, Beatriz Zurita, Patricia
Hernández, Rafael Lozano, Francisco Franco, Revista Calidoscopio de la Salud.
243
“Los pueblos indígenas y la pobreza en América Latina: un análisis empírico”, Estudios socio demográficos en pueblos
indígenas, Serie E, No. 40 (LC/DEM/G.146), Santiago de Chile, División de Población, Centro Latinoamericano y Cari-
beño de Demografía (CELADE).
244
http://www.s21.com.gt/nacionales/2012/02/13/mortalidad-materna-se-triplica-indigenas.
090 ξ Chapter 4
State of the World’s Indigenous Peoples
In Chile the indigenous population is estimated to be 10.3 per cent
245
of the total population, and
16 per cent of the indigenous population lives in poverty. The infant mortality rate in general is
11 per 1,000 live births, while the rate for the indigenous peoples is 12.8 per 1,000 live births.
246
In
Bolivia the indigenous population is 52 per cent
247
of the total population. Poverty among indige-
nous peoples has reached 64.3 per cent.
248
The maternal mortality rate in Potosí, the province with
the largest indigenous population, is 496 per 100,000.
249
In Peru the indigenous population is 40.25 per cent of the total population and 79 per cent of the
indigenous population is poor. The Peruvian Institute for Statistics has no consolidated number
for the infant mortality rate for indigenous children but has indicated that in indigenous commu-
nities the infant mortality rate goes from 99 to 153 per 1,000 live births. In Puno, one of the prov-
inces with a large indigenous population, the maternal mortality rate reaches 36 per 100,000.
250
In Ecuador, according to the 2011 census, the indigenous population is 7.1 per cent of the total
population, and 49.9 per cent
251
of the indigenous population is poor. The infant mortality rate
among indigenous children is 67.6 per 1,000 live births, while the rate for the population in general
is 29.9
252
per 1,000 live births. The maternal mortality rate is 210 per 100,000.
253
The above figures provide a visible overview of the health gaps that still exist between the indig-
enous peoples and the rest of the population. Indigenous peoples’ health disparities are linked to
social, cultural, economic and political factors. There are national and international norms that
go towards enhancing and supporting indigenous peoples, particularly in the area of health, as
well as national eorts to improve the situation of indigenous persons. However, these actions
are clearly not enough for achieving health equity for indigenous peoples. There is a need for
recognizing a human-rights-based approach which calls for the inclusion of interculturality and
recognition of collective rights.
A gap persists between advances in intercultural health and concrete possibilities of contributing
to improving health conditions for indigenous peoples, in spite of the fact that there exists an
important basis of information on the fundamental concepts and data on beliefs, expressions and
cultural practices of indigenous peoples in various countries.
245
“La identificación de poblaciones indígenas en los censos de América Latina”, in: América Latina: aspectos concep-
tuales de los censos del 2000, CEPAL/CELADE, Santiago de Chile, p. 361.
246
http://celade.cepal.org/redatam/PRYESP/SISPPI.
247
“La identificación de poblaciones indígenas en los censos de América Latina”, in: América Latina: aspectos concep-
tuales de los censos del 2000, CEPAL/CELADE, Santiago de Chile, p. 361.
248
“Los pueblos indígenas y la pobreza en América Latina: un análisis empírico”, Estudios socio demográficos en pueblos
indígenas, Serie E, No. 40 (LC/DEM/G.146), Santiago de Chile, División de Población, Centro Latinoamericano y Cari-
beño de Demografía (CELADE).
249
http://www.un.org/spanish/News/story.asp?newsID=2649#.Ukj8YtjIwis.
250
“SITUACIÓN DE LAS MUJERES EN LOS PUEBLOS INDÍGENAS DE AMÉRICA LATINA. OBSTÁCULOS Y RETOS”, Judith
Bocos Ruiz.
251
http://websie.eclac.cl/sisgen/ConsultaIntegrada.asp?idAplicacion=14.
252
http://celade.cepal.org/redatam/PRYESP/SISPPI/.
253
http://www.opsecu.org/jspui/bitstream/123456789/130/1/130.pdf.
Chapter 4 ξ 091
Indigenous Peoples’ access to Health Services
Interculturality and health
It must be recognized that advancements in establishing norms for compliance with health rights
of indigenous peoples are the result of the hard struggles by indigenous peoples themselves.
They have promoted actions to the States demanding recognition of their rights, the elaboration
of public policy and plans to revert situations of inequality in which they live, their social and
economic marginalization, and their exclusion through racial discrimination, as well as addressing
their deplorable health situation in comparison to other social and cultural groups.
The elaboration of policies, plans and projects and other initiatives for indigenous peoples have
taken place in the Central, South America and the Caribbean region since the beginning of the
1990s. Several countries in the region have included an intercultural approach for health in their
development plans. At the same time, sociocultural and linguistic barriers continue to exist, as
well as barriers in terms of geographic access to health services and the lack of recognition of
indigenous peoples’ own knowledge and practices regarding the holistic connection between
health, disease and healing. These barriers generate resistance and lack of trust among indige-
nous peoples in terms of using conventional medicine health services.
Such barriers may be overcome through the incorporation of an intercultural approach in the
provision of health services, in order to guarantee intercultural management models and health
care; culturally relevant health services and medical sta with intercultural competencies. There
is also a need to articulate traditional/ancestral medicine with conventional medicine through
intercultural-related health mechanisms. In this sense, it is important to reorient health services,
include intercultural education and training for health professionals and to have health information
systems that improve the provision of health services based on an intercultural approach.
Reorientation of health services
The reorientation of health services towards an intercultural approach implies respect for and
compliance with the individual and collective rights of indigenous peoples; the recognition of
diverse knowledge and wisdom regarding the process of health-disease-treatment-healing; in-
teraction of knowledge and practices between conventional medicine and the knowledge that
indigenous peoples possess, as well as their complementary role; and the achievement of equity
in health for both indigenous individuals and collectives.
One must have in mind that intercultural health, if it is to be presented as a reference for transver-
sal interest with application to any society, cannot be imposed within the state only by decree. If
it is not valued and given the consensus of all sectors involved, unfortunate situations may arise
that would result in serious diculties for health care and hide the reasons for the lack of equity
for indigenous peoples. Interculturality promotes a horizontal dialogue between cultures, a re-
spectful relationship with no hierarchies. This means the inhibition of one’s criteria and criticisms
and one’s prejudices, as well as concentrating on cultural practices that are often quite dierent
from the rest of society. It is a matter of limiting ethnocentrism, which is the trend for interpreting
other cultures based on the principles of one’s own culture. Therefore, key words regarding the
concept of interculturality are: respect for diversity, interaction, dialogue and horizontality.
254
254
Cited in “Diagnostico y Fortalecimiento de la Inclusión de Interculturalidad en la Formación del personal de Salud”
(informe de avance), Martha Escobar, MSP Ecuador 2013.
092 ξ Chapter 4
State of the World’s Indigenous Peoples
Interculturality must be considered as an initiative for changing the health conditions, as long as
change serves to improve epidemiology indicators, that is, to get people to live longer and better.
If, on the other hand, change is understood as only having the objective of giving new value to
traditional medicine, it will be dicult for health services to improve, and therefore to produce
improvements in the health of the population.
255
In this sense, countries in Latin America with indigenous peoples have incorporated the intercul-
tural approach in their laws, policies, management and health care models, and technical norms,
in order to contribute to health equity according to the sociocultural contexts of indigenous peo-
ples. The big challenge is to make those instruments function.
In Guatemala, the Inclusive Health Model (MIS, Modelo Incluyente de Salud) has been implement-
ed since 2003 by the Consorcio Médicos del Mundo Navarra-CORDAID in coordination with the
Ministry of Public Health and Social Assistance (MSPAS, Ministerio de Salud Pública y Asistencia
Social) and with the financial support of the European Commission and the Government of Na-
varra. It is a model for individual, family and community care at the primary level, based on three
pillars: the right to health, interculturality, and gender perspective.
256
The intercultural approach
of MIS recognizes the existence of health concepts and practices that originate from cultural di-
versity and promotes interactive processes (it includes referral and cross-referral) between dier-
ent knowledge and practices of care and treatment.
257
In Mexico, the National Program for Action “Salud y Nutrición para los pueblos indígenas”
258
(Health
and Nutrition for indigenous peoples) has the responsibility for promoting the strategy for good
quality health services with cultural sensitivity and has been able to implement “Unidades de
Salud Competentes”
259
(competent health units), which make health services culturally adequate
(cultural infrastructure and equipment), incorporating medical sta with intercultural capacities,
intercultural care of births and intercultural services including indigenous traditional medicine.
The implementation of the National Health Program 2007-2012 has made it possible to promote
integrated intercultural policies, increase the knowledge and use of traditional/ancestral medicines
according to requirements of the population, as well as the application of mixed models for care
that combine traditional/ancestral medicine with conventional medicine.
In Bolivia, successful experiences have been identified. These have been supported by the Ministry
of Health and Sports (Ministerio de Salud y Deportes) and carried out by agencies for interna-
tional cooperation together with public health institutions.
260
One case is from the Department
of Potosí,
261
and its main components are the articulation of diverse health systems. Integrating
255
Salud Intercultural: Crítica y problematización a partir del contexto boliviano, Susana Ramírez Hita, La Paz, ISEAT, 2011,
pp. 31-38.
256
Del Dicho al Hecho: Los avances un primer nivel de atención en salud incluyente, Medicus Mundi Navarra—Guatemala,
Sacatepéquez, Guatemala, 2008, p.7: http://www.saludintegralincluyente.com/ftp/saludintegralincluyente/DOCU-
MENTOS/PDF/antecedentes/guatemala/DEL%20DICHO%20AL%20HECHO.pdf.
257
Ibid. p. 47.
258
http://ssj.jalisco.gob.mx/sites/ssj.jalisco.gob.mx/files/programapueblosindigenasfinal_1.pdf.
259
http://guerrero.gob.mx/programas/programa-de-salud-y-nutricion-para-los-pueblos-indigenas-prosani/.
260
Vice-Ministry of Traditional Medicine and Inter-culturality: http://www.sns.gob.bo/index.php?ID=ViceMedicinaTradicional.
261
Program designed and implemented by the Italian Development Cooperation and the Department of Posotí:
“Programa de Apoyo al Desarrollo del Sistema Socio-Sanitario del Departamento de Potosí”:
http://www.utlamericas.org/2013/?page_id=645&lang=es.
Chapter 4 ξ 093
Indigenous Peoples’ access to Health Services
diversity in hospitals includes having adequate spaces for both conventional medicine and tra-
ditional medicine, training human resources about interculturality incorporating graduate stud-
ies on intercultural health, and making the premises culturally adequate with construction and
equipment that facilitates an intercultural approach, combined with community participation in
health units and adequate housing for family.
In Peru, the Ministry of Health (MINSA), following the guidelines for sector policies for the period
2002-2012, incorporates the intercultural approach in management by respecting cultural diver-
sity, strengthening traditional medicine, and complementing it with conventional medicine.
262
An
example of this is caring for births in culturally adequate health units that provide maternal and
neonatal care in the Department of Ayacucho. The most important results have been an increase
in the number of people from indigenous peoples seeking birth care and a decrease in maternal
deaths, mainly of indigenous women. This model counts on community participation, as well as
the participation of regional governments, the support of civil society organizations, NGOs and
agencies for international cooperation.
263
In Chile, the Ministry of Health incorporates the intercultural approach by organizing and provid-
ing health services that are culturally appropriate (protocols, construction, equipment, pertinent
health sta and information systems), strengthening the health system of indigenous peoples,
and complementing conventional medicine with traditional medicine. An example of the way tra-
ditional medicine is strengthened is the program for intercultural health for the Mapuche (Hos-
pital Makewe, Health Center Boroa Filulawen and Intercultural Hospital Nueva Imperial), which
involves the indigenous world view, or cosmovisión, and knowledge of ancestral medicine in the
processes for self care and promotion of individual, family and community health.
264
In Ecuador, the Modelo de Atención Integral de Salud Familiar, Comunitario e Intercultural (MAIS-
FCI, Integral Care Model for Family, Community and Intercultural Health) recognizes the manage-
ment and care of intercultural health by implementing mechanisms to allow health promotion
from the various world views and knowledge approaches, culturally appropriate health services,
sta with intercultural competencies for improving sociocultural access, enhancing the wisdom
of dierent peoples, and coordination between conventional health systems and the traditional
and ancestral wisdom.
265
In this sense, it is possible to highlight important experiences the Pan American Health Organiza-
tion (PAHO) has recognized. One of them is “Improving the life conditions and the defence of the
identity of the Andean population of Cotacachi-Ecuador”,
266
which has the objective of reducing
maternal mortality among indigenous women by strengthening the competencies of health sta
262
UNFPA, Atención en Salud con Pertinencia Intercultural, Módulo Técnico - Teórico, Lima, 2011, p. 17:
http://www.unfpa.org.pe/publicaciones/publicacionesperu/SSL-Atencion-en-Salud-Modulo-Tecnico.pdf.
263
Ibid. p. 75.
264
CCTCEM, Salud intercultural y la patrimonialización de la Salud Mapuche en Chile, 22, Junio de 2013:
http://www.enelvolcan.com/jun2013/261-salud-intercultural-y-la-patrimonializacion-de-la-salud-mapuche-en-chile.
265
Manueal del Modelo de Atención Integral del Sistema Nacional de Salud Familiar, Comunitario e Intercultural (MAIS-
FCI), p. 40.
266
PAHO/WHO honours eorts to improve gender equity in health in Latin America, 7 June 2013:
http://www.paho.org/hq./index.php?option=com_content&view=article&id=8769%3Apahowho-honors-eorts-to-im-
prove-gender-equity-in-health-in-latin-america&catid=740%3Anews-press-releases&Itemid=1926&lang=en.
094 ξ Chapter 4
State of the World’s Indigenous Peoples
in the area of intercultural and ancestral health assistance. With this purpose, a system of referral
and cross-referral was established and a certificate was issued to midwives in order to link them
to the maternal health services. This initiative has increased the number of institutional births by
45 per cent, and it has helped to bring down to zero the number of maternal deaths in the last
four years. It has been carried on by Ecuador’s Red Cross in cooperation with the Ministry of Public
Health, the municipal government in Cotacachi and indigenous community organizations, and it
has counted on the support of the Agencia Catalana de Cooperación al Desarrollo (España) and
the United Nations Population Fund (UNFPA).
For most of the countries (Bolivia, Peru, Ecuador and Guatemala) the main eort is directed to-
wards allowing culturally adequate births for women. This includes providing spaces in hospitals
and health centres, allowing relatives and a midwife to assist women, and returning the placenta
to the women, providing traditional herbal teas and foods pre- and post-delivery, and using in-
fusions. While this has been an important achievement as a women’s rights concern, there has
been no formal evaluation process of this service. Currently, there is no evidence on whether the
program improves the quality of service for indigenous women.
In this sense, the recommendations regarding management and care of health services are:
ɜ to promote the implementation of the legal and programmatic norms at the level of or-
ganizational structure of the Ministries of Health and of the communities;
ɜ to promote the complementary actions with equity between conventional medicine (bio-
medicine), traditional medicine (ancestral and popular medicine), and culturally pertinent
alternative medicine;
ɜ to strengthen the experiences regarding health services with intercultural pertinence and
to seek their replication as validated and sustainable practices;
ɜ to reinforce the formation of management, technical and sociopolitical capacities of hu-
man resources with an intercultural approach; and
ɜ to promote from the territory the articulation and strengthening of ancestral medicine.
In addition, in relation to the management of the knowledge, it is necessary to promote plans for
institutional and community education and communication with an intercultural approach and
identity; to carry out research on the world view and ancestral knowledge and practices in the
process addressing health, disease, care issues; and to systematize, publish and share experienc-
es of intercultural health already validated, sustainable and replicable.
Human Resource Training in Health
The Pan American Health Organization (PAHO)
267
promotes “the integral training of human re-
sources in health to respond to the epidemiologic profile and sociocultural context of the com-
munity by formal and non-formal education, applying the “learning by doing” paradigm through
the exchange of experiences, and taking advantage of theoretical and technical capacities for the
intercultural approach in health”.
267
Organización Panamericana de la Salud-Organización Mundial de la Salud (OPS-OMS) (1998). “Incorporación del Enfo-
que Intercultural de la Salud en la Formación y Desarrollo de Recursos Humanos”. OPS-OMS, Washington (E.U.A.).
Chapter 4 ξ 095
Indigenous Peoples’ access to Health Services
To promote health care with equity that is responsive to the needs of various ethnic groups, in-
cluding prevention services, the training of human resources in health aims to improve the tech-
nical and human skills of the institution’s sta. This training is envisaged to have positive eects
including improved respect for patients, acknowledgement of their treatment experiences and
recognition of the world views.
Among advances in this area a study within the framework of the Andean Plan for Intercultural Health
of ORAS-CONHU shows advances in the “Intercultural approach in university training of human re-
sources for health in the Andean region”, which allows one to observe how, since the last decade,
countries have had a significant increase in applying the inclusion of the intercultural approach in
the training of health professionals. This document contributes to: 1) the analysis of curricula about
interculturality in health of the current education opportunities oered by educational institutions in
the subregion at the undergraduate and graduate levels; 2) the update of the existing inventory on
oerings in education and training in interculturality in health; and 3) the elaboration of a proposal of
academic contents regarding interculturality in health that should be incorporated in the education
curricula for health professionals at the undergraduate and graduate levels.
In 2005, the important contribution made by the Indigenous Fund started the Program of Educa-
tion and Training through the Universidad Indígena Intercultural (Intercultural Indigenous Univer-
sity). This program has promoted education with an intercultural perspective for indigenous and
non-indigenous professionals in positions of leadership to take charge of the tasks of articulation,
participation and decision-making aecting politics, economics and social organization of their re-
spective societies. This program has a master’s degree in Intercultural Health within the Universidad
de la Región Autónoma de la Costa Caribe Nicaragüense, with the following academic objectives:
“to contribute to the improvement of life conditions and the health status of indigenous peoples
and Afro-descendant and ethnic communities, as well as to the generation of new paradigms based
on an intercultural vision of health within the framework of compliance of the Millennium Devel-
opment Goals and the objectives of the Second International Decade of the World’s Indigenous
Peoples” and “to promote space for dialogue and negotiations on current topics related to health in
Latin American countries, such as: structural reforms, problems of social exclusion, inequity, insti-
tutional racism and geographical marginalization; as well as other integral problems a multi-ethnic
and multicultural society faces”.
268
In this scenario health and education face joint challenges in
terms of contributing to the development of public policies for a multicultural country; undoubtedly
universities are called upon to contribute in these transformation processes.
Inclusion of the ethnic variable in health registers
A clear process is required for the production of systematic, relevant and pertinent information
for the design and monitoring of public health policies that ensure compliance with the individual
and collective rights of indigenous peoples and other ethnic groups. Such a process is necessary
for knowing the epidemiologic profiles of the various indigenous peoples in a constant and rigor-
ous way, with the following objectives: a) to identify health inequalities and inequities between
countries, between peoples, and among countries and peoples; b) to collect, process, analyse and
268
Antecedentes, situación actual y perspectivas de la salud intercultural en América Latina, Víctor Manuel del Cid Luce-
ro, URACCAN, Noviembre 2008, p. 8.
http://www.fondoindigena.org/apc-aa-files/74656d706c6174653132333435363738/FI___m30asi_1.pdf.
096 ξ Chapter 4
State of the World’s Indigenous Peoples
spread all the pertinent information for the development of peoples, as well as to elaborate a
legal and normative framework, as well as public policies on health information, for making indig-
enous peoples visible in the statistical systems of health.
269
Currently, most of the systems of information regarding health in the Latin American countries
do not produce disaggregated data based on ethnic groups, peoples or communities. Because of
that, it is not possible to formulate dierentiated epidemiologic diagnosis or to determine their
morbidity and mortality profiles.
Within a framework of rights, the invisibility of indigenous peoples and Afro-descendants in the
information systems of health, and consequently, the lack of information about their health con-
ditions, is by itself an expression of ethnic discrimination, which must be overcome in light of the
recommendations provided by international bodies and the current demands from such groups.
270
It is necessary to overcome the sort of planning that has the purpose of reaching homogeneous
perceptions, which is sustained on the notion that there are no dierences among the epidemiologic
profiles of the various peoples. That planning considers that no specific policies focused on those
various peoples will be required. Thus, as long as no epidemiological evidence is produced and health
inequalities and inequities are not consistently and rigorously identified for countries, ethnic groups
and regions in Latin America, concrete health policies and plans for these groups will be restricted to
initiatives of a cultural character, limiting the transversal nature of the approach and mainly, imped-
ing the elaboration of health objectives that are both demandable and apt for evaluation.
271
As indicated by international bodies, the challenge of overcoming health inequities implies focusing
actions specifically targeted to those peoples and communities whose rights have been violated
most, to concentrate on the groups with the highest risks of preventable morbidity and premature
mortality. Thus four specific steps are critical. First, to assess the damage; second, to identify their
social determinants, both structural and immediate; third, to design interventions that are focused,
ecient and pertinent; and fourth, to monitor advances in terms of equity and fulfillment of rights.
272
A balance of the process of inclusion of the ethnic approach in the sources of data (see Table 1)
allows us to verify that the main advancement has been the incorporation of variables for ethnic
identification in the sources of social and demographic data, mainly in the population census.
Such incorporation has fallen behind, on the other hand, in surveys and vital statistics, for which
achievements are rather heterogeneous.
269
“Elementos para la incorporación del enfoque étnico en los sistemas de información en salud (SIS). Guía básica”, Ana
María Oyarce, Malva-marina Pedrero, Octubre 2012.
270
Permanent Forum on Indigenous Issues, Follow-up to the recommendations of the Permanent Forum: (a) Economic
and Social Development Report of the international technical expert meeting on “Keeping track—indicators, mech-
anisms and data for assessing the implementation of indigenous peoples’ rights”, E/C.19/2011/11; Permanent Forum
on Indigenous Issues, Implementation of recommendations on the six mandated areas of the Forum and on the
Millennium Development Goals Indicators of well-being, poverty and sustainability relevant to indigenous peoples,
E/C.19/2008/9; Permanent Forum Recommendations: 2nd Sesión, recommendation 68; 5th Session, recommenda-
tions 92, 101, 102, 110, 165, ; 6th Session, recommendation 57, 60, 61, 101, 119, 124, 127; 7th Session, recommendations 63,
78, 111; 11th Session, recommendation 21; 12th Session, recommendation 110.
271
“Elementos para la incorporación del enfoque étnico en los sistemas de información en salud (SIS). Guía básica”, Ana
María Oyarce, Malva-marina Pedrero, Octubre 2012.
272
“Mortalidad infantil y en la niñez de pueblos indígenas y afrodescendientes de América Latina: inequidades estructurales,
patrones diversos y evidencia de derechos no cumplidos”, CEPAL y CELADE, Naciones Unidas, Santiago de Chile 2010
http://www.eclac.cl/Celade/publica/bol62/BD6206.html.
Chapter 4 ξ 097
Indigenous Peoples’ access to Health Services
Table 1: Latin America: Overview of the process of incorporation of variables
for the ethnic identification in continuous data registration regarding health
Country
Policy/
Program
Ethnic
Identification
(need to
footnote
short forms)
Registers/registries Variables
Argentina Yes Yes (Pi)
Case history
Perinatal case history
Self-identification
Bolivia Yes Yes (Pi)
Case history model SNIi
Perinatal case history
Snis
Certificate for the
recently born
Self-aliation
Spoken language
Mother tongue
Brazil Yes
Yes (Pi Y A)
Unified public health
system
Ethnic and racial
self-identification
Si (Pi)
Family registry
Forms for those seeking
medical treatment
Personal records
Registration log book
Monthly consolidated
report of activities
Forms for referral and
cross-referral
Vaccination registers
Territorial
Colombia Yes Yes (Pi Y A)
Case history
Certificate for the
recently born
Death certificate
Other registers (violence)
Self-identification
Costa Rica Yes N/A
Chile Yes Yes
Registry of discharges
from hospital
Self-identification of
peoples
Medical treatment
agenda (South Arau-
canía SS)
Self-identification
Last names
098 ξ Chapter 4
State of the World’s Indigenous Peoples
Ecuador Yes Yes (Pi Y A)
Form 001 for admittance
and discharge
MSP
Cultural Group
Form 051 Perinatal case
history
MSP
Ethnic group
Daily register of people
seeking medical treat-
ment MSP
Ethnic aliation
Live births/deaths sta-
tistical report
INEC
Mother ethnic group
Mother self-identification
Foetal death
INEC
Mother self-identification
Death in general
INEC
Ethnic self-identification
El Salvador No Yes Family registry
Guatemala Yes Yes (Pi)
Daily register of people
seeking medical treat-
ment in hospitals and
centres
Self-aliation to peoples
Self aliation to linguis-
tic community
Mother tongue
Daily register of people
seeking medical treat-
ment and follow-up
Self-aliation to peoples
Self-aliation to linguis-
tic community
Mother tongue
Registry of births Self-aliation to peoples
Self-aliation to linguis-
tic community
Mother tongue
Registry of deaths Self-aliation to peoples
Self aliation to linguis-
tic community
Mother tongue
Honduras Yes N/A Registry of births Self-aliation to peoples
Mexico Yes Yes
Complete these blank
boxes
Chapter 4 ξ 099
Indigenous Peoples’ access to Health Services
Nicaragua Yes Yes
Panama Yes N/A
Paraguay Yes Yes
Basic case history Ethnic group
Registry of discharges
from hospital
Ethnic group
Daily register of people
seeking medical treat-
ment
Ethnic group
Peru No Yes
HIS system
Daily register of people
seeking medical treat-
ment
Ethnic group
Bolivarian
Republic of
Venezuela
Yes Yes
Primary care
Immunization
Epidemiologic records
Register of people seek-
ing medical treatment
Ethnic self-identification
Race
Ethnic group
Indigenous peoples
Source: Ana María Oyarce, 2012.
In the case of surveys, variables for ethnic identification have been incorporated in demographic
and health surveys, as well as in home surveys in 11 countries. On the other hand, regarding vital
statistics, there are only recent experiences of incorporating variables of this type in registries of
birth and death in 8 countries in Latin America.
273
Various advances are also observed in continuous health registers and registries. Based on their
coverage, recent experiences of national scope are identified (such as in Bolivia, Brazil, Colombia,
Chile, Ecuador, Guatemala and Paraguay), as well as other experiences focused on specific terri-
tories of concentrations of indigenous peoples (such as Argentina, El Salvador, Honduras, Mexico,
Nicaragua, Peru and Bolivia).
Recommendations regarding the systems for registration are: 1) to incorporate health registers
as well as registers of ethnically pertinent benefits; 2) to indicate an ethnic variable in health
and epidemiologic data; 3) to include quantitative and qualitative indicators; 4) to ensure high-
quality information by enhancing the processes for collection and consolidation of data; and 5) to
guarantee that the information is used for analysis, as well as to have a decision-making process
based on that information.
273
“Elementos para la incorporación del enfoque étnico en los sistemas de información en salud (SIS). Guía básica”, Ana
María Oyarce, Malva-marina Pedrero, Octubre 2012.
100 ξ Chapter 4
State of the World’s Indigenous Peoples
Conclusion
International and national frameworks exist for the protection of the rights of indigenous peoples,
which authorize signatory states to ensure the application of the right to health by policy actions
that promote health with an intercultural approach, providing health services with intercultural
management and care, and fostering citizen participation of indigenous peoples in the analysis
and decision-making on health.
However, despite the existence of international and national legal norms for the protection of
indigenous peoples, health inequalities persist, which are characterized by 1) the prevalence of
preventable diseases and illnesses easily solvable when addressed in a timely way; 2) barriers to
both geographic and sociocultural access to high-quality and culturally relevant health services;
3) scant recognition of the wisdom and practices of the traditional medicines of indigenous peo-
ples in the process health, disease, care and healing.
Health experiences for indigenous peoples have focused on culturally adequate birth care
(Bolivia, Peru, Ecuador, Guatemala and Mexico), and only in limited cases on the strengthening
of traditional/ancestral medicine as a part of the health services (Mexico, Chile). Regarding the
strengthening of ancestral/traditional medicine, it is necessary to discuss the pertinence of
being a part of health services (Mexico and Chile) and/or if they should rather be preserved and
strengthened within the indigenous peoples’ territories.
The epidemiological profiles do not incorporate the sociocultural profile, which includes ethnocul-
tural diseases or diseases with a cultural aliation, as part of the analysis of the health situation
of indigenous peoples for policy decision making and action regarding health.
Plans for training health human resources with an intercultural approach are still in a preliminary
stage in Latin America, which has impacts with regard to 1) development of an intercultural re-
lation, dialogue and negotiations between health providers and those seeking their services; 2)
the intercultural management and care are not provided according to the sociocultural needs in
health; and 3) the articulation and complementary action between ancestral health knowledge
and conventional medicine.
Some of the important strategies that need to be considered include:
ɜ Apply mechanisms and instruments to implement national and international legal frame-
works for compliance with the health rights of indigenous peoples.
ɜ Recognize, strengthen and protect the ancestral health wisdom and practices of indige-
nous peoples, and to articulate them within the national health systems.
ɜ Implement spaces for intercultural dialogue for the exchange of wisdom and practices,
as well as their mutual enrichment from the various health and health care approaches.
ɜ Strengthen, consolidate and replicate successful and validated intercultural health expe-
riences, both at the national and international levels, acknowledging their local sociocul-
tural contexts.
ɜ Institutionalize in the national health systems and in the curriculum plans of the insti-
tutions educating human resources in health, both the approach to and the concept of
intercultural health.
Chapter 4 ξ 101
Indigenous Peoples’ access to Health Services
ɜ Organize conferences, seminars and forums to allow for the understanding of the situa-
tion of health among indigenous peoples and the holistic process of connecting health,
disease, care and healing from the perspective of dierent world views to strengthen wis-
dom about traditional medicine and to define mechanisms for the interaction and com-
plementary nature of traditional medicine and conventional medicine.
ɜ Support processes of community legitimization for traditional/ancestral physicians and
to develop registers for indigenous therapists at the Ministry of Health, in coordination
with indigenous organizations and indigenous peoples in each country.
ɜ Establish an intercultural epidemiological profile incorporating traditional diseases and
health determinants for indigenous peoples.
ɜ Diasggregate data from databases to include analysis using the indigenous identifiers
and ethnic variables in health registers for national information systems, to produce reg-
ular reports of the health situation according to the epidemiological profile of indigenous
peoples and indicators for intercultural health management and care, information on the
services provided by traditional/ancestral physicians and traditional midwives as part
of the process of integral health information and the interaction of traditional/ancestral
medicine, conventional medicine and other types of medicine existent in the territory.
ɜ Strengthen by specific and targeted capacity building measures the participation of
indigenous peoples in the ongoing analyses of their health status, intercultural health
management and care, articulation and harmonization of traditional/ancestral medicine
with alternative medicine, conventional medicine and health promotion.
ɜ Promote research and systematic organization of ancestral wisdom and practices in
health and traditional/ancestral medicine.
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UN Photo/Broddi Sigurdarson
Chapter 5 ξ 105
Indigenous Peoples’ access to Health Services
Chapter Five
Access to Health Services
by Indigenous Peoples in
North America
UN Photo/Broddi Sigurdarson
106 ξ Chapter 5
State of the World’s Indigenous Peoples
Chapter Five
Access to Health Services
by Indigenous Peoples
in North America
Introduction
This chapter on North America applies to the United States of America and Canada as per the
Permanent Forum’s seven sociocultural regions which gives broad representation to the world’s
indigenous peoples. In the United States, indigenous peoples are collectively known as Native
Americans, which include American Indians and Alaska Natives as well as the people indigenous
to Hawaii, or Native Hawaiians.
274
In Canada, the collective term aboriginal peoples refers to three
groups namely, First Nations, Métis and Inuit defined by section 35 (2) of the Canadian Constitu-
tion Act 1982.
Many indigenous peoples are geographically dispersed across North America. Some live on their
traditional territories or other Native-controlled land areas while others live in urban and rural
areas beyond the boundaries of their indigenous controlled regions. Indigenous peoples living in
urban areas maintain often close ties to their communities and the tribes with which they are af-
filiated, as well as develop bonds with other indigenous peoples in their urban settings. According
to the 2006 census in Canada more than 50 per cent of indigenous peoples
275
live in urban areas.
According to the Oce of Minority Health, 60 per cent of the indigenous peoples in the USA
276
now live in cities.
Indigenous peoples living in border areas face unique challenges when traditional territories cross
national boundaries including tribes living along the United States-Mexico border, the United
States-Canadian border, Alaska Natives living along the borders of Eastern Russia and Cana-
da. Heightened border security measures implemented in recent years have increasingly made
cross-border contact between members of the same tribes very dicult.
277
United States of America
The United States presently recognizes and maintains what it refers to as government-to-
government relations with approximately 566 American Indian and Alaskan native tribes and
villages, around 230 of these being Alaskan native groups. Most of the tribes and villages determine
274
The health issues of Native Hawaiians are covered in the chapter on the Pacific in this report.
275
http://www.aadnc-aandc.gc.ca/eng/1100100014265/1369225120949.
276
http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=52.
277
James Anaya Report of the Special Rapporteur on the rights of indigenous peoples, The situation of indigenous peo-
ples in the United States of America A/HRC/21/47/Add.1 30 August 2012 p. 6.
Chapter 5 ξ 107
Indigenous Peoples’ access to Health Services
their own membership. Federally recognized tribes have reservations or other lands that have
been left or set aside for them, over which they exercise their own powers of self-government.
278
Many other groups in the United States that identify as indigenous peoples have not been fed-
erally recognized, although some of these have achieved recognition at the state level.
279
Today,
according to the United States census, people who identify as Native American represent approx-
imately 1.7 per cent of the overall population of the United States, with 5.2 million persons iden-
tifying as American Indian or Alaska Native.
280
It should be noted that this number significantly
exceeds the number of those who are enrolled or registered members of federally recognized
indigenous groups.
Canada
Membership and identification as an indigenous person in Canada is complex. Given limited space
here, this chapter will briefly describe an overview of the membership categories. In the context of
health services these categories determine access by government jurisdiction to a range of health
services and program eligibility in areas including health and beyond health.
According to Statistic Canada’s National Household Survey (NHS) in 2011, the total number of
people who self-identified as indigenous peoples in Canada was 1.4 million, representing 4.3 per
cent of the total Canadian population of 30 million inhabitants.
281
First Nations represent 60.8 per
cent of the total aboriginal population and 2.6 per cent of the total Canadian population. Of the
aboriginal population, 33 per cent are Métis and 4 per cent are Inuit. The greatest numbers of First
Nations peoples live in Ontario and the western provinces including British Columbia, Alberta,
Sasketchewan and Manitoba. The regions with the largest proportion of indigenous peoples in the
total population are the Nunavut, the Northwest Territories, the Yukon Territory and the Provinces
of Manitoba and Saskatchewan.
First Nations
Today, there are more than 600 federally recognized First Nations, 2,787 First Nation reserves
(land set apart and designated as a reserve for the use and occupancy of an Indian group or band)
across the country.
282
A significant number of indigenous peoples are not registered Indians under
the Federal Government’s 1876 Indian Act, which defines who is considered a “status Indian” or
not, and the law stipulates specific criteria which must be met to determine whether an individual
is eligible to receive a range of services and benefit from a range of programmes oered by federal
and provincial government agencies.
283
278
James Anaya Report of the Special Rapporteur on the rights of indigenous peoples, The situation of indigenous peo-
ples in the United States of America A/HRC/21/47/Add.1 30 August 2012 p. 5.
279
James Anaya Report of the Special Rapporteur on the rights of indigenous peoples, The situation of indigenous peo-
ples in the United States of America A/HRC/21/47/Add.1 30 August 2012 p. 5.
280
U.S. Census Bureau, the American Indian and Alaska Native Population: 2012, pp. 1-3.
281
“An Overview of Aboriginal Health in Canada”, National Collaborating Centre for Aboriginal Health p. 1.
282
Aboriginal Peoples in Canada in 2006: Inuit, Métis and First Nations, p. 9.
283
“An Overview of Aboriginal Health in Canada”, National Collaborating Centre for Aboriginal Health p. 1.
108 ξ Chapter 5
State of the World’s Indigenous Peoples
In 2011, some 637,660 First Nations people were reported as Registered Indians, representing
74.9 per cent of all First Nations peoples, the remainder were non-status First Nations peoples
who identify with a specific First Nations but do not meet the Indian Act membership criteria and
they represent one-quarter of First Nations people (213,900), 15.3 per cent of the total aboriginal
population and less than 1 per cent of the total Canadian population.
284
Registered Indians are
estimated to be 45.5 per cent of the total aboriginal population and 1.9 per cent of the total Ca-
nadian population. Due to an amendment of the Indian Act in 1985, a large number of indigenous
peoples who had lost their status under the Act’s old provisions were able to regain status and
more recently Bill C-3 changed membership criteria of the Indian Act (2011) to address discrimi-
nation against First Nations women. A minority of status Indians in Canada now live on reserves
and settlements, with greater than 50 per cent now living o-reserve, with most residing in urban
metropolitan cities. As mentioned, residency is fluid because people live o reserve to find em-
ployment however it does not mean they have relinquished their First Nations community mem-
bership or tribal membership status.
Inuit
In 2011, 59,445 people identified as Inuit. They represented 4.2 per cent of the total aboriginal
population and 0.2 per cent of the total Canadian population.
285
The Inuit of Canada’s Arctic re-
gions are closely related to the Inuit of Greenland, Alaska and Russia. For many centuries, out-
siders have called Inuit “Eskimos”. This term is no longer considered acceptable. The Inuit prefer
the name by which they have always known themselves, Inuit, which means “the people” in their
language, Inuktitut.
286
The Inuit inhabit vast areas of Nunavut, Yukon and the Northwest Territo-
ries, Nunavik in northern Quebec and Labrador. Together these regions comprise just less that 40
per cent of Canada. Population density is extremely low, and the total population of this region is
less that 50 per cent indigenous. Inuit people also live in urban Canadian cities and towns.
Métis
The 1982 constitutional amendments included the Métis peoples as one of the three indigenous
groups of Canada. The Métis are the descendents of French-Canadian fur traders and native
women, mainly Cree, Ojibwa, or Saulteaux women. In 2011, 451,795 people identified as Métis. They
represented 32.3 per cent of the total aboriginal population and 1.4 per cent of the total Canadian
population. Although the Métis represented just1.4 per cent of the total population of Canada,
they accounted for larger shares of the population in the West. Métis represented 8 per cent of
the total population of the Northwest Territories, 6.7 per cent of Manitoba’s population and 5.2 per
cent of Saskatchewan’s population. Among census metropolitan areas, Winnipeg had the highest
population of Métis, 46,325 people, or 6.5 per cent of its total population. It was followed by Ed-
monton with 31,780, Vancouver with 18,485 and Calgary with 17,040. In addition, 11,520 Métis lived
in Saskatoon, and 9,980 resided in Toronto.
287
284
Aboriginal Peoples in Canada: First Nations People, Métis and Inuit (2011).
285
Aboriginal People in Canada: First Nations People, Métis and Inuit (2011).
286
http://www.arcticinuksuk.com/inuit-culture.html.
287
Aboriginal Peoples in Canada: First Nations People, Métis and Inuit (2011).
Chapter 5 ξ 109
Indigenous Peoples’ access to Health Services
Historically, distinct Métis communities developed along the routes of the fur trade and across the
Canadian Northwest within the Métis Nation Homeland. As stated above, this Homeland includes
the three Prairie Provinces (Manitoba, Saskatchewan, Alberta), as well as, parts of Ontario, British
Columbia, the Northwest Territories and the Northern United States. Today, many of these historic
Métis communities continue to exist along rivers and lakeswhereforts and posts were hubs of
fur trade activity from Ontario westward. The Métis have their own language and unique culture,
and large numbers of Métis citizens now live in urban centres within the Métis Nation Homeland.
International frameworks
Health is a fundamental human right. Every human being is entitled to the enjoyment of the high-
est attainable standard of health conducive to living a life in dignity. It was first articulated in the
1946 Constitution of the World Health Organization (WHO), whose preamble defines health as “a
state of complete physical, mental and social well-being and not merely the absence of disease
or infirmity”.
288
The preamble further states, “the enjoyment of the highest attainable standard of
health is one of the fundamental rights of every human being without distinction of race, religion,
political belief, economic or social condition”.
289
The 1948 Universal Declaration of Human Rights
also mentions health as part of the right to an adequate standard of living (art. 25). The right
to health is also recognized as a human right in the 1966 International Covenant on Economic,
Social and Cultural Rights (art. 10 and 12).
290
The Convention on the Elimination of All Forms of
Discrimination against Women (1979) and the Convention on the Rights of the Child (1989) have
traditionally provided the legal framework for the foundation of international human rights, in-
cluding the right to health. These instruments include provisions for the right to life and for the
“right of everyone to enjoy the highest attainable standard of physical and mental health”,
291
with
some specifically recognising the rights of individuals from marginalized populations, including
indigenous peoples as follows.
ILO Convention No. 169
Article 3 of ILO Convention 169 (1991), states that indigenous peoples “must fully enjoy funda-
mental human rights without obstacles or discrimination”.
292
Article 2 gives governments re-
sponsibility for ensuring that all indigenous peoples have the same rights and opportunities as
non-indigenous peoples. Article 7 specifically refers to the obligation that states parties have
with regard to the improvement of the conditions of life, work, levels of health and education as
a matter of priority in national plans. Article 25 enshrines the obligations of states parties with
regard to the right to social security and health which in summary include: availability of health
services to indigenous peoples; implementation of community-based services which shall take
into account traditional preventive care and healing practices and medicines; and the training of
local community health workers.
288
Constitution of the World Health Organization http://www.who.int/governance/eb/who_constitution_en.pdf.
289
Constitution of the World Health Organization http://www.who.int/governance/eb/who_constitution_en.pdf.
290
E/C.12/2000/4, 11 August 2000.
291
International Covenant on Economic, Social, and Cultural Rights, Article 12.1.
292
http://www.ilo.org/dyn/normlex/en/f?p=NORMLEXPUB:12100:0::NO::P12100_ILO_CODE:C169#A3.
110 ξ Chapter 5
State of the World’s Indigenous Peoples
United Nations Declaration on the Rights of Indigenous Peoples (2007)
The right to health is also recognized specifically for indigenous peoples in the United Nations
Declaration on the Rights of Indigenous Peoples (2007). The United Nations Declaration on the
Rights of Indigenous Peoples articulates several health rights and incorporates the concept of
collective rights. It also includes government obligations to provide indigenous peoples’ access
to health services and to respect indigenous health systems. In particular Articles 23 and 24 state
that indigenous peoples have the right to the enjoyment of the highest standard of physical and
mental health and that indigenous peoples have the right to be actively involved in developing
and determining health programmes aecting them and to administer such programmes through
their own institutions.
293
Further, indigenous peoples have the right to their traditional medicines
and to maintain their health practices, including the conservation of their vital medicinal plants,
animals and minerals. Indigenous individuals also have the right to access, without any discrim-
ination, to all social and health services.
294
In accordance with Article 29, “States shall also take
eective measures to ensure, as needed, that programmes for monitoring, maintaining and re-
storing the health of indigenous peoples, as developed and implemented by the peoples aected
by such materials, are duly implemented”.
295
National Frameworks
It is a noted irony that indigenous peoples living in the richest countries of United States and Can-
ada are among their poorest citizens. In terms of addressing indigenous peoples’ health situation
there are structural issues that require consideration because in many instances, governments
worldwide are willing to address issues of inequality for indigenous peoples but at the same time
are unwilling to address issues of dierence. Many governments seek to end any distinct political
or legal status of indigenous peoples and many are reluctant to directly address certain indige-
nous agendas, which impact the health of indigenous peoples.
296
As mentioned, at the national level, the federal government in both the United States and Cana-
da have responsibility for indigenous health for those who meet the national registration criteria.
Health services were originally provided for federally recognized indigenous tribes living on reser-
vations. However, there is jurisdictional ambiguity and a lack of clarity on the respective roles and
responsibilities between the federal, provincial, territorial and state government vis-à-vis health
and social services to indigenous peoples in North America.
United States of America
In the United States, the Indian Health Service (IHS) provides services to Members of 566 federally
recognized American Indian and Alaska Native Tribes and their descendants. The IHS is an agen-
cy within the federal Department Health and Human Services. The provision of health services
293
United Nations Declaration on the Rights of Indigenous Peoples, Article 23.
294
United Nations Declaration on the Rights of Indigenous Peoples, Article 24.1.
295
United Nations Declaration on the Rights of Indigenous Peoples, Article 29.3.
296
Stephen Cornell “Indigenous peoples, poverty and self-determination in Australia, New Zealand, Canada and the
United States” in Indigenous Peoples and Poverty: An International Perspective eds. Eversole, McNeish and Cimadore
(2005) pp. 199, 203.
Chapter 5 ξ 111
Indigenous Peoples’ access to Health Services
to members of federally recognized tribes grew out of the special government-to-government
relationship between the federal government and Indian tribes. This relationship, established in
1787, is based on Article I, Section 8 of the Constitution, and has been given form and substance
by numerous treaties, laws, Supreme Court decisions, and Executive Orders. The IHS operates a
comprehensive health service delivery system for approximately 2 million American Indians and
Alaska Natives. The majority of those who receive IHS services live mainly on reservations and in
rural communities in 36 states, mostly in the western United States and Alaska.
297
Since 1972, the IHS has embarked upon a series of initiatives to fund health-related activities in
o-reservation settings, which will make health care services accessible to urban Native Ameri-
cans including Indians and Alaska Natives. Currently, the IHS funds 33 urban Indian health orga-
nizations, which operate at sites located in cites throughout the United States. Approximately
600,000 American Indians and Alaska Natives are eligible to utilize this program. The 33 pro-
grams administer medical services, dental services, community services, alcohol and drug abuse
prevention, education and treatment, AIDS and sexually transmitted disease education and pre-
vention services, mental health services, nutrition education and counselling services, pharmacy
services, health education, optometry services, social services, and home health care.
298
Canada
In Canada, the federal government established the Health Canada’s role in First Nations and Inuit
health in 1945, when Indian health services were transferred from Indian Aairs to Health Canada.
By 1962, Health Canada was providing direct health services to First Nations people on reserve
and to Inuit communities in the north. By the mid 1980s, work began to have First Nations and
Inuit communities control the administration of community health services by implementing the
health transfer policy. The First Nations and Inuit Health Branch (FNIHB) within the Department
of Health Canada has headquarters in Ottawa, Ontario, the capital city of Canada and regional
oces in every province and supports the delivery of public health and health promotion services
on reserve and in Inuit communities. It also provides drug, dental and ancillary health services
to First Nations and Inuit people regardless of residence. Within FNIHB are the community pro-
gramme directorate, primary health care and public health directorate, non-insured health ben-
efits directorate, the oce of nursing services, and the oce of community medicine, business
planning and management directorate, strategic policy, planning and analysis directorate and
the chief advisor of First Nations and Inuit relations. The Health Transfer Policy acknowledges the
special relationship between First Nations and the federal government but does not recognize
health as an aboriginal treaty right. While it transfers a range of services to First Nations and Inuit
communities, it retains the major decision-making powers. For example, First Nations proposals
for community health plans must be approved by the federal government. Further, the Health
Transfer Policy does not recognize the role of traditional healers, nor does it fund the training of
First Nations health care professionals.
299
However, First Nations can fund education assistance
to members from the limited education and training resources available to the community.
297
http://www.ihs.gov/aboutihs/.
298
http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=52.
299
Naomi Adelson, “The embodiment of Inequality: Health Disparities in Aboriginal Canada”, Canadian Journal of Public
Health, Vol. 96 (2005), p. 558.
112 ξ Chapter 5
State of the World’s Indigenous Peoples
First Nations, Inuit and Métis living in urban centres often find themselves excluded from many
of the benefits and services that arise from the FNIHB. Indigenous peoples moving into or living
in urban areas are faced with having to negotiate a range of health care provisions as they exit
their community health networks and enter the provincially funded public health care system. While
there are various successful, culturally appropriate urban initiatives across Canada, there remains a
problem of inadequate assessment of health care needs and often there are very few resources to
oer appropriate services to the urban, and particularly the poor, women, men and children. Aborig-
inal women continue to search for services that are gender-sensitive, culturally appropriate and at
the same time inclusive of their children.
300
For the northern territories of Nunavut, the Northwest
Territories and the Yukon health services funding are allocated by the territorial governments.
Analysis of the Health Situation for Indigenous Peoples in USA and Canada
Overview
The appropriation and displacement of indigenous peoples from their lands and their subsequent
marginalization from the rest of society is a historical reality with continuing repercussions today
in the United States and Canada.
301
Indigenous peoples current social inequalities results from a
combination of socioeconomic deficits that are ongoing such as colonization, globalization, and
migration, loss of language and culture and disconnection from land. The severance of ties to
their lands, can aect indigenous peoples’ associated cultural practices and participation in tra-
ditional economies, all of which are essential for health and well-being.
302
One of the most devastating consequences of colonialism in both the United States and Canada
which are still felt today, was the forced assimilation policy involving the systematic removal of
indigenous children from their families to place them in government or church-run residential or
boarding schools, with the objective of expunging their indigenous identities. The Indian boarding
or residential school policy which began in the 1880s continued well into the mid-1900s. That emo-
tional, physical and sexual abuse occurred in boarding schools, as well as punishment for speaking
their languages and practicing their cultures has been well documented, has been acknowledged
and has tarnished the human rights record of Canada and the United States. The eects of boarding
schools on generations of indigenous peoples, including generations still living and future genera-
tions, cuts deep in indigenous communities throughout the United States and Canada, where many
believe are the root cause of pervasive social problems such as alcoholism and sexual abuse and
the widespread loss of indigenous languages.
303
Negative memories of this institutionalization are
thought to have created a social climate of distrust of other government-funded institutions such
as hospitals and clinics, resulting in avoidance until an illness is advanced.
300
Cecilia Benoit, Dena Carroll, Munaza Chaudhry “In search of a Healing Place: Aboriginal women in Vancouver’s Down-
town Eastside” Social Science & Medicine 56 (2003) 821-833, p. 831.
301
Carolyn Stephens, John Porter, Clive Nettleton, Ruth Willis “ Disappearing, displaced and undervalued: a call to action
for indigenous health worldwide”, www.thelancet.com, Vol 367, June 17, 2006, p. 2023.
302
Malcolm King, Alexandra Smith, Michael Gracey “ Indigenous Health part 2: the underlying causes of the health gap”,
www.thelancet.com, Vol 374, July 4, 2009, p. 76.
303
James Anaya Report of the Special Rapporteur on the rights of indigenous peoples, The situation of indigenous peo-
ples in the United States of America A/HRC/21/47/Add.1 30 August 2012 p. 5.
Chapter 5 ξ 113
Indigenous Peoples’ access to Health Services
Urbanization is part of the continuing transformation of indigenous peoples’ culture; however, it
can also aect residential instability, which is also marked by frequent migration back and forth
from cities and towns to reserves, as well as high mobility within the cities and towns. This insta-
bility aects indigenous peoples in a number of ways especially where there is high proportion of
female lone-parent families with low incomes. These families often face many challenges in their
eorts to deal with urban living. Other marginalized indigenous groups also suer poor health
and social exclusion and/or exploitation such as women, elders, youth, two-spirited people,
304
and persons with disabilities. The push factors that determine the patterns of rural to urban mi-
gration include unemployment, poor social and economic conditions, boredom and low quality of
life, overcrowding due to scarcity of housing, health facilities and educational opportunities.
The relationship between HIV/AIDS and indigenous peoples has not received due international
attention despite the fact that indigenous peoples have particular vulnerabilities to acquiring
HIV/AIDS. Many indigenous cultures have traditionally understood sexuality as part of creation,
connected to ancestry and cultural traditions and the cycle of life. In some indigenous cultures,
sexual diversity was accepted and celebrated. Unfortunately, stigma and discrimination exists in
many indigenous communities against lesbians, gay, bisexual and transgender or two-spirited
persons which makes it hard for them to access services and support programmes. Likewise,
women and girls can also be vulnerable to HIV infection, particularly in situations of racialized and
sexual violence or where their daily survival strategies include trading unsafe sex for money, food,
shelter or drugs and where needle sharing occurs. The rate of HIV infection among indigenous
youth is also increasing.
305
In addition to concerns such as land loss, and control over resources there are other emerging
health issues. The Arctic regions of the United States (Alaska) and Canada (Northern Canada)
have the highest levels of persistent organic pollutants (POPs) on earth. POPs are artificially
created organic compounds that resist natural breakdown and can persist for many years. The
toxic health-threatening substances are transported over long distances by rivers, oceans and air
currents from warmer parts of the world to the colder polar regions. They also accumulate in the
fatty tissue of seals and whales which traditionally play a key role in Arctic indigenous peoples’
diet and can be passed directly to infants through maternal breast milk, causing disruption of the
hormone and immune systems and aecting postnatal growth.
306
United States
The indigenous peoples of the United States are diverse and geographically dispersed, and the
large majority are economically disadvantaged. Disease patterns among American Indians and
Alaska Natives are strongly associated with the adverse consequences of poverty, limited access
to health services, and cultural dislocation. Inadequate education, high rates of unemployment,
discrimination, and cultural dierences all contribute to unhealthy lifestyles and disparities in ac-
cess to health care for many indigenous peoples. Despite the funding appropriated by the United
States Congress to deliver health care services, indigenous peoples continue to suer dispropor-
tionately from a variety of illness and diseases. While the incidence and prevalence of infectious
304
Indigenous lesbian, gays, bi-sexual and transsexuals (LGBT).
305
HIV/AIDS and Indigenous Peoples: Final Report of the 5th International Policy Dialogue, International Aairs Director-
ate, Health Canada, October 21-23, 2009 Ottawa, Canada, pp. 7-8.
306
State of the World’s Minorities and Indigenous Peoples 2013, p. 115.
114 ξ Chapter 5
State of the World’s Indigenous Peoples
diseases have been dramatically reduced through increased clinical care and public health eorts
such as vaccinations for infectious diseases and the construction of sanitation facilities, newer
threats such as diabetes and other chronic conditions mean that indigenous peoples continue to
experience health disparities and higher death rates than the rest of the population.
307
The data on health disparities provided by the Indian Health Service’s own fact sheets presents
enormous health issues for Native Americans and Alaska Natives. Indigenous peoples born today
have a life expectancy that is 5.2 years less than the US population of all races (72.6 years to 77.8
years, respectively). They also die at higher rates than other Americans from tuberculosis (500 per
cent higher), alcoholism (514 per cent higher), diabetes (177 per cent higher), unintentional injuries
(140 per cent higher), homicide (92 per cent higher) and suicide (82 per cent higher).
308
Mortality disparity rates for American Indians and Alaska Natives (AI/AN) in the IHS Service
Area 2005-2007 and U.S. All Races 2006 (age-adjusted mortality rates per 100,000 population)
AI/AN rate
2005-2007
U.S. All-race rate
2006
Ratio: AI/AN to
U.S. all races
All causes 953.7 776.5 1.2
Alcohol induced 45 6.9 6.5
Breast cancer 19.6 23.5 0.8
Cerebrovascular 43.8 43.6 1
Cervical cancer 2.8 2.4 1.2
Diabetes 65.6 23.3 2.8
Heart disease 191.7 200.2 1
HIV infection 3.2 4 0.8
Homicide (assault) 11 6 1.8
Infant Deaths
1
7. 3 6.7 1.1
Malignant neoplasm 170.1 180.7 0.9
Maternal deaths 20.2 13.3 1.5
Pneumonia/influenza 24.3 17.8 1.4
Suicide 19 10.9 1.7
Unintentional injuries* 94.8 39.8 2.4
1
Infant deaths per 1,000 live births.
* Unintentional Injuries include motor vehicle crashes.
Note: Rates are adjusted to compensate for misreporting of American Indian and Alaska Native race
on state death certificates. American Indian and Alaska Native death rate columns present data for the
three-year period specified. U.S. All Races columns present data for a one-year period. ICD-10 codes were
introduced in 1999; therefore, comparability ratios were applied to deaths for years prior to 1999. Rates are
based on American Indian and Alaska Native alone; 2000 census with bridged-race categories.
307
American Indians and Alaska Natives: Health Disparities Overview http://itepsrv1.itep.nau.edu/itep_course_down-
loads/AQ-Alaska_Resources/HealthEects/AIAN_Disparities_Overview.pdf.
308
http://www.ihs.gov/newsroom/factsheets/disparities/.
Chapter 5 ξ 115
Indigenous Peoples’ access to Health Services
Suicide is the second leading cause of death behind unintentional injuries among indigenous chil-
dren and young adults, according to the IHS. Native Americans aged 15-24 years commit suicide
3.5 times higher than the national average and incidence is rising. Moreover, 40 per cent of indig-
enous suicides occur within this age group. Suicide figures vary by community however, suicide
rates have consistently been higher among Alaska Natives than any other racial/ethnic group
in the United States. Suicide ranked fourth among the leading causes of death among Alaska
Natives in 2008.
309
Alaska has the highest rate of suicide per capita in the country. A 1983-1984
study noted that although Alaska Natives represented 14 per cent of the population in Alaska,
they accounted for 33 per cent of the suicides.
310
During 2003-2006, Alaska Natives comprised 16
per cent of Alaska’s total population, and accounted for 38 per cent of the suicides.
311
In 2008, the
suicide rate among Alaska Natives (42.9 per 100,000) was 1.9 times higher than the rate for Alas-
ka’s total population (24.6 per 100,000) and 3.7 times that for the U.S. total population (11.6 per
100,000).
312
Suicide rates among Alaska Natives have been consistently the highest among adult
males under 35 years of age.
313
A more recent study by the Alaska Native Tribal Health Consortium
showed that during 2004-2008, the median age of suicide among Alaska Whites was 43 years,
while the median age among Alaska Natives was 26 years.
314
Some researchers also mentioned that self-destruction and suicide may also be hidden in some
instances. For example, accidental death from motor vehicle crashes is higher among indigenous
peoples than the general population of the United States. Fatal single vehicle crashes involving
indigenous peoples were found to be a higher risk group for self-destruction than either Na-
tive American fatal multiple vehicle crashes or non-Native fatal crashes. Single-vehicle crashes
among indigenous youths may hide some forms of self-destruction and/or suicide as they do in
other populations.
315
In some indigenous communities in North America, there are certain rituals
and customs around death so suicide is regarded as taboo and as a result, suicides often go un-
reported or get classified by police as accidental death.
316
There have been profound changes over the last 75 years among Alaska Natives; in the past,
males aged 20-29 years would have had families of their own and would have been involved in
subsistence activities in order to support their families. According to studies, there are likely to
be a multitude of psychosocial factors that contribute to the extremely high suicide rates among
Alaska Natives. For example, mental health disorders (particularly depression and substance
abuse) are associated with more than 90 per cent of all cases of suicide. At the same time, suicide
is thought to be a consequence stemming from many complex sociocultural factors and is more
309
Jessica Craig, MPH, Alaska Native Tribal Health Epidemiology Center, and Deborah Hull-Jilly, MPH, Alaska Section of
Epidemiology “, Characteristics of Suicide Among Alaska Native and Alaska non-Native People, 2003-2008”, (2012) p. 3.
310
Hlady W.G., Middaugh J.P., The epidemiology of suicide in Alaska, 1983-1984. Alaska Med. Nov-Dec 1987;29(5):158-164.
311
Perkins R., Sanddal, T.L., Howell M., Sanddal N.D., Berman A., Epidemiological and follow-back study of suicides in
Alaska. Int J Circumpolar Health. 2009;68(3):212-223.
312
Web-based Injury Statistics Query and Reporting System (WISQARS). 2007. http://www.cdc.gov/ncipc/wisqars.
313
Perkins R., Sanddal T.L., Howell M., Sanddal N.D., Berman A. Epidemiological and follow-back study of suicides in Alas-
ka. Int J Circumpolar Health. 2009;68(3):212-223.
314
Day G., Holck P., Provost E., Alaska Native Mortality Update: 2004-2008: Alaska Native Epidemiology Center; October 2011.
315
Philip A. May, “Suicide and Self-Destruction among American Indian Youth”, American Indian and Alaska Native Mental
Health Research, 1(1), June 1987, p. 68.
316
Laurel Morales “Native Americans Have Highest Rate of Suicide”, August 31, 2012
http://www.fronterasdesk.org/content/native-americans-have-highest-rate-suicide.
116 ξ Chapter 5
State of the World’s Indigenous Peoples
likely to occur during periods of socioeconomic, family and individual crisis (e.g. loss of a loved
one, unemployment, sexual orientation, diculties with developing one’s identity, disassociation
from one’s community or other social/belief group and honour). Other factors include alcohol and
drug abuse, access to firearms, exposure to domestic/family violence, physical health problems
and less access to suicide prevention and intervention programs.
317
The prevalence of diabetes is higher among the American Indian and Alaska Native population
(16.5 per cent) than any other major racial or ethnic group in the United States, and the prev-
alence of diabetes has been increasing.
318
Diabetes kills roughly four times as many American
Indians and Alaska Natives as it does members of the mainstream United States population.
319
In general, people are more likely to develop type 2 diabetes and die from its complications as
they grow older, a pattern that is even more pronounced among American Indians and Alaska
Natives.
320
Many people do not know they have type 2 diabetes until the symptoms of compli-
cations appear.
321
Indigenous peoples with diabetes are six times more likely than the general
population to have kidney disease and between three to four times more likely to require low-
er-limb amputations. In this way, diabetes not only contributes to early mortality but it is among
one of the leading causes of disability, contributing to unemployment and poverty. Gestational
diabetes is also of great concern and is noted to occur more frequently among American Indian
and Alaska Native women than women in other minority groups. Women who experience ges-
tational diabetes have a 20 to 50 per cent chance of developing type 2 diabetes in 5 to 10 years
after pregnancy.
322
Children whose mothers had diabetes during pregnancy are at increased risk
of developing type 2 diabetes themselves.
In April 2007, Amnesty International issued a report entitled Maze of Injustice: The failure to protect
Indigenous women from sexual violence in the United States. The report confirmed what Native
American and Alaska Native advocates have long known: that sexual violence against indigenous
women is at epidemic proportions and that survivors are frequently denied justice. The United States
Department of Justice’s own statistics indicate that Native American and Alaska Native women are
more than two and a half times more likely to be raped or sexually assaulted than women in the
United States in general and that 86 per cent of the reported crimes are committed by non-Native
men. Health Service providers have a key role to play in providing survivors with medical attention
they may need. However, many IHS facilities do not consistently provide forensic sexual assault
317
Jessica Craig, MPH, Alaska Native Tribal Health Epidemiology Center, and Deborah Hull-Jilly, MPH, Alaska Section of
Epidemiology “Characteristics of Suicide Among Alaska Native and Alaska non-Native People”, 2003-2008 (2012), p. 7
http://www.epi.hss.state.ak.us/bulletins/docs/rr2012_01.pdf.
318
Patricia M. Barnes, M.A.; Patricia F. Adams; and Eve Powell-Griner, “Health Characteristics of the American Indian or
Alaska Native Adult Population: United States, 2004-2008” http://www.cdc.gov/nchs/data/nhsr/nhsr020.pdf.
319
Indian Health Service. Trends in Indian Health, 2000-2001. Washington, DC: U.S. Department of Health and Human
Services. http://www.ihs.gov/NonMedicalPrograms/IHS_Stats/files/Trends00-01_Part4.pdf.
320
Indian Health Service. Trends in Indian Health, 2000-2001. Washington, DC: U.S. Department of Health and Human
Services. http://www.ihs.gov/NonMedicalPrograms/IHS_Stats/files/Trends00-01_Part4.pdf.
321
Centers for Disease Control and Prevention. National Diabetes Fact Sheet: General Information and National Esti-
mates on Diabetes in the United States. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for
Disease Control and Prevention, 2005. http://www.cdc.gov/diabetes.
322
Centers for Disease Control and Prevention. National Diabetes Fact Sheet: General Information and National Esti-
mates on Diabetes in the United States. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for
Disease Control and Prevention, 2005. http://www.cdc.gov/diabetes.
Chapter 5 ξ 117
Indigenous Peoples’ access to Health Services
examinations. IHS also lack clear protocols for treating victims of sexual violence, are severely un-
derfunded and lack personnel trainers to provide services in the event of sexual violence.
323
Age-adjusted percentages of persons 18 years of age and over with diabetes, 2004-2008
American Indian/
Alaska Native
White
American Indian/
Alaska Native/white ratio
Men and women 17. 5 6.6 2.7
Men 18.2 7. 2 2.5
Women 16.2 6.2 2.6
Source: CDC 2010. Health Characteristics of the American Indian and Alaska Native Adult Population:
United States, 2004-2008.
Radioactive tailings are one of the major concerns for many indigenous peoples living near aban-
doned uranium mines on tribal lands. The first major uranium mine in the United States was start-
ed in 1953 near Laguna Pueblo, New Mexico.
324
Since that time there have been over 15,000 urani-
um mines with a majority of those being on indigenous peoples’ lands. Most of the other mines lay
abandoned with radioactive tailings and dust present at almost all of them. Most of the mining
has been on the Colorado Plateau, but other areas in Washington State and the Dakotas have
also been impacted. Indigenous peoples have had their water sources impacted by the radioactive
tailings from the mine operations. A large part of the workforce for these mines included a large
number of indigenous peoples. A few decades after uranium mining began in the Navajo Nation,
increased numbers of cancer cases, lung cancer in particular, began to show up in the miners.
325
The area where most of the mines are located is typically dry, and the dust that comes o of the
wasted rock tailings is radioactive. This dust, mixed with the air, is thought to cause lung cancer
and other breathing ailments. Elevated radon levels have also been associated with these aban-
doned mines. The eect of long-term radiation exposure in the levels associated with these mines
is largely unknown. Despite the obvious need, there have not been to date any comprehensive
studies of radiation and heavy metal contamination in the United States.
326
Food security remains an issue for indigenous peoples. This is especially so in Alaska where Alas-
kan Natives are subject to a particular legal regime under the Alaska Native Claims Settlement Act
1971 which extinguished all claims of aboriginal title including any aboriginal hunting and fishing
rights that may exist, throughout Alaska. The act set up a system of Native-run corporations. Since
then, indigenous hunting and fishing rights are subject to the same regulatory regime that applies
to non-indigenous activities. Subsistence hunting and fishing remains crucial both for cultural pur-
poses and for food security. Subsistence activities are also subject to a state regulatory regime
323
Amnesty International Maze of Injustice: One Year Update, 2008, pp. 1, 10.
324
Philip Sittnick, Uranium Mining and Its Impact on Laguna Pueblo: A Study Guide for an Interdisciplinary Unit, July 1998,
p. 17, http://www.miningwatch.ca/sites/www.miningwatch.ca/files/umine_0.pdf.
325
Kevin Zeese/Margaret Flowers America’s “Secret Fukushima”: Uranium Mining is Poisoning the Bread Basket of the
World, The Fourth Media 17 June 2013 http://www.4thmedia.org/.
326
Kevin Zeese/Margaret Flowers America’s “Secret Fukushima”: Uranium Mining is Poisoning the Bread Basket of the
World, The Fourth Media 17 June 2013 http://www.4thmedia.org/.
118 ξ Chapter 5
State of the World’s Indigenous Peoples
that allows for, competing land and resource uses, such as mining and other activities, including
hunting and fishing for sport, which also threatens the natural environments and food sources.
327
Canada
Prior to European contact indigenous peoples in Canada practiced their own systems of health
knowledge. However, the traditional health systems were devastated during colonization as dis-
eases and conflicts impacted indigenous peoples.
Today, health care for indigenous peoples in Canada continues to be a complex and diverse is-
sue. While the health of indigenous peoples in Canada has seen improvement in recent years,
they continue to experience considerably lower health outcomes than non-indigenous Canadi-
ans. Comparing the wider society to indigenous peoples on many health indicators, indigenous
peoples continue to experience higher infant and young-child mortality rates; higher maternal
morbidity and mortality rates; a heavy infectious disease burden; malnutrition; shortened life ex-
pectancy; diseases and death associated with cigarette smoking; social problems, illnesses and
deaths linked to misuse of alcohol and other drugs; accidents, poisonings, interpersonal violence,
homicide and suicide; obesity, diabetes, hypertension, cardiovascular, and chronic renal disease
(lifestyle diseases); and diseases caused by environmental contamination (for example, heavy
metals, industrial gases and euent wastes).
328
The disparities in health between the indigenous and non-indigenous populations are linked to the
underlying causes that sit largely outside of the constituted health domain and are referred to as
the determinants of health. Health disparities are directly and indirectly associated with or related
to social, economic, cultural and political inequities; the end result of which is a disproportionate
burden of ill health and social suering. There are major dierences in the socioeconomic circum-
stances and lived world experiences of First Nations, Inuit, and Métis peoples, between status and
non-status, on-reserve and o-reserve, as well as urban and rural indigenous peoples. At the same
time, census data and other research show a persistent gap in socioeconomic status and well-be-
ing between indigenous and non-indigenous peoples in Canada.
329
For example, Canada’s 2006
statistics indicated that fewer indigenous peoples between the ages of 25 and 34 obtained high
school diplomas (68.1 per cent) than non-indigenous people (90 per cent).
330
The 2005 median in-
come for indigenous peoples was CAN$ 16,752 which is almost CAN$ 10,000 (or 35 per cent) lower
than for non-indigenous people (CAN$ 25,955),
331
and despite a 10 per cent increase in aboriginal
employment between 1996 and 2006 (compared to a 4.1 per cent increase in non-indigenous em-
ployment during the same time period), the unemployment rate for indigenous peoples in 2006
327
James Anaya Report of the Special Rapporteur on the rights of indigenous peoples, The situation of indigenous peo-
ples in the United States of America A/HRC/21/47/Add.1 30 August 2012 p. 6.
328
An Overview of Aboriginal Health in Canada, National Collaborating Centre for Aboriginal health, p. 3.
329
Naomi Adelson, “The Embodiment of Inequity: Health Disparities in Aboriginal Canada” Canadian Journal of Public
Health, March-April, 2005), p
330
A Demographic and Socio-Economic Portrait of Aboriginal Populations in Canada, Indian and Northern Aairs Cana-
da, 2009, p. 4, http://publications.gc.ca/collections/collection_2010/ainc-inac/R3-109-2009-eng.pdf.
331
A Demographic and Socio-Economic Portrait of Aboriginal Populations in Canada, Indian and Northern Aairs Cana-
da, 2009, p. 4, http://publications.gc.ca/collections/collection_2010/ainc-inac/R3-109-2009-eng.pdf.
Chapter 5 ξ 119
Indigenous Peoples’ access to Health Services
was still 13.0 per cent which was more than 2.5 times higher compared to non-indigenous people
(5.2 per cent).
332
Indigenous peoples in Canada face many urgent health issues. For example, indigenous Cana-
dians are overrepresented in HIV infection rates. Indigenous peoples are especially vulnerable
to HIV infection when compared the general Canadian population due to poor access to health
services, high rates of poverty, substance abuse, intravenous drug use and also tattooing. While
indigenous peoples account for 4.3 per cent of the total Canadian population, they account for 8
per cent of people living with HIV and 12.5 per cent of new infections in 2008. Indigenous peoples
also experience disproportionate rates of tuberculosis at 26.4 times the rate of Canadian borne
non-indigenous peoples. While there are limited data on the rates of diabetes in Métis and Inuit
communities, type 2 diabetes is considered to have reached epidemic level in First Nations com-
munities.
333
In some First Nations communities, youth suicide occurs at a rate of 800 times the
national average.
334
The suicide rate among Inuit communities in Arctic Canada is 10 times that of
the general Canadian population.
335
The 2008-2010 First Nations Regional Health Survey (RHS) indicated that household overcrowd-
ing and poor housing conditions (dwellings in need of major repair) in indigenous communities
show some improvement, but regional statistics indicate that this remains a major concern in
some areas. The rates of household overcrowding remained steady in Canada’s non-indigenous
population at 1.4 per cent, the rates of overcrowding in the total indigenous population went from
7.6 per cent in 1996 to 4.3 per cent in 2006.
336
At the same time, overcrowding rates reached 23
per cent in Nunavut and 8 per cent in Saskatchewan (Indian and Northern Aairs Canada, 2009).
Similarly, indigenous peoples were three times as likely as non-indigenous people to live in houses
in need of major repair, and over 22 per cent of dwellings in indigenous communities in 5 provinc-
es and 3 territories (Manitoba, Saskatchewan, Northwest Territories, Yukon, and Nunavut) were in
need of major repair in 2006, compared with an average of 7.0 per cent in non-indigenous com-
munities in Canada.
337
More than half of Canada’s aboriginal population live in urban centres, and the two-thirds of
this population lives in Western Canada.
338
Canada’s urban aboriginal people today comprise a
332
A Demographic and Socio-Economic Portrait of Aboriginal Populations in Canada, Indian and Northern Aairs Cana-
da, 2009, p. 6,. http://publications.gc.ca/collections/collection_2010/ainc-inac/R3-109-2009-eng.pdf.
333
H.V. Thommasen, J. Patenaude, N. Anderson, A. McArthur and H. Tildesley “Dierences in diabetic co-morbidity be-
tween Aboriginal and non-Aboriginal people living in Bella Coola, Canada” Rural and Remote Health 4:319 (online)
2004 http://www.rrh.org.au/publishedarticles/article_print_319.pdf.
334
Chandler, M.J. and Lalonde, C. (1998) “Cultural continuity as a hedge against suicide in Canada’s First Nations”. Trans-
cultural Psychiatry, 35: 191-219.
335
Kral, M.J. (2012). “Postcolonial Suicide among Inuit in Arctic Canada”. Culture, Medicine, and Psychiatry. 36(2): 306-325.
336
A Demographic and Socio-Economic Portrait of Aboriginal Populations in Canada, Indian and Northern Aairs Cana-
da, 2009, p. 7, http://publications.gc.ca/collections/collection_2010/ainc-inac/R3-109-2009-eng.pdf.
337
A Demographic and Socio-Economic Portrait of Aboriginal Populations in Canada, Indian and Northern Aairs Cana-
da, 2009, p. 7, http://publications.gc.ca/collections/collection_2010/ainc-inac/R3-109-2009-eng.pdf.
338
Hanselmann, C. (2001). Urban Aboriginal people in Western Canada: Realities and policies. Calgary, Alberta: Canada
West Foundation.
120 ξ Chapter 5
State of the World’s Indigenous Peoples
diverse, youthful and growing population.
339
Despite their growing numbers, urban aboriginal
people in Canada continue to earn far below the median average income for non-urban coun-
terparts. Urban aboriginal people also tend to have comparatively higher rates of homelessness,
greater housing needs and higher rates of suicide and are particularly at risk of substance abuse,
contracting tuberculosis and/or HIV or developing diabetes. This indicates that many aboriginal
people, especially those residing in urban areas, are in danger of falling through the cracks of the
Canadian health care system and social security safety net.
340
Other examples where the underlying causes or determinants of health are most felt is the expe-
rience of the Indian residential school system survivors. In Canada and the United States, as well
in other colonized nations, many generations of indigenous children were sent away from parents
and their communities to residential schools. The eect of this experience is collective trauma,
consisting of, the structural eects of disrupting families and communities; the loss of parenting
skills as a result of institutionalization; patterns of emotional response resulting from the absence
of warmth and intimacy in childhood; the carryover of physical and sexual abuse; the loss of indig-
enous knowledge, languages and traditions; and the systemic devaluing of indigenous peoples’
identity. The legacies of these and other policies of forced assimilation are also seen in the pres-
ent relationships of indigenous peoples with the larger society.
The situation of indigenous women in Canada remains a serious social issue and a major concern.
According to Canadian government statistics, indigenous women are five times to seven times
more likely than other women to die as the result of violence. The Native Women’s Association of
Canada, through its own hard work, documented more than 582 cases of missing and murdered
indigenous women in Canada, most within the last three decades. Due to the gaps in police and
government reporting, the actual numbers may be much higher.
341
Vulnerable and marginalized women are exposed to a higher risk of violence including sexual
assault, murder and serial predation. The phenomenon of missing and murdered women is one
stark example of this exposure and is seen as part of a broader pattern of marginalization and
inequality. The increased vulnerability of certain groups of women, such as women involved in the
sex trade, play an important role in providing victims for serial killers.
The loss of the missing women and the unsatisfactory police, government and public response
has resulted in widespread physical and emotional distress, particularly within families but ex-
tending to other important relationships. One dimension of this distress is the guilt and shame
at having failed to protect loved ones. In some cases, these emotions have caused what appears
to be irreparable damage to families. Some described personal struggles with addiction, some
described the agony of watching other family members using alcohol or drugs to cope with their
pain, and some experienced both of these situations. Health problems and the practical require-
339
Dion Stout, M., Kipling, G. and Stout, R. (2001). Aboriginal Women’s Health Research Synthesis Paper: Final Report.
Centres of Excellence for Women’s Health. Ottawa, Women’s Health Bureau.
340
Cecilia Benoit, Dena Carroll, Munaza Chaudhry, “In search of a Healing Place: Aboriginal women in Vancouver’s Down-
town Eastside” Social Science & Medicine 56 (2003) 821-833, p. 822.
341
Native Women’s Association of Canada. (2010). What their stories tell us: Research findings from the Sisters in Spirit
initiative, Ottawa, ON, http://www.nwac.ca/sites/default/files/reports/2010_NWAC_SIS_Report_EN.pdf.
Chapter 5 ξ 121
Indigenous Peoples’ access to Health Services
ments of dealing with surviving children have meant that family members have been unable to
work; these financial concerns have sometimes caused further health impacts on families.
342
Discrimination and marginalization of indigenous women in Canada is not new; it has a long colo-
nial history. In 1857, indigenous men were allowed to renounce their indigenous status and the right
to live on reserve lands in order to assimilate into non-indigenous society. Indigenous women, on
the other hand were not given the same choice. In fact, in contrast to traditional indigenous matri-
archal family structure the post colonial indigenous women’s status was determined by the choices
made by her husband or father. A second law passed in 1869, stripped women of their indigenous
status and their place in their community if they married a man from another community, even if he
was also indigenous.In addition, children born to an indigenous woman who married a non-indig-
enous man would also be denied status. This was not true for Indian men, whose non-Indian wives
gained status as Indians upon marriage.These laws remained in place for more than a century.
In 1985, after a long, hard struggle by indigenous women, which included bringing a successful
complaint to the UN Human Rights Committee, 35 the policies were repealed for being incom-
patible with protections against discrimination in the new Canadian Charter of Rights and Free-
doms. While Bill C-31 (1985) addressed many of these problems, it did not reduce discrimination
against women. Under the new Act, anomalies can develop where the children of a status Indian
woman can pass on status to their children only if they marry registered Indians, whereas the
grandchildren of a status male will have full status, despite the fact that one of their parents does
not have status.
343
While a person may be a Status Indian, it is up to a Band whether she or he is
considered a Band member. Entitlements reinstated under Bill C-31 do not necessarily translate
into Band membership. This can be problematic for women and their families who have had their
Status reinstated through Bill C-31. Women may not have many connections to a Band, or there
may be a shortage of resources for such things as housing, education programs or health care on
the reserve, so that Bands can be reluctant to accept new members.
344
Poverty has clear outcomes on health because, in part, it determines what kinds of foods house-
holds have available to them and what they can aord to purchase. Thus, families at lower in-
comes are subject to the stress of food insecurity from a compromised diet that results when
food is no longer available. In 1998-1999, indigenous peoples living o reserve were almost three
times more likely to be living in households experiencing food insecurity than was the case for all
Canadians (27 per cent to 10 percent). This condition is strongly related to low incomes as well as
single parent status, both of which are more likely to occur in aboriginal households.
In 2012, the Special Rapporteur on the right to food, Mr. Olivier De Schutter, undertook a country
visit to Canada. In his report
345
he stated he was disconcerted by the deep and severe food in-
security faced by aboriginal peoples living both on- and o-reserve in remote and urban areas.
In the Yukon, the Northwest Territories and Nunavut, where the greatest concentration of Inuit
342
Forsaken: the Report of the Missing Women Commission of Inquiry (2012) Vol. 111, p. 41.
343
Report of the Aboriginal Justice Inquiry of Manitoba (1999)http://www.ajic.mb.ca/volumel/chapter13.html#4.
344
Kathy Bent, Joanne Havelock, Margaret Haworth-Brockman, “Entitlements and health services for First Nations and
Métis women in Manitoba and Saskatchewan”, The Prairie Women’s Health Centre of Excellence, August 2007, http://
www.pwhce.ca/pdf/entitlementsHealthServices.pdf.
345
A/HRC/22/50/Add.1.
122 ξ Chapter 5
State of the World’s Indigenous Peoples
populations resides, food insecurity in 2007-2008 was 11.6 per cent, 12.4 per cent and 32.6 per cent
respectively. Health Canada,
346
The Special Rapporteur also stated that First Nations Regional
Longitudinal Health Survey (RHS 2008-2010) indicates that 17.8 per cent of First Nations adults
(ages 25-39) and 16.1 per cent of First Nations adults (ages 40-54) reported being hungry, but did
not eat due to lack of money for food in 2007-2008.
347
Though the situation of food insecurity is
monitored through surveys such as the Canadian Community Health Survey, the Inuit Health Sur-
vey and the First Nations Food, Nutrition and Environment Study, Canada, the Special Rapporteur
found there were no data on food insecurity in Métis population.
348
The Special Rapporteur also stated that despite programmes such as the Canada Prenatal Nutri-
tion Program (including the First Nations and Inuit component); Aboriginal Head Start (includes
on-reserve and urban and northern component); the Aboriginal Diabetes Initiative; and Nutrition
North Canada, discussed in greater detail below, research conducted by the University of Mani-
toba noted that in 2008-2009, nearly 60 per cent of First Nations children in northern Manitoba
households were food insecure.
349
The Inuit Health Survey reported that 70 per cent of adults
living in Nunavut were food insecure. This is six times higher than the national average and rep-
resents the highest documented food insecurity rate for any aboriginal population in a developed
country.
350
Among o-reserve aboriginal households, approximately one in five households was
food insecure, including 8.4 per cent severely food insecure.
351
These rates are three times higher
than among non-aboriginal households, where 7.7 per cent were food insecure, including 2.5 per
cent with severe food insecurity.
352
In March 2011, one in 10 of the 851,014 who relied on food banks
across Canada self-identified as an aboriginal person.
353
Families in remote and isolated indigenous communities frequently lack access to aordable nu-
tritious foods, particularly perishables such as fruits, vegetables and meats, due to limited food
selections, high food prices and poor quality of fresh produce. Expensive transport costs and dif-
ficult logistics (e.g., air freight charges, and uncertainty of travel on winter roads, where they exist,
or air travel subject to weather conditions), high poverty rates and a continuing decline in the use
of traditional foods result in few healthy food choices.
354
The high prevalence of food insecurity
for aboriginal people is not surprising. In the literature, food insecurity is related to health out-
comes that include multiple chronic conditions, obesity, distress and depression.
346
Health Canada, “Household Food Insecurity in Canada in 2007-2008: Key Statistics and Graphics”, http://www.hc-sc.
gc.ca/fn-an/surveill/nutrition/commun/insecurit/key-stats-cles-2007-2008-eng.php.
347
A/HRC/22/50/Add.1.
348
A/HRC/22/50/Add.1.
349
Children’s Food Insecurity poster, http://home.cc.umanitoba.ca/~thompso4/Poster_ CHILDRENfinalagconference.ppt.pdf.
350
R. Rosol et al., “Prevalence of armative responses to questions for food insecurity: International Polar Year Inuit
Health Survey, 2007-2008” and International Journal of Circumpolar Health, vol. 70, No. 5 (2011), pp. 488-497; G.M.
Egeland, IPY Inuit Health Survey speaks to need to address inadequate housing, food insecurity and nutrition transi-
tion. International Journal of Circumpolar Health, vol. 70, No. 5 (2011), pp. 444-446.
351
Health Canada, “Household Food Insecurity in Canada in 2007-2008: Key Statistics and Graphics”, http://www.hc-sc.
gc.ca/fn-an/surveill/nutrition/commun/insecurit/key-stats-cles-2007-2008-eng.php#fn-np8.
352
Health Canada, “Household Food Insecurity in Canada in 2007-2008: Key Statistics and Graphics”,
http://www.hc-sc.gc.ca/fn-an/surveill/nutrition/commun/insecurit/key-stats-cles-2007-2008-eng.php#fn-np8.
353
Food Banks Canada, “Hungercount 2011”, p. 7, www.foodbankscanada.ca/hungercount.
354
A/HRC/22/50/Add.1.
Chapter 5 ξ 123
Indigenous Peoples’ access to Health Services
Access to health services in the United States and Canada
Indigenous peoples in the United States and Canada do not have easy access to basic western
health care when needed. Access is constrained by financial, geographical and cultural barriers.
Indigenous peoples tend to be low on Government priority lists, especially when they live in re-
mote areas where services are dicult and costly to provide. When services are available, indige-
nous peoples are often reluctant or afraid to use them because sta can be insensitive, discrimi-
natory and unfriendly.
In Canada, within the fly-in or isolated communities, some indigenous women are required to fly
over a thousand kilometres to reach a hospital in order to give birth, have a tooth extracted or
treat and illness. Many have never left their community before and there is a reluctance to do so
in many cases. Even when aordable health services do exist within indigenous communities, they
are often of lower quality than services available for non-indigenous peoples. While health care
priorities may be set by the Government may do not match the priorities of indigenous communi-
ties, there has been some progress made in terms of indigenous peoples and their communities’
managing and administering their own health care systems.
355
In Canada, there is long-standing jurisdictional conflict between the provincial and federal
governments over responsibility for health services which has negatively impacted indigenous
peoples who have had to cope with a patchwork of fragmented services. To a large degree,
jurisdictional issues which impact on accessibility to health services stem from the decades of
a “tug of war” over which level of government is responsible for provision of services. Although
provincial governments are required to provide equal access to health care services under the
Canada Health Act for all residents of the province including indigenous peoples living on reserves,
the provincial governments often take the position that the federal government is responsible
for certain health services to indigenous peoples who are registered as Status Indians under the
Indian Act. As a result, some health services not covered by the Canada Health Act but otherwise
provided by the provinces through the Regional Health Authorities may or may not be provided to
indigenous communities. The provincial government’s position is that the federal government has
responsibility for certain health services to indigenous peoples as Indians under the Indian Act.
On the other hand, the federal government’s position is that provincial services should extend
to reserves under the cost-sharing arrangements that apply to the general population. This
fundamental disagreement translates in a very real way into program fragmentation, problems
with coordinating programs, underfunding, inconsistencies, service gaps, and lack of integration.
Critics argue that the federal government routinely tries to rid itself, or limit, indigenous programs
and services by continuing to diminish what it determines as discretionary health services.
Barriers to accessing health care services in the United States include the unavailability of public
and private transportation and given the low income levels of most residents, procuring trans-
portation to IHS services can be a significant burden. Also, when specialty care is required, IHS
referrals often send patients to larger contracted hospitals in urban areas, significantly far away
from the patient’s home and family. For individual patients from the tight-knit communities that
serve as the center of tribal culture in many rural regions, travelling to a distant region to receive
355
Interagency coalition on Aids and Development “HIV/AIDS and Indigenous Populations in Canada and Sub-Saharan
Africa” http://www.icad-cisd.com/pdf/HIV_and_Indigenous_Populations_EN.pdf.
124 ξ Chapter 5
State of the World’s Indigenous Peoples
specialty care causes a significant loss in the community support systems one would typically rely
on during times of need.
356
As stated previously, the IHS-funded health services are provided through a network of hospitals,
clinics, and health stations that are managed directly by IHS, by tribes or tribal organizations,
and urban Indian health programs. Some services are provided through contract with non-Indian
providers. In general, services provided through IHS and tribally operated facilities are limited to
members of and descendants of members of federally recognized tribes that live on or near feder-
al reservations. Urban Indian health programs serve a wider group of American Indians and Alaska
Natives, including those who are not able to access IHS or tribally operated facilities because they
do not meet eligibility criteria or reside outside the service areas. IHS funding is limited and must
be appropriated by Congress each fiscal year. In 2013, total program funding was $5.46 billion. Al-
though the IHS budget has increased over time, funds are not equally distributed across facilities
and they remain insucient to meet health care needs. As such, access to services through IHS
varies significantly across locations, and American Indians and Alaska Natives who rely solely on
IHS for care often lack access to needed care.
357
Addressing health gaps
Indigenous peoples in North America like elsewhere in the world, view health and well-being far
more broadly than merely physical health and the absence of disease. Indigenous peoples often
use their own words that translate roughly to “living well’ which combines beliefs in the impor-
tance of balance. The four elements of life: physical, emotional, mental and spiritual are all are
intricately woven together and interact to support a strong and healthy person. Balance also
requires the need for an individual to live in harmony with others, their community and the spir-
it world. Hence, indigenous peoples’ idea of sickness or illness tends to refer to an absence of
well-being. The connection to family and relatives are essential components of well-being.
358
Government-sponsored social and health services have made eorts to become more culturally
sensitive and to respond more eectively to the needs of indigenous clients. Indigenous liaison
and caseworkers are able to oer more culturally sensitive services and are working hard to im-
pact the policies and practices of their organizations to be more responsive to indigenous clients.
As well, a growing number of indigenous organizations in urban centres have been developing
innovative programs to address the gaps in services provided by mainstream government depart-
ments and agencies and to oer more culturally sensitive alternatives.
There are still a large number of gaps, where the health system is failing indigenous peoples.
These include the protection and safety of children. Too often children must leave their homes
and, in many instances their communities, in order to be safe and more often than not are placed
in non-indigenous foster care which results in children having no contact with extended family
356
Tshona Reneé Corbin Barriers to health care access among American Indian and Alaska Native populations (2008)
http://d-scholarship.pitt.edu/7075/1/TRCorbin2010.pdf.
357
Henry J Kaiser Foundation “Health Coverage and Care for American Indians and Alaska Natives” October 2013 | Issue
Brief http://kaiserfamilyfoundation.files.wordpress.com/2013/10/8502-health-coverage-and-care-for-american-in-
dians-and-alaska-natives.pdf.
358
Malcolm King, Alexandra Smith, Michael Gracey “ Indigenous Health part 2: the underlying causes of the health gap”,
www.thelancet.com, Vol 374, July 4, 2009, p. 77.
Chapter 5 ξ 125
Indigenous Peoples’ access to Health Services
and for this reason do not have a strong connection to their language, culture, sense of identity
and sense of belonging. In later years some become alienated from their families and communities
resorting to negative behaviours such as alcohol and drug use, gang aliation and patterns of vi-
olence. Social assistance provisions for women, even those with children, who are leaving abusive
situations, are not adequate for women to re-establish themselves and sustain their daily needs.
Women end up trapped in poverty without the resources to get the urgent counselling and other
supports they may need or to improve their circumstances through further education and training.
Social and mental health services are fragmented, forcing people to interact with many dierent
agencies, each with its own narrow eligibility criteria and range of services. Clients end up demor-
alized, confused and frustrated as they attempt to negotiate a maze of departments and agencies
in order to get the financial, legal and psychological help they need. This task is, of course, particu-
larly dicult for individuals who are traumatized by the abuse to which they have been subjected.
As well, this situation results in critical gaps between their needs and available services.
Many small communities have virtually no services for the victims of abuse and no means for en-
suring their safety. Also, they have very little to oer the perpetrators of abuse. In instances like
these, indigenous peoples are forced to go to larger centres to get help, where they are cut o
from family and friends and may have virtually no support system.
The role of colonialism in diminishing indigenous peoples’ identity is seen as a root cause to a
myriad of mental health problems. The wounds of the past continue to fester and often in silence.
The path to healing is voicing the abuse and receiving validation from culture. The high suicide
rates indicate a crisis in mental health and may be due to underservicing of indigenous commu-
nities’ mental health systems. Mental health strategies should be a priority in any current mental
health initiatives within Canada and the United States.
359
Indigenous peoples’ mental health is-
sues are best understood in the context of colonialism.
Positive indigenous representations and role models and authority figures are needed to facilitate
the development of healthy identities based on cultural strengths, not on disadvantage, disease
burden and discrimination. 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. Assaults on identity contribute to a self-perpetuating circle that keeps
indigenous peoples where they are. Language is crucial to identity, health and relations. 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 revitalization can be seen, therefore, as a health promotion strategy.
One of the major areas of concerns are the gaps in data information. Public health assessments
and interventions depend on accurate statistical data. Unfortunately in both the United States
and Canada there are serious deficits in the availability of accurate disaggregated data for
indigenous peoples. For example, in Canada health data initiatives have not been collected for
non-registered First Nations peoples or Inuit and Métis peoples living in urban areas. There are also
inconsistencies in First Nation Inuit and Métis ethnic identifiers in provincial health data collected
through vital statistics registrations systems, hospital administration databases and acute and
359
Warry, 2000.
126 ξ Chapter 5
State of the World’s Indigenous Peoples
chronic disease surveillance systems. As a result, these populations are often invisible in health
statistics.
360
It is important to acknowledge dierences in the socioeconomic circumstances and
lived world experiences of First Nations, Inuit, and Métis peoples, between status and non-status,
on-reserve and o-reserve, as well as urban and rural aboriginal populations
361
in order for data
to be accurate, complete and up-to-date.
Research based on existing administrative, survey, population and other data sets is limited by how
populations were included. For example Statistics Canada uses several methods for identifying
aboriginal ancestry, most often using a broad definition, allowing survey and census respondents
to self-identify as having aboriginal ancestry. However some First Nation reserves refused to take
part in some national surveys (Census Canada, for instance), and in other cases survey design
did not include residents of the northern territories, most of whom are aboriginal (e.g., Canadian
Community Health Surveys).
362
British Columbia’s tripartite Transformative Change Accord are steps in the right direction. The
Transformative Change Accord commits the Government of British Columbia to improving the
mental health and addictions problems of aboriginal peoples through the establishment of men-
tal health programs, as well as through concerted eorts to equalize the socioeconomic dierenc-
es (that underlie many of the health problems facing aboriginal peoples) between aboriginal and
non-aboriginal people in British Columbia.
363
The British Columbia Tripartite Framework Agree-
ment on First Nation Health Governance was made in October 2011 between the Federal Minister
of Health, the Provincial Minister of Health for the Province of British Columbia and the First
Nations Health Authority as endorsed by the First Nations Health Council of British Columbia.
364
Federal funding for British Columbia First Nations health care services has been transferred to the
First Nations Health Authority and the transition is being implemented.
365
This is an important
and exciting development that could have global implications as an innovative model for indig-
enous peoples health system governance administered at the provincial level and mandated by
indigenous peoples themselves.
Traditional healing
Despite considerable health issues, indigenous peoples in North America continue to demonstrate
resilience and strive for wellness based on indigenous peoples’ knowledge and well-being.
Indigenous peoples are reclaiming traditional tribalspiritualityand rituals to cleanse the bodies and
360
Smylie, J., and M. Anderson, 2006, “Understanding the health of Indigenous peoples in Canada: key methodological
and conceptual challenges”, Canadian Medical Association Journal 175(6): 602-605.
361
Reading, C. and Wien, F., 2009, Health inequalities and social determinants of Aboriginal Peoples’ health. Prince
George, BC: National Collaborating Centre for Aboriginal Health.
362
Kathy Bent, Joanne Havelock, Margaret Haworth-Brockman, “Entitlements and health services for First Nations and
Métis women in Manitoba and Saskatchewan”, The Prairie Women’s Health Centre of Excellence, August 2007. http://
www.pwhce.ca/pdf/entitlementsHealthServices.pdf.
363
Government of British Columbia, Government of Canada and Leadership Council Representing the First Nations of
British Columbia (2005). Transformative Change Accord. Retrieved July 16, 2010 from http://www.gov.bc.ca/arr/social/
down/transformative_change_accord.pdf.
364
http://www.hc-sc.gc.ca/fniah-spnia/pubs/services/tripartite/framework-accord-cadre-eng.php.
365
http://www.fnhc.ca/index.php/news/article/interim_health_plan_overview/.
Chapter 5 ξ 127
Indigenous Peoples’ access to Health Services
souls of their community members. Sweat lodge ceremonies have been used to treat alcoholism,
post-traumatic stress disorder in both white and Native veterans. Prisons in several states have
allowed indigenous inmates to practice sweat lodge and other tribal religious ceremonies as part
of their rehabilitation.
Traditional medicine is a very important part of First Nations health that is almost always
overlooked by the health care system. Traditional medicine uses a holistic model of well-being
through the integration of emotional, physical, mental and spiritual aspects of being. Even
though specific practices vary between dierent tribes, all traditional medicine is based on the
understanding that humans are part of nature and health is a matter of balance. Therefore, there
is respect for the land and all of her oerings. Traditionally, elders understood the importance of
respecting and using their environment for foods, medicines, and ceremonies for overall health.
In September 2009, the First Nations Health Society, on behalf of the First Nations Health Council
conducted an environmental scan to gather information from the 123 First Nations Health Cen-
tres in British Columbia Canada, on traditional models of wellness (or traditional practices and
medicines). This project is aimed at providing background information for the FN Health Society
to undertake further work, if needed, on promoting traditional models of wellness within British
Columbia for First Nations.
During the environmental scan on traditional models of wellness, such models of wellness were
defined as having a healthy mind, body and spirit and that wellness from a traditional perspective
encompassed a person feeling well emotionally, physically and spiritually and leading a healthy
lifestyle, which involved connection to the land and one’s culture and beliefs. Maintaining wellness
involved carrying out traditional practices of the community such as fishing, hunting, berry gather-
ing and participating in healing circles, sweats, drumming and learning the language. Identity and
connection to culture were seen as integral to maintaining wellness from a traditional perspective.
Conclusion
Indigenous peoples in North America have long experienced lower health status when compared
with the rest of the population. Lower life expectancy and the disproportionate disease burden
exist because of inadequate education, disproportionate poverty, discrimination in the delivery of
health services, and cultural dierences. These are broad quality of life issues rooted in economic
adversity and poor social conditions.
Indigenous health is at a crisis and there is an urgent need for a more holistic vision of health and
health intervention driven by indigenous peoples’ own vision of health and well-being. Further
research and action, driven by indigenous peoples themselves is required at the international and
national levels but most importantly at the local levels as well.
Commentators and Scholars across all sectors of the health studies of indigenous peoples concur
that, despite inadequacies in the health care delivery system and regardless of peoples’ relative
access to or use of the biomedical system, the problems are entrenched in the history of relations
between indigenous peoples and the nation state.
Restoring traditional healing practices and knowledge is an important pathway to both empow-
erment and health for indigenous communities. The traditional knowledge once practiced in his-
128 ξ Chapter 5
State of the World’s Indigenous Peoples
torical indigenous societies needs to be restored as an intervention to begin to addictions and the
epidemics of preventable conditions facing indigenous peoples.
In spite of the considerable health issues and challenges outlined above, indigenous peoples con-
tinue to demonstrate resilience and strive for wellness based in indigenous ways of knowing and
being. Indigenous peoples’ approaches to health are often rooted in a healthy balance of four el-
ements or aspects of wellness: physical, emotional, mental and spiritual. These four elements are
sometimes represented in the image of the medicine wheel.
366
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UN Photo/Broddi Sigurdarson
Chapter 6 ξ 131
Indigenous Peoples’ access to Health Services
Chapter Six
Access to Health Services
by Indigenous Peoples in the
Pacific Region
Dr. Collin Tukuitonga
UN Photo/Broddi Sigurdarson
132 ξ Chapter 6
State of the World’s Indigenous Peoples
Chapter Six
Access to Health Services by
Indigenous Peoples in
the Pacific Region
Dr. Collin Tukuitonga
Introduction
This chapter addresses indigenous peoples’ access to health services in the Pacific region. It pro-
vides a background of the historic, political and cultural factors which have shaped events in the
various countries, and influenced the health status of indigenous peoples in the Pacific region. It
describes the current health situation, social determinants of health, health service funding and
delivery, major challenges as well as the initiatives that have been shown to be eective in im-
proving indigenous peoples’ access to all levels of health care.
The Working Group on Indigenous Populations Working paper on the concept of “indigenous peo-
ple” lists the following factors that have been considered relevant to the understanding of the
concept of “indigenous” by international organizations and legal experts:
367
ɜ Priority in time, with respect to the occupation and use of a specific territory;
ɜ The voluntary perpetuation of cultural distinctiveness, which may include the aspects
of language, social organization, religion and spiritual values, modes of production, laws
and institutions;
ɜ Self-identification, as well as recognition by other groups, or by state authorities, as a
distinct collectivity;
ɜ An experience of subjugation, marginalization, dispossession, exclusion or discrimination,
whether or not these conditions persist.
Self-identification as indigenous or tribal is considered as a fundamental criterion and this is
the practice followed by the United Nations. Article 33 of the United Nations Declaration on the
Rights of Indigenous Peoples refers to the right of indigenous peoples to decide their own identi-
ties and procedures of belonging.
The Pacific region includes indigenous peoples of the Pacific Ocean which stretches between the
Southern Ocean, Asia, Australia, and North and South America. Thousands of islands are spread
across this expanse, which adds to the region’s considerable geographical, cultural, and linguistic
diversity. For example, the region accounts for only a tiny fraction of the global population, but it
367
http://www.ohchr.org/EN/Issues/IPeoples/Pages/WGIP.aspx.
Chapter 6 ξ 133
Indigenous Peoples’ access to Health Services
contains close to a quarter of the world’s languages.
368
Some of the indigenous peoples of the Pa-
cific are well known e.g. Maori in Aotearoa/New Zealand, but the needs of others are less well rec-
ognized e.g. Kanaks of New Caledonia. According to the sociocultural regions of the United Nations
Permanent Forum on Indigenous Issues, the Pacific is seen to include Australia, New Zealand, Pap-
ua New Guinea, the province of West Papua, the small island states of the Pacific region, including
the Federated States of Micronesia, the Northern Mariana Islands and Marshall Islands, the indige-
nous peoples of Hawaii as well as indigenous peoples of Rapa Nui (Easter Island). For the purposes
of this chapter the regions of Asia and North America are covered elsewhere in this publication.
Colonized by European powers relatively late in global terms, the Pacific indigenous peoples were
also among the last to be decolonized. Since the early 1960s the process of decolonization has
created independent small island States (Fiji, Kiribati, Nauru, Papua New Guinea, Samoa, Solomon
Islands, Tonga, Tuvalu, Vanuatu). It should be noted that Tonga is the only Pacific island country
not formally colonized by a foreign power. Other countries remain as territories or self-governing
states in “free association” with a former colonial power (American Samoa, Cook Islands, Federat-
ed States of Micronesia, French Polynesia, Guam, Marshall Islands, New Caledonia, Niue, Northern
Mariana Islands, Palau and Tokelau).
369
The Pacific islands are a culturally diverse region and indigenous peoples have distinct cultures
that have existed for thousands of years and have unique systems of knowledge and understand-
ing, such as those related to ocean navigation, vessel construction and traditional medicines.
Pacific peoples, especially those who still live in the islands are more likely to speak their mother
tongue and view their culture as something that is lived and continuously demonstrated. In con-
trast, political and economic transformations have displaced large numbers of Pacific people who
have moved away from their home islands to inhabit a diaspora spanning the globe, from Austra-
lia and New Zealand to Europe and North America. There are also communities of Pacific peoples
living on other islands, creating further cultural diversity in an already complex region. Pacific
peoples today as in the past have adopted a number of creative survival strategies in the face of
rapid cultural, social, political, and economic transitions. Among these are abilities to navigate
multiple worlds that might include both Christian and indigenous spiritual practices, western and
indigenous lifestyles, and western and “traditional” political and economic structures, while still
maintaining a commitment to family and community relations.
Indigenous peoples in the Pacific region have unique characteristics that reflect their local sit-
uations but they also share a number of characteristics with other indigenous peoples globally,
such as:
ɜ The diversity of languages and cultural practices, although some similarities are seen
where indigenous peoples share common origins e.g., the Maori of New Zealand, Native
Hawaiians in Hawaii and Maori in the Cook Islands.
370
368
Ian Anderson, Sue Crengle, Martina Leialoha Kamaka, Tai-Ho Chen, Neal Palafox, Lisa Jackson-Pulver “Indigenous
health in Australia, New Zealand, and the Pacific” www.thelancet.com Vol 367 May 27, 2006
369
Howe, K. R., Robert C. Kiste, and Brij V. Lal. Tides of history: the Pacific Islands in the twentieth century. Honolulu: Uni-
versity of Hawaii Press, 1994.
370
Greenhill, S, and Russell D. Gray. “Testing Population Dispersal Hypotheses Pacific Settlement”. In. The Evolution of
Cultural Diversity: Phylogenetic Approaches. Ed. Ruth Mace et al. London: UCL Press, 2005. 31-52.
134 ξ Chapter 6
State of the World’s Indigenous Peoples
ɜ The proportion of the total population of these countries that identify as indigenous
ranges from 2.9 per cent in Australia to 15 per cent in New Zealand. There are also dier-
ences and distinctions in definitions of who is indigenous and who is not, who are counted
and who are not. Overall, indigenous peoples in all Pacific countries are enjoying a revival
in their culture and languages.
371
ɜ Populations of indigenous peoples in all the Pacific countries are growing rapidly and
have lower median ages in direct contrast to the ageing, non-indigenous populations
which presents challenges for the future of local economies and the workforce. Unfortu-
nately younger ages have higher death rates and higher child to adult dependency ratio,
in comparison to the non-indigenous populations.
The total population estimate of the 22 nations and territories (see list in Annex) in this area is just
under 12 million, with approximately 8 million people in Papua New Guinea alone. In New Zealand,
there are 682,200 people claiming to be indigenous descent (Maori or Pacific Islander) which com-
prises 15 per cent out of a total population. In Australia there are 669,736 which is 2.9 per cent of
a total population.
372
The Native Hawaiian population is 527,077 which comprise 0.17 per cent of
the total population of the USA.
373
Fiji and New Caledonia are interesting and unique situations in the Pacific. Historically, in Fiji, the
indigenous Melanesian Fijians and indentured Indians and now have almost equal numbers in the
total population of approximately 850,000 people. Between 1879 and 1916, when Fiji was under
British rule, Fijian Indians were brought to Fiji by the British as to work as labourers in the cane
fields. Recently, several military coups, have led to significant out-migration by the Indian people
and indigenous Melanesian Fijians now have resumed political dominance in the country although
the Indian population continues to dominate the economic and business sectors and academia.
374
In New Caledonia, the Kanak people are the indigenous Melanesian inhabitants that constitute 44
per cent of the total population of 260,166. Europeans make up 34 per cent of the total popula-
tion, while Polynesian people (mainly Wallisians) and Asians make up the remainder. New Caledo-
nia is an overseas territory (collectivity) of France and remains within the French Republic. While
the total number of indigenous peoples in New Caledonia is a majority in the country, the Europe-
an population has political or economic dominance.
Indigenous peoples of the Pacific region experience poorer health for many indicators compared
to the non-indigenous general populations. The gap in life expectancy at birth between indig-
enous and non-indigenous population was estimated to be 19-21 years in Australia, 8 years in
New Zealand. Rates of avoidable deaths among indigenous people are generally higher than for
non-indigenous people. Diabetes prevalence is increasing among all indigenous populations as
371
Denoon, Donald et al., The Cambridge History of the Pacific Islanders. Cambridge, U.K.: Cambridge University Press, 1997.
372
Estimates of Aboriginal and Torres Straight Islander Australians, retrieved 29/09/1023 from http://www.abs.gov.au/
ausstats/abs@.nsf/Latestproducts/3238.0.55.001Media%20Release1June%202011?opendocument&tabname=Sum-
mary&prodno=3238.0.55.001&issue=June%202011&num=&view=Australian Bureau of Statistics.
373
U.S. Census Bureau, 2010 Census.
374
Veitayaki, J. “Breaking Fiji’s Coup Culture through Eective Rural Development”. In 1987: Fiji TwentyYears On. Ed. Lal B
V et al. Lautoka, Fiji: Fiji Institute of Applied Studies, 2008.
Chapter 6 ξ 135
Indigenous Peoples’ access to Health Services
part of increased incidence of non-communicable diseases (NCDs). Cardiovascular diseases are
central to the high mortality among indigenous people in all three countries.
375
While some improvements are being made in the overall health situation of indigenous peoples
in the Pacific region, their health needs are greater, and indigenous peoples generally have lower
access to and use of health care services at all levels of the health system. Indigenous people
also tend to received substandard care for many of the common conditions.
376
,
377
For example,
non-indigenous women are overscreened for cervical cancer while indigenous women are under-
screened, despite higher incidence of cervical cancer among them.
378
Determinants of health
Like all people, the health status of indigenous peoples is influenced by the social, economic and
cultural determinants such as education, income, food supply, housing and availability of health
and medical care services. Social determinants of health (SDH) are shaped by more distal factors
such as the prevailing political ethos, local environment and historical factors, such as colonial-
ism. Indigenous peoples tend to be more susceptible to these factors which partly explain the
significant health inequalities that exist. Figure 1 outlines the social determinants of health for all
populations, including indigenous peoples, and the influence of colonization, Christianity, urban-
ization and globalization on health.
379
The interactions between various social determinants of health are complex and the poten-
tial impacts can be indirect. With higher levels of educational attainment, individuals have in-
creased income but are also more likely to have better working conditions with less hazardous
jobs that reduce their risks associated with workplace injuries. Education attainment improves
access to employment that is more secure, better retirement policies and comprehensive health
care insurance for services that that may not covered by government health programs. Educa-
tion is also associated with health literacy, which refers to the understanding that individuals
have about their health and how to access health services and health information. Thus, individ-
uals are better able to understand the health information they are provided and to take control
of their health.
380
375
Ring I, Brown N. The health status of indigenous peoples and others BMJ 2003 23; 327 (7412): 404-405.
376
Medical Council of New Zealand (2010). Best health outcomes for Pacific peoples; practice implications.
377
Tukuitonga C. (Chapter 6) in Coles Medical Practice in New Zealand 2013 Edition. Medical Council of New Zealand
378
Tracking Disparity: trends in ethnic and socioeconomic inequalities in mortality, 1981-2004. NZ Ministry of Health, 2007.
379
Adapted from Lehane, L., Mary J Ditton (2012) Health challenges for Burmese migrants in Thailand. 8 January 2012,
viewed 27 February 2014, http://asiapacific.anu.edu.au/newmandala/2012/01/08/health-challenges-for-burmese-mi-
grants-in-thailand/.
380
Pulver LJ, Haswell MR, Ring C et al. Indigenous Health—Australia, Canada, Aotearoa New Zealand and the United States
- Laying claim to a future that embraces health for us all. World Health Report 2010. World Health Organisation.
136 ξ Chapter 6
State of the World’s Indigenous Peoples
Figure 1: Social Determinants of Health
Framework for analysis of social determinants of health
Colonization
Christianity
Urbanization
Globalization
Structural determinants
(income, education, gender, ethnicity, ageing)
Intermediary determinants
(living and working conditions;
health related behaviours)
Socioeconomic and political context
(culture, religion, social system, human rights,
labour market, education system)
Health systems
Biological processes
(physical and mental health)
Sowip 2_Figure 1_Social Determ. of Health-Framework for (page
159).xlsx
Colonization
Indigenous peoples share similar histories dating back to the colonial era through to the modern
influences and socioeconomic determinants of health, including urbanization and globalization.
Colonization has had a profound impact on the lives of indigenous peoples and is an important
determinant of the health status of indigenous peoples and their descendants. Direct eects of
colonialism or colonial policies on indigenous health include the introduction of contagious dis-
eases for which indigenous peoples had no or little resistance. The impact was profound because
introduced diseases decimated much of the local populations, drastically impacting local com-
munities and their social structures.
The suppression of traditional medicine was achieved in New Zealand through legislation. The
Tohunga Suppression Act 1907 (repealed in 1962) was intended to stop traditional Maori healing
practices which were believed to have relied upon a supernatural or spiritual element. Thus the act
was designed to replace traditional Maori healers with “modern” science based medicine. Tohunga
were the holders of the knowledge of most rites, including health matters (or rongoa) as they were
experts in the use of medicinal plants and herbs.
381
Colonization has also been shown to have residual eects across generations through the pro-
tracted eects of land dispossession, marginalization, discrimination, personal and institutional
racism and other factors that limit the ability of indigenous peoples to participate fully in the ma-
jor institutions of the societies in which they live. Indigenous peoples in the Pacific region continue
to have limited representation in their national parliaments and other institutions such as the
381
Tohunga Suppression Act, retrieved (04/11/2013) from http://www.teara.govt.nz/en/document/28223/tohunga-sup-
pression-act.
Chapter 6 ξ 137
Indigenous Peoples’ access to Health Services
judiciary. Indigenous peoples are underrepresented in most professions although there are several
armative action training programmes with encouraging results in New Zealand.
382
,
383
In the ma-
jority of instances, indigenous peoples have limited financial capital needed to participate fully in
the private sector and are often employed in low-paid jobs. The health eects of colonization have
been described in a number of studies in New Zealand, Australia, Hawaii and elsewhere.
384
,
385
,
386
Christianity
Christianity as a function of colonization and assimilation has also had a profound eect on Pa-
cific cultures and peoples. Early missionaries systematically destroyed all forms of local religious
symbols and convinced indigenous communities that their spirituality was false and had no power.
Indigenous peoples’ religious structures were disrespected in many ways thus breaking all forms
of cultural taboo. Once established, church doctrine was integrated into local customs and use of
local clergy ensured that Christian principles dominated most cultures of the Pacific. Protestant
churches were established early to be self-financing, self-governing as well as self-propagating.
387
Indigenous clergy were the ideal state of aairs. Tonga was so heavily missioned that historians and
anthropologists conclude that Christianity has reworked Tongan culture into a missionary frame-
work.
388
The integration of Christian traditions and practices into local Pacific cultures has been so
successful that it is often dicult to dierentiate local culture from introduced Christian traditions.
The London Missionary Society (LMS) was particularly influential in the Pacific region from 1830
onwards. The LMS established the Malua Theological College in the village of Malua, Samoa in
1844, where several hundred missionaries were subsequently sent to a number of other Pacific
islands.
389
Pacific churches continue to be influential forces in the migration and establishment
of Pacific communities in Pacific Rim countries and beyond. The impact of Christianity on Pacific
.cultures included significant impact on attitudes related to health and illness, which are often
described as traditional cultural practices. Colonization and Christianity destroyed many local
healing and other customary health practices so eectively that many of the traditional methods
have been lost, and indigenous peoples are struggling to reclaim some of these ancient healing
practices. Indigenous knowledge has been slowly eroded over the course of subsequent genera-
tions because most Pacific societies transmit knowledge and information orally.
382
Curtis E., Reid P., Indigenous Health Workforce Development: challenges and success of the Vision 20:20 programme.
ANZ J Surg 83 (2013) 49-54.
383
Curtis E., Wikaire E., Stokes K., Reid P., Addressing indigenous health workforce inequities: a literature review exploring
“best” practice for recruitment into tertiary programmes. Int J. Equity Health 2012; 11:1-15.
384
Eects of colonisation on Maori, retrieved (14/10/2013) from http://www.teara.govt.nz/en/death-rates-and-life-
expectancy/page-4.
385
Social determinants and the health of indigenous peoples in Australia—a human rights based approach, retrieved
(14/10/2013) from http://www.humanrights.gov.au/…/social-determinants-and-health-indigenous-peoples.
386
Liu D, Alameda A. “Social determinants of health for Native Hawaiian children and adolescents” Hawaii Med J 2011
November, 70(11 Suppl 2): 9-14.
387
Hezel F. Christianity in Micronesia, Introducing World Christianity Edited by Charles Farhadian, London: Blackwell
Press, 2010.
388
Christianity in the Pacific, retrieved 10/10/2013 from http://epress.anu.edu.au/austronesians/austronesians/mobile_
devices/ch17s03.html.
389
Samoan and London Missionary Society Church History, retrieved 04/10/2013 from http://www.scncucc.org/
voices/2009/11/ucc-conference-church-life/samoan-london-missionary-society-church-history/.
138 ξ Chapter 6
State of the World’s Indigenous Peoples
Urbanization
Rapid industrialization of New Zealand and Australia following the Second World War saw in-
creased migration from rural areas to cities and urban areas for work. Maori peoples in New Zea-
land best exemplify the urban migration by indigenous peoples in the Pacific. Before the Second
World War (pre 1939), over 80 per cent of Maori were living in rural areas, primarily within their own
tribal districts. For most Maori it was a deliberate migration in search of what has been described
as “the Big Three”: work, money and pleasure. In the beginning, the majority of migrants were un-
married young Maori looking for a more “modern” life. By the 1960s families had begun to migrate
in significant numbers. The government had also realized that the economic future of most Maori
lay in the larger towns and cities. The Hunn Report of 1961, made recommendations for social
reforms of the Maori as “relocation” of Maori became ocial policy and rural Maori families were
encouraged to move to the cities with the provision of accommodation, employment and general
assistance in adjusting to a new life. The urban migration of Maori has been described as the most
rapid movement of any population in the world. In 1945, 26 per cent of the Maori population lived
in the towns and cities. By 1956 this had increased to 35 per cent. The urban population grew to
62 per cent in 1966, and reached nearly 80 per cent by 1986. Today, 84 per cent of Maori live in
urban areas.
390
Urbanization is a two-edged sword with risks and benefits. Migration to urban areas is usually
associated with increased isolation from family, land, language, traditions and cultures but ur-
banization also improves education, employment prospects and socioeconomic circumstances of
many indigenous families. While urbanization can improve the socioeconomic circumstances of
many people, it can often be dicult to find employment with an adequate level of income need-
ed for city living. When indigenous peoples migrate to urban areas, links with the “home area” re-
main but may weaken over time as families develop new lifestyles in urban areas. In recent times,
some indigenous people have returned “home” to their tribal lands, partly in response to increased
unemployment in the cities as a result of the global financial crisis.
Globalization
Globalization is an important influence on the health status of indigenous peoples especially
since the mid-1990s. New Zealand, Australia and the United States are among the world leaders
in promoting free trade. In simple terms, globalization is the free flow of goods, ideas and ser-
vices across national borders. Globalization is a process by which national and regional econo-
mies, societies, and cultures have become integrated through the global network of trade, com-
munication, immigration and transportation.
391
Globalization was often primarily focused on the
economic side, such as trade, foreign direct investment and international capital flows but more
recently the term has been expanded to include a broader range of areas and activities such as
culture, media, technology, sociocultural and political factors.
392
390
“Urbanisation—Urban Mā ori –”. Te Ara Encyclopedia of New Zealand. http://www.teara.govt.nz/en/urban-maori/page-
1 (accessed 04/10/2013).
391
Globalisation and Trade, retrieved 04/10/2013 from http://www.wto.org/english/res_e/booksp_e/anrep_e/wtr08-2b.
392
“Definition of globalisation”. Financial Times Lexicon. http://lexicon.ft.com/Term?term=globalisation (accessed
4/10/2013).
Chapter 6 ξ 139
Indigenous Peoples’ access to Health Services
While globalization has resulted in many social and economic benefits for indigenous people and
mainstream populations globally, it has also led to increased unemployment and job losses in
some countries. Inevitably, indigenous peoples are usually the most aected by job losses due to
shifts in manufacturing, food production etc. as the unskilled workers in developed countries are
displaced from their livelihoods. In addition to the indirect eects of globalization on the health
status of indigenous peoples, they are also more directly impacted by the free trade in food,
sugar-sweetened beverages, alcohol and other factors that contribute to the rising incidence of
non-communicable diseases (NCDs) such as diabetes, heart disease and some cancers. People in
many Pacific islands import half of all the foods they consume, which are often highly processed
foods that contain usually high levels of salt, sugar, fats and other additives which are regarded
as not part of a healthy diet. Indigenous peoples now have some of the highest rates of obesity,
diabetes and heart disease in the world. Indigenous peoples also have higher rates of smoking
and alcohol abuse compared with non-indigenous peoples in New Zealand, Australia and Hawaii.
Alcohol is a major cause of health and social problems among indigenous people in the Pacific
and is partly responsible for child abuse, violence against women, road trac injuries and other
problems.
393
Globalization has also led to increased migration of skilled health workers from small islands and
rural areas to the cities and beyond. This is one of the major weaknesses for health systems in
the Pacific region where there is a shortage of human resources. In general, skilled health workers
migrate from the small island states to New Zealand, Australia and Hawaii, as well as to Europe
and the mainland United States, thus reducing the availability of trained indigenous health care
workers locally.
394
Migration of indigenous health workers is a global phenomenon linked to the
movement of people across borders as part of the broader migration and globalization process.
395
In figure 2, the table reproduced from Negin (2008) shows the brain drain of Pacific-trained doc-
tors, nurses and midwives who migrate to Australia and New Zealand, diminishing the health
workforce of the smaller Pacific nations.
393
Alcohol and Harm, retrieved 04/10/2013, from http://www.lawcom.govt.nz/sites/default/files/publications/2010/04/
Publication_154_464_Part_8_Chapter%203%20-%20Alcohol%20and%20harm.pdf.
394
University of New South Wales. Human Resources for Health Knowledge Hub. Migration of Health Workers in the
Asia-Pacific Region. Dec. 2010. http://www.hrhhub.unsw.edu.au/HRHweb.nsf/resources/1_HWMig_Summary_
Dec2010.pdf/$file/1_HWMig_Summary_Dec2010.pdf.
395
World Health Organization Commission on Social Determinants of Health. Globalization Knowledge Network.
Globalization and Health Worker Crisis. Aug. 2007, http://www.who.int/social_determinants/resources/gkn_packer_
al.pdf.
140 ξ Chapter 6
State of the World’s Indigenous Peoples
Table 1 and 2: Pacific-born doctors and nurses in Australia and New Zealand
by country to the domestic workforce
Doctors
Aus.
and
NZ
Domestic
Per cent
in Aus.
and NZ
relative
to
domestic
Nurses and
Midwives
Aus.
and
NZ
Domestic
Per cent
in Aus.
and NZ
relative
to
domestic
Niue 7 4 175 Niue 47 22 213.6
Fiji 361 380 95 Fiji 469 310 151.3
Tonga 26 30 86 Tonga 421 350 120.3
Samoa 42 50 84 Samoa 1828 1660 110.1
Cook
Islands
12 20 60
Cook
Islands
77 80 96.3
Papua
New Guinea
160 275 58.2
Papua
New Guinea
12 63 19
Nauru 4 10 40 Nauru 441 2841 15.5
Kiribati 6 20 30 Kiribati 7 50 14
Tuvalu 3 10 30 Tuvalu 30 360 8.3
Solomon
Islands
12 60 20
Solomon
Islands
18 260 6.9
Vanuatu 4 30 13.3 Vanuatu 37 653 5.7
Timor-Leste 8 79 10.1 Timor-Leste 48 1795 2.7
Micronesia 0 60 0 Micronesia 0 250 0
Palau 0 30 0 Palau 0 152 0
Marshall
Islands
0 24 0
Marshall
Islands
0 121 0
Source: Negin, J (2008) “Australia and New Zealand’s contribution to the Pacific Island health worker brain drain”.
Health services of indigenous peoples in the Pacific Region
Some of the countries of the Pacific region are very small, geographically isolated from the rest
of the world by vast amounts of ocean and heavily dependent on development assistance and
remittances.
396
Consequently, they are often forgotten or simply ignored by other nations of the
world.
397
Such invisibility is just one of the significant barriers that these tiny nations face as they
struggle to ensure the health of their citizens in the new millennium. Indigenous peoples of the
396
United Nations Development Programme. Subregional Programme Document for the Pacific Island Countries
and Territories (2013-2017). Nov. 2012. http://www.undp.org/content/dam/rbap/docs/programme-documents/FJ-
SRP-2013-2017.pdf.
397
Reilly, B., and Elsina Wainwright. “The South Pacific”. In. Making States Work: State Failure and the Crisis of Governance.
Ed. Simon Chesterman et al. Tokyo: United Nations University Press, 2005. 122-142.
Chapter 6 ξ 141
Indigenous Peoples’ access to Health Services
Pacific region are in worse health than the general population in both the developed and devel-
oping countries alike.
Malnutrition and undernutrition are common within the region with more than one fifth of children
and pregnant women being anemic. Iron deficiency anemia aects more than 25 per cent of the
general population. This has a direct impact on the productivity of the workforce as well as an
immediate eect on one’s sense of well-being and stamina and yet can easily be rectified. In Fiji,
Papua New Guinea and Vanuatu, iodine deficiency and related goitre are endemic although, in Fiji
and Papua New Guinea, great progress has been made recently through salt iodization. About 40
per cent of the Pacific island region’s population has been diagnosed with a non-communicable
disease, notably cardiovascular disease and hypertension and cancers, which are on the increase
and are being diagnosed in younger people.
398
These diseases account for three-quarters of all
deaths across the Pacific archipelago and 40-60 per cent of total health care expenditure. Infec-
tiousdiseasessuch as malaria, leprosy, filariasis, tuberculosis, hepatitis and sexually transmitted
infections including HIV/AIDS in some islands are major health issues. These can be controlled
through environmental and public health measures.
399
In many areas of the Pacific region, the inadequacy of communication and infrastructure and
lack of access to health care also result in indigenous women dying from the complications of
pregnancy and childbirth at rates which approach those in sub-Saharan Africa. However, despite
this, birth rates in the region are high. Coupled with greater infant and childhood survival, popu-
lation growth rates are high. Furthermore between 40 per cent and 50 per cent of the population
of some countries are less than 15 years old. Young people in some societies are sexually active
early, but this occurs in the absence of informed choices about behaviour and responsibility. Con-
sequently, there are high rates of sexually transmitted infections and teenage pregnancy with its
consequential physical and social risks including HIV.
Maori peoples have the poorest health of any population group in New Zealand. In 2012, life ex-
pectancy at birth for Maori men was 72.8 years, while life expectancy at birth for non-Maori men
was 80.2 years. Life expectancy at birth for Maori women was 76.5 years, while life expectancy
at birth for non-Maori women was 83.7 years. Avoidable death rates are almost double for Maori
than for other New Zealanders, and Maori die, on average, eight-ten years earlier. Maori have a
higher mortality rate than non-Maori as well as higher rates of illness. For example, excess cancer
deaths among Maori account for two-thirds of the excess male cancer deaths and one-quarter of
the excess female cancer deaths in New Zealand, compared to Australia.
400
Inequalities in overall Maori health persist even when confounding factors such as poverty, edu-
cation and location are eliminated, demonstrating that cultural or biological factors or something
about the lived social experiences, seemingly specific to Maori theoretically exert an independent
influence as an indigenous determinant of health. It is also likely that part of the cause if unequal
access to health services and medical treatment and care.
398
“Pacific Islanders Pay Heavy Price for Abandoning Traditional Diet”. Bulletin of the World Health Organization 88 (7
July 2010): 484-485.
399
http://www.who.int/bulletin/volumes/88/7/10-010710/en/
400
Jansen P, Jansen D 2013. Māori and Health. Chapter 5 in St George IM (ed.). Cole’s medical practice in New Zealand,
12th edition. Medical Council of New Zealand, Wellington.
142 ξ Chapter 6
State of the World’s Indigenous Peoples
Maori women have rates of breast, cervical and lung cancer that are several times those of
non-Maori women. There is high incidence of obesity in the Maori community, which contributes
to the higher incidence of diabetes, and the younger age of diagnosis. Maori have lower access to
medical care and rehabilitation services when compared with non-Maori. Even though Maori turn
up for general practitioner appointments at the same rate as non-Maori, they obtain fewer diag-
nostic tests, less eective treatment plans and are referred for secondary or tertiary procedures
at significantly lower rates than non-Maori patients.
401
In Australia, indigenous peoples are a much younger population. According to estimates from the
2011 Census, about 36 per cent of indigenous peoples were less than 15 years of age, compared
with 18 per cent of their non-Indigenous counterparts in that age group.
402
In 2011 the Census
showed a 21 per cent increase in the population of indigenous peoples compared with the 2006
Census. A number of reasons contributed to the growth of the indigenous population;
ɜ higher fertility rates of indigenous women compared with the rates of other Australian
women;
ɜ the significant numbers of indigenous babies born to indigenous fathers and non-
indigenous mothers;
ɜ this increase may also be due to a higher rate of self-reported boriginal identity and the
way identity was collected and analysed, possibly reflecting increasing pride with identi-
fying as an indigenous person.
The majority of indigenous peoples live in cities and towns. Overall, slightly more than one-half
of the indigenous population lived in areas classified as “major cities” or “inner regional” areas,
compared with almost nine-tenths of the non-indigenous population. Almost one-quarter of in-
digenous peoples lived in areas classified as “remote” or “very remote” in relation to having “very
little access to goods, services and opportunities for social interaction”.
403
In Australia, most of
the indigenous peoples live in low socioeconomic circumstances with low educational achieve-
ment, high unemployment and low income and overcrowded housing. Many are located in areas
with inadequate social support services.
404
During the early colonial period in Australia, introduced diseases was certainly the major cause
of death for indigenous peoples but direct conflict and occupation of their lands also contributed
substantially to indigenous mortality. Conflict escalated in many places, in some instances re-
sulting in overt massacres of indigenous peoples. Prior to arrival of the British colonizers in 1788,
indigenous peoples were able to define their own sense of being through control over all aspects
of their lives, including ceremonies, spiritual practices, medicine, social relationships, manage-
401
Davis P., Suaalii-Sauni T., Lay-Yee R., Pearson J., 2005, Pacific Patterns in Primary Health Care: A comparison of Pacific
and all patient visits to doctors: The National Primary Medical Care Survey (NatMedCa): 2001-2002. Report 7. Welling-
ton: Ministry of Health
402
Gray C, Brown A, Thomson N. Review of cardiovascular health among Indigenous Australians. Australian Indigenous
HealthBulletin 12(4), http://healthbulletin.org.au/articles/review-of-cardiovascular-health-among-indigenous-australians.
403
Australian Indigenous HealthInfonet (2013) summary of Australian Indigenous health, retrieved (15/10/2013) from
http://www.healthinfonet.ecu.edu.au/health-facts/summary.
404
“Social determinants and the health of Indigenous peoples in Australia: A Human Rights Based Approach”. Australian
Human Rights Commission, N.p., n.d. Web. 27 Feb. 2014, https://www.humanrights.gov.au/news/speeches/social-de-
terminants-and-health-indigenous-peoples-australia-human-rights-based.
Chapter 6 ξ 143
Indigenous Peoples’ access to Health Services
ment of land, law and economic activities. In addition to the impacts of introduced diseases and
conflict, colonization of indigenous peoples’ lands undermined the ability of indigenous peoples
to lead healthy lives by devaluing their culture, destroying their traditional food base, separating
families and dispossessing whole communities. This loss of autonomy undermined social vitality,
which, in turn, aected the capacity to meet life’s challenges, including maintaining health as a
vicious cycle of dispossession, demoralization and poor health was established.
These impacts on indigenous peoples eventually forced colonial authorities to try to “protect”
remaining indigenous people. This pressure led to the establishment of Aboriginal “protection”
boards, the first established in Victoria by the Aboriginal Protection Act of 1869. A similar Act
established the NSW Aborigines Protection Board in 1883, with the other colonies also enacting
legislation to “protect” indigenous populations within their boundaries. The “protection” provid-
ed under the provisions of the various Acts imposed enormous restrictions on the lives of many
indigenous peoples. These restrictions meant that, as late as 1961, in eastern Australia “nearly
one-third of all Australians recorded as being of Aboriginal descent lived in settlements”. The
provisions of the Acts were also used to justify the forced separation of indigenous children from
their families “by compulsion, duress or undue influence”. The National Inquiry into the separation
of the children concluded that “between one in 3 and one in 10 Indigenous children were forcibly
removed from their families and communities in the period from approximately 1910 until 1970”. It
was the 1960s, at the earliest, when the various “protection” Acts were repealed.
405
The health status of Australia’s indigenous peoples is poor in comparison to the remainder of the
Australian population.
406
There remains a large inequality gap in Australia across all health and
social statistics. For example, for all age groups below 65 years, the age-specific death rates for
indigenous Australians are at least twice those experienced by the non-indigenous population.
The causes of death with the largest contribution to excess mortality among indigenous males
are circulatory diseases, cancers, injuries, respiratory diseases and endocrine, metabolic and nu-
tritional disorders. The indigenous male death rates due to external causes (injuries) were more
than three times those for non-indigenous males aged 25 to 44 years.
407
Between 2004 and 2008, two-thirds (66 per cent) of indigenous deaths occurred before the age
of 65 years compared with 20 per cent of non-indigenous deaths. In that same period, endocrine,
metabolic and nutritional disorders contributed to raise indigenous mortality up to six to
seventimes the non-indigenous rates. For indigenous females, the causes of death with the largest
contribution to excess mortality are circulatory diseases, endocrine, metabolic and nutritional
disorders, digestive diseases, neoplasms and respiratory diseases. The indigenous infant mortality
rate declined between 1991 and 2008, though it remains twice that of non-indigenous infants.
A range of risk factors contribute to excess indigenous mortality, including tobacco smoking,
excessive alcohol consumption, high overweight/obesity, poor nutrition and lower utilization of
405
“Aboriginal Societies: The Experience of Contact”, Australian Law Reform Commission. N.p., n.d. Web. 27 Feb. 2014.
http://www.alrc.gov.au/publications/3.%20Aboriginal%20Societies%3A%20The%20Experience%20of%20Contact/
changing-policies-towards-aboriginal.
406
Australian Insitute of Health and Welfare 2011. The health and welfare of Australia’s Aboriginal and Torres Strait Is-
lander people, an overview 2011. Cat. no. IHW 42 Canberra: IHAW.
407
Australian Institute of Health and Welfare 2011. The health and welfare of Australia’s Aboriginal and Torres Strait Is-
lander people, an overview 2011. Cat. no. IHW 42. Canberra: AIHW.
144 ξ Chapter 6
State of the World’s Indigenous Peoples
health services relative to need.
408
The 2012-2013 National Australian Aboriginal and Torres Strait
Islander Health Survey (NATSIHS) is the largest survey of indigenous Australians health status,
and results are being released progressively during 2013-2014.
While there have been improvements on some measures of indigenous health status, they have
not matched the rapid health gains made in the general population in Australia. For example,
death rates from cardiovascular disease in the general population have fallen 30 per cent since
1991, and 70 per cent in the last 35 years, whereas indigenous peoples do not appear to have made
any reduction in death rates from cardiovascular disease over this period.
409
Important determinants of indigenous health inequality in Australia include the lack of equal
access to primary health care and inadequate infrastructure and support services in indigenous
communities compared to other Australians.
A clear relationship exists between the social disadvantages experienced by indigenous peoples
and their current health status. Whereas the health disparities and vulnerabilities experienced by
indigenous peoples in Australia can be considered as having their roots in the history of coloniza-
tion, present-day perpetuation of indigenous peoples disadvantage owes much to contemporary
civil society turning a blind eye to the disparities. Education, employment, income, housing, ac-
cess to health services, social networks, connection to land, racism, and incarceration are issues
where indigenous peoples are experience substantial disadvantage.
Holistic Health
It is also important in considering indigenous health to understand how indigenous people them-
selves conceptualize health. Like most indigenous peoples in the world, indigenous Australians’
perspective of health is holistic. It encompasses everything important in a person’s life, including
land, environment, physical body, community, relationships, and law. Health is the social, emo-
tional, and cultural well-being of the whole community and the concept is therefore linked to the
sense of being indigenous.
410
When Captain James Cook arrived in Hawaii in 1778, it was estimated that there were between
300,000 and 400,000 Native Hawaiians, the kanaka maoli. Over the course of the next century
the Native Hawaiian population dropped between 80-90 per cent. This decline was due, in large
part, to the diseases introduced by contact with foreigners. By 1878, the native population was
estimated to be between 40,000 and 50,000 people. While drastically smaller than the popula-
tion of just one hundred years previously, the Native Hawaiians still comprised over 75 per cent of
the total population of Hawaii.
411
408
Ibid.
409
National Health and Medical Research Centre, “Promoting the health of Australians, Case studies of achievements in
improving the health of the population”, AGPS, Canberra, 1997, Thomson, N. and Brooks, J., “Cardiovascular Disease”, in
Editor, Thomson, N., The Health of Indigenous Australians, Oxford University.
410
“The context of Indigenous health”. Australian Indigenous HealthInfoNet. N.p., n.d. Web. 27 Feb. 2014, http://www.
healthinfonet.ecu.edu.au/health-facts/overviews/the-context-of-indigenous-health.
411
The Native Hawaiian Population and other Pacific Islander Population (2010), retrieved 04/10/2013 from http://www.
census.gov/prod/cen2010/briefs/c2010br-12.pdf.
Chapter 6 ξ 145
Indigenous Peoples’ access to Health Services
The 1900 U.S. Census identified 37,656 residents of full or partial Native Hawaiian ancestry. Today,
there are fewer than 8,000 Native Hawaiians alive who are 100 per cent blood quantum.
412
On the
contrary, the number of those who identify as having part Native Hawaiian ancestry and who con-
sider themselves to be Hawaiian, has increased steadily since the turn of the century. Today, esti-
mates are between 225,000 and 250,000 people with Hawaiian blood living in Hawaii. According
to the U.S. Census Bureau report for 2000, there were 401,162 people who identified themselves
as being Native Hawaiian alone or in any combination, and 140,652 people identified themselves
as being Native Hawaiian alone. Two-thirds live in the State of Hawaii while the other one-third is
scattered among other states, with a high concentration in California.
413
Today, Native Hawaiians are still fighting to regain their language, culture, rights and land. One
eort under way is the move to have Native Hawaiians federally recognized as the indigenous peo-
ple of the Hawaiian islands thereby allowing a government-to-government relationship between
mainland Native American tribes and Alaska natives in the United States. Native Hawaiian culture
has seen a revival in recent years as a consequence of decisions made at the 1978 Hawaii State
Constitutional Convention. At the convention, the Hawaii state government committed itself to a
progressive study and preservation of Native Hawaiian culture, history and language. A compre-
hensive Hawaiian culture curriculum was introduced into the State of Hawai’i’s public elementary
schools teaching ancient Hawaiian art, lifestyle, geography, hula and Hawaiian language vocabu-
lary.
414
Indigenous Hawaiians have the poorest health and socioeconomic indicators of the various ethnic
groups in the State of Hawaii.
415
When compared to the U.S. all-race population, Native Hawaiians
have death rates that are 44 per cent higher for heart disease, 39 per cent higher for cancer, 31 per
cent higher for strokes and 196 per cent higher for diabetes The Native Hawaiian infant mortality
rate was more than twice that for Whites. High Native Hawaiian infant mortality was equally due
to neonatal and post-neonatal deaths. Preterm-related causes of death accounted for 43.9 per
cent of the infant mortality disparity, followed by sudden unexpected infant death (21.6 per cent)
and injury (5.6 per cent). Maternal educational inequality was associated with the largest portion
of the neonatal mortality disparity (20.9 per cent); younger maternal age (12.2 per cent) and smok-
ing (9.5 per cent) were the only significant contributors to the post-neonatal mortality disparity.
416
Tobacco smoking, high-fat diet, alcohol drinking, hyperlipidemia and obesity are the major life-
style risk factors.
417
Although cigarette smoking in the general U.S. population has decreased con-
412
Pentaris, P. “Culture and Death: A Multicultural Perspective”. Hawaii Pacific Journal of Social Work Practice 4.1 (2011):
45-84. Print.
413
United States: Race reporting for the Native Hawaiian by Selected Categories: 2010, retrieved 10/10/2013 from http://
www.ohadatabook.com/QT-P9_United%20States.pdf.
414
Wilson, W.H”.The Sociopolitical Context of Establihsing Hawaiian-medium Education” In. Indigenous Communi-
ty-Based Education. Ed. Stephen May. Clavedon, UK: Multilingual Matters, 1999. 95-108.
415
Native Hawaiian Fact Sheet 2011. Oce of Hawaiian Aairs, Honolulu. HI.
416
Hirai AH, Hayes DK, Taualii MM et al. Excess Infant Mortality Among Native Hawaiians: Identifying Determinants for
Preventive Action .Am J Public Health l2013 Nov;103(11):e88-95. doi: 10.2105/AJPH.2013.301294. Epub 2013 Sep 12.
417
Noncommunicable diseases - Fact sheet. (n.d.). World Health Organization. Retrieved February 26, 2014, from http://
www.who.int/mediacentre/factsheets/fs355/en/.
146 ξ Chapter 6
State of the World’s Indigenous Peoples
siderably over the past several decades, prevalence rates among Native Hawaiians have remained
elevated by comparison with other groups.
Figure 2. Current smoking among adults by demographic characteristics in Hawaii
418
13.2
13.7
23.2
12.7
21.9
12.7
18.2
2 7.0
23.1
12.1
18.7
18.4
16.1
6.5
15.4
18.4
4035302520151050
White
African American
Hispanic
Asian
Native Hawaiian/Pacific Islander
***American Indian/Alaska Native
Female
Male
More than high school degree
Less than high school degree
High school degree
18-24 years old
25-44 years old
45-64 years old
65+ years old
Hawaii
Figure 4. Current Smoking among Adults
by Demographic Characteristics in Hawaii, Ibid
National (median)
Sowip 2_Figure 4_Current Smoking (171).xlsx
418
Centers for Disease Control and Prevention, Tobacco Control State Highlights, 2010, Atlanta: U.S. Department of
Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Preven-
tion and Health Promotion, Oce on Smoking and Health, 2010.
Chapter 6 ξ 147
Indigenous Peoples’ access to Health Services
Figure 3. Current smoking among adults by demographic characteristics in California
419
14.3
24.3
13.5
7. 4
33.5
23.4
10.3
1 7. 8
16.8
19.6
11.3
16.8
15.8
14.1
6.5
14
18.4
4035302520151050
White
African American
Hispanic
Asian
Native Hawaiian/Pacific Islander
American Indian/Alaska Native
Female
Male
More than high school degree
Less than high school degree
High school degree
18-24 years old
25-44 years old
45-64 years old
65+ years old
California
Figure 4. Current Smoking among Adults
by Demographic Characteristics in California, Ibid
National (median)
Sowip 2_Figure 4_Current Smoking (171).xlsx
419
Ibid.
148 ξ Chapter 6
State of the World’s Indigenous Peoples
New Zealand
The landmark Social Security Act introduced in 1938 established the “cradle to the grave” welfare
philosophy and universal access to health care in New Zealand. The policy included the availability
of the General Medical Subsidy (GMS), a fee-for-service arrangement, in which private general prac-
titioners were able to claim part of the cost of treating patients at the primary care level. Hospital
and other specialist services, including pharmaceuticals, were free to the user. Doctors claimed that
the GMS failed to keep pace with rising costs and they were forced to introduce extra billing by pa-
tients to increase charges for physician consultations. Over the years, the system of the GMS and
patient part charges led to an “oversupply” of doctors in auent areas due to the prosperous resi-
dents’ ability to pay. Conversely, less auent and rural areas had fewer doctors with fewer services
despite high levels of need. Most indigenous Maori (and other minority groups) live in less auent
areas as a result of high unemployment, low income and availability of social housing.
420
Developments in Maori health have been strengthened by the presence of an eective political
voice in the Aotearoa/New Zealand Parliament. The Maori Party was formed in 2004 as a result
of the foreshore and seabed controversy, a debate about whether Maori have legitimate claim
to ownership of part or all of New Zealand’s foreshore and seabed. The Maori Party is formally in
coalition, along with two other minor political parties, with the national party-led Government.
Their presence in parliament has been widely regarded as being influential in a number of sig-
nificant policy and funding that benefit Maori and other minority groups, e.g., Whanau Ora is an
interagency approach that includes services and opportunities to support the aspiration of Maori
whanau (extended families) to become more self-managing and to take responsibility for their
economic, social and cultural development. They have also made significant gains in tobacco con-
trol, including substantial rises in tobacco taxes and funding for rheumatic fever and rheumatic
heart disease prevention.
Indigenous health providers
The introduction of the New Zealand Health Strategy and the Primary Health Care Strategy in
2001 made major changes to the way primary health care was organized, governed and fund-
ed.
421
,
422
He Korowai Oranga (Maori Health Strategy) was introduced in 2002 outlining the direc-
tion for Maori health development in New Zealand.
423
These strategies led to a number of changes
including capitation funding rather than a fee for service and introduced greater participation by
Maori in the provision of primary health care services. The availability of a Maori Provider Devel-
opment Scheme (MPDS) and additional funding for “high need” populations led to the growth of
a number of Maori-owned Community Controlled Primary Health Care (PHC) clinics and related
services. An independent evaluation of the MPDS showed that the scheme had made a positive
420
Barwick H., “Improving access to primary care for Maori and Pacific peoples. A literature review”, commissioned by the
Health Funding Authority. Wellington: Ministry of Health; 2000.
421
The New Zealand Health Strategy retrieved 10/10/2013 from http://www.health.govt.nz/publication/new-zea-
land-health-strategy.
422
The Primary Health Care Strategy retrieved 10/10/2013 from http://www.moh.govt.nz/notebook/nbbooks.ns-
f/0/8255DFFA80749680CC2569F0006F9FF3/$file/PHCStrat.pdf.
423
He Korowai Oranga retrieved 10/10/2013 from http://www.health.govt.nz/publication/he-korowai-oranga-maori-
health-strategy.
Chapter 6 ξ 149
Indigenous Peoples’ access to Health Services
contribution to the development of the capacity and capability of Maori health providers.
424
Ka
tika ka ora is the Maori Health provider programme managed by the New Zealand Ministry of
Health (MOH) on behalf of District Health Boards (DHBs).
425
The programme is designed to de-
velop a comprehensive national picture of activities that the Ministry and DHBs have planned to
undertake to support the Maori health provider sector and provide a foundation for building a
consistent approach in supporting a solid body of Maori health providers. Maori health providers
have made a big impact on health care delivery in New Zealand and increasingly accepted as an
integral part of the health care landscape.
426
Since He Korowai Oranga was implemented as policy in 2002, substantial progress has been made
in building capacity of the Maori health and disability workforce. This policy could be considered
a best practice for other health systems around the world. Key factors in successful programs to
increase Maori health workforce recruitment and retention include Maori leadership, mentorship
and peer support and comprehensive support within study programs and in the transitions be-
tween school, university and work. The interventions to date provide a strong basis for ongoing
action to address inequities in health workforce participation, and are likely to be relevant to health
workforce development approaches for other indigenous people.
427
There is an active Maori health
research programme health funded by the Health Research Council of New Zealand and academic
institutions.
428
The research programmes supports both the development of a Maori health research
workforce and research projects into priority health issues of concern to Maori. The research pro-
gramme includes investigations involving Maori research concepts and interventions.
429
Australia
Indigenous health policy in Australia is guided by the National Aboriginal and Torres Islander
Health Plan 2013-2023.
430
One of the nine guiding principles of this policy is the directive that
Governments adopt a holistic approach, recognizing that the improvement of indigenous Aus-
tralians’ health status must include attention to physical, spiritual, cultural, emotional and social
well-being, community capacity and governance.
The Indigenous Health Service Delivery Division (IHSDD) formerly known as the Oce for Aboriginal
and Torres Strait Islander Health (OATSIH) in the Department of Health and Ageing was established
in 2013 to give greater focus to the health needs of indigenous Australians in mainstream health
424
Evaluation of the Maori Provider Development Scheme retrieved 10/10/2013 from http://www.health.govt.nz/publica-
tion/evaluation-maori-provider-development-scheme.
425
Ka tika ka ora retrieved 10/10/2013 from http://www.health.govt.nz/our-work/populations/maori-health/maori-
health-providers/ka-tika-ka-ora-maori-health-provider-work-programme.
426
Ministry of Health. 2009. Maori Provider Work Programme. Wellington: Ministry of Health.
427
Ratima M, Brown R, Garrett N et al. Strengthening Maori participation in the New Zealand health and disability work-
force. Med J Aust 2007 186 (10): 541-543.
428
Māori Health Research. (n.d.). Health Research Council of New Zealand. Retrieved February 27, 2014, from http://www.
hrc.govt.nz/funding-opportunities/maori-development.
429
Jones, B., Ingham, T.R., Cram, F., Dean, S. & Davies, S. (2013). An Indigenous approach to exploring health-related expe-
riences among Māori parents: The Pukapuka Hauora asthma study. BioMed Central 13:228 (15 March 2013).
430
National Aboriginal and Torres Strait Islander Health Plan 2013-2023, retrieved 09/11/2013 from http://www.health.
gov.au/internet/main/publishing.nsf/content/B92E980680486C3BCA257BF0001BAF01/$File/health-plan.pdf.
150 ξ Chapter 6
State of the World’s Indigenous Peoples
programmes, and to administer funding to Aboriginal and Torres Strait Islander community con-
trolled clinics. IHSDD funds a comprehensive range of services for indigenous Australians with the
aim to close the gap in health outcomes within the 2013-2023 decade. The aim is to provide coordi-
nated clinical care, population health and health promotion programs for disease prevention, early
intervention and eective disease management. The IHSDD pursues a three way approach, namely;
ɜ to improve access to, and responsiveness of the mainstream health system;
ɜ to ensure complementary actions through Aboriginal and Torres Strait Islander specific
health initiatives;
ɜ to increase collaboration across governments and the health sector to improve service
delivery and health outcomes.
The National Aboriginal Community Controlled Health Organization (NACCHO)
NACCHO was established in 1992 and is a peak body on Aboriginal health representing the in-
terests of Aboriginal Community Controlled Health Services (ACCHSs). ACCHSs deliver a range
of services to meet the complex health needs of indigenous Australians. ACCHSs plays a central
role due to the religious, cultural, spiritual and social needs including provision of culturally ap-
propriate primary health care services specific to the needs of local communities. ACCHSs aims
to respond to the unique needs of indigenous Australians through a network of centres through-
out Australia. Examples of ACCHSs initiatives include the Aboriginal Health Worker Forum, the
Kimberley Aboriginal Medical Services Council Inc., Nunkuwarrin Yunti of SA Inc., Wu Choppe-
ren Social Health Programme in Cairns and others. In 2013, NACCHO launched the HEALTHY FU-
TURES 10-point plan 2013-2030, which outlines priorities and strategies for ACCHSs, government
and other stakeholders for improving the health of indigenous Australians.
431
The plan includes a
range of measures including research, funding and support for the workforce to deliver innovative
and comprehensive primary health care.
432
Like most indigenous societies, indigenous Australians have a rich and sophisticated system of
traditional medicine and healing practices. Traditional medicine practice (TMP) by indigenous
Australians encompasses a holistic world view, which recognizes good health as a complex sys-
tem involving interconnectedness with the land, spirit and ancestry and the connectedness of so-
cial, mental, emotional and physical well-being of the individual and community. A recent review
of the role of TMP in primary care within Aboriginal Australia showed that the practices were used
concurrently or sequentially with conventional health care services.
433
431
Investing in Healthy Futures for Generational Change, retrieved from 10/10/2013 from http://www.naccho.org.au/
download/naccho_health_futures/NACCHO%20Healthy%20Futures%2010%20point%20plan%202013-2030.pdf.
432
“Aboriginal Male Healthy Futures for Generational Change”. National Aboriginal Community Controlled Health Organ-
isation. N.p., 1 Aug. 2013. Web. 28 Feb. 2014. http://www.naccho.org.au/download/naccho_health_futures/A%20Blue-
print%20for%20Aboriginal%20Male%20Healthy%20Futures%20.pdf.
433
Oliver S. The role of traditional medicine practice in primary health care within Aboriginal Australia: a review of the
literature. Journal of Ethnobiology and Ethnomedicine 2013, 9:46 doi:10.1186/1746-4269-9-46.
Chapter 6 ξ 151
Indigenous Peoples’ access to Health Services
Hawaii
Until recently, the United States of America does not have a purposeful national publically system
of health care as much as a laissez fare practices that have developed over time. The central
element is a financial arrangement that pays for health care services through employer-purchased
insurance. Historically, patients have had the right to choose any physician, and physicians have
been free to choose among specialties and to practice where and how they like. New managed care
plans increasingly restrict both of these choices. Market incentives encourage the development of
new drugs and high-tech treatments. For some of the uninsured, the government pays for health
care through Medicare, Medicaid, the military, Native American Health Service, the Veterans
Administration, and other programs. This leads to great complexity, since all of these plans
follow dierent eligibility, underwriting, benefit, and reimbursement policies. Hawaii’s health
care plan makes a basic package of health benefits available to all residents through employer-
mandated insurance, supports health promotion and disease prevention, and controls health care
expenditures.
Hawaii was the first state in the USA to enact laws creating a near universal health care coverage
system, with the Hawaii Prepaid Health Care Act which was passed in 1974.
434
The Act required
employers to provide health insurance to employees. Legislation in 1989 added those not covered
by Medicare, Medicaid, or private insurance and emphasized comprehensive, preventive care. In
1994, health care programs for Medicaid and other low-income groups were converted into man-
aged care plans. Managed care plans are financing systems that control health care costs in two
ways. First, they lock in consumers to specific lists of providers (physicians, hospitals, nursing
homes, etc.) who agree to accept reduced fees. Second, many require the insurance company’s
approval before providing benefits. The first managed care plans were started in the 1940s, with
the development of several health maintenance organizations (HMOs). Their purpose was to pro-
vide comprehensive health care for a set monthly fee, rather than fee for service. Considered
radical at the time, HMOs and other managed care products are now mainstream. Many have
demonstrated cost savings and quality outcomes by emphasizing preventive care and conserva-
tive use of treatments.
435
In Hawaii, there have been several health initiatives implemented to address the needs of Native
Hawaiians. Na Pu’uwai, Inc. is a community-based Native Hawaiian organization on the island
of Molokai, dedicated to the betterment of the health conditions of Native Hawaiians.
436
It was
founded in 1985 as an advisory committee to the Molokai Heart Study in collaboration with the
University of Hawaii, WHO and OHA. In 1987, in collaboration with the University of Oregon, Na
Pu’uwai conducted the Ho’oke ‘Ai—Molokai Diet Study which laid the foundation, and served as
the catalyst to renewed interest in the benefits of the traditional Hawaiian diet.
437
The results of
these research projects and the ongoing information that Na Pu’uwai has gathered through the
Cardiovascular Risk Clinics have had a major impact on the understanding and management of
434
Hawaii Prepaid Health Care Act, retrieved 10/10/2013 from http://labor.hawaii.gov/dcd/home/about-phc/.
435
Cooper, E, and Liz Taylor. “Comparing Health Care Systems”. Context Institute. N.p., 9 Sept. 1994. Web. 28 Feb. 2014.
http://www.context.org/iclib/ic39/cooptalr/.
436
Na Pu’uwai Native Hawaiian Health Care System, retrieved 10/10/2013 from http://www.napuuwai.com/page2.html
437
“Our History”. Na Pu´uwai, Inc. N.p., n.d. Web. 28 Feb. 2014. http://www.napuuwai.com/.
152 ξ Chapter 6
State of the World’s Indigenous Peoples
risk factors and cultural barriers aecting the health conditions of Native Hawaiians.
438
The Molo-
kai Diet study has served as a model for current traditional Hawaiian Diet Programs such as the
Waianae Diet Program and the Waimea Diet Program.
439
The aggregation of Native Hawaiian smoking data with that of Asians has drawn attention away
from the serious smoking problems that Native Hawaiians experience, thus, limiting funding, pro-
grams, and policies to reduce tobacco-related health disparities in their respective communities.
In California, community-based organizations (CBOs) have played a major role in supporting the
state’s comprehensive tobacco control program, which is arguably one of the most successful in the
nation. One study described the tobacco control activities of five Native Hawaiian serving CBOs in
Southern California and how they have provided anti-tobacco education for thousands of Native
Hawaiians, Chamorros, Marshallese, Samoans, Tongans, and other Pacific Islander subgroups, and
used advocacy and coalition building to promote smoke-free environment policies in their commu-
nities. The concerted eorts of the CBOs and their community members have made vital contribu-
tions to the reduction of tobacco-related disparities for indigenous populations in California.
440
Small islands of the Pacific
In most of the small islands of the Pacific, governments are the main funders and providers of
health services.
441
Several small island states spend less than 5 per cent of GDP on health care
services. It is generally accepted that health expenditure above this threshold is required in or-
der to ensure the availability of basic health care services.
442
Rural areas and outer islands tend
to have lower availability of health care services and residents need to travel to cities and urban
areas for health care.
443
Most small island states are struggling to fund and provide health care
services as a result of a growing and ageing population as well as the demands caused by people
with NCDs, including costly complications such as kidney failure needing dialysis. NCDs have be-
come the major causes of costly o-island referrals.
444
Discussion
Indigenous peoples in the Pacific region have similar health status, due in large part to their
shared colonial history and health determinants. Socioeconomic determinants of health are part
of the environmental causes of ill health that aect population health. They point to evidence
that highlights higher susceptibility to illness and disease as a product of particular socioeco-
438
Ibid.
439
Ibid.
440
Palmer P.H., Lee C., Sablan-Santos L. et al., Eliminating tobacco disparities among Native Hawaiian pacific islanders
through policy change: the role of community-based organizations. Health Promot Pract. 2013 Sep;14(5 Suppl):36S-9S.
doi: 10.1177/1524839913486150. Epub 2013 May 10.
441
Anderson, I. The World Bank. East Asia and Pacific Regino. Economic Costs of Non-Communicable Diseases in the
Pacific Islands. Washington, DC: The World Bank, 2012. Print. http://www.worldbank.org/content/dam/Worldbank/doc-
ument/the-economic-costs-of-noncommunicable-diseases-in-the-pacific-islands.pdf.
442
World Health Organization. Western Pacific Region. Health in Asia and the Pacific: Chapter 10. Health Systems. Print.
Health in Asia and the Pacific.
443
Enhancing the Role of Government in the Pacific Island Economies. Washington, DC: World Bank, 1998.
444
Anderson, I. Economic Costs of Non-Communicable Diseases in the Pacific Islands.
Chapter 6 ξ 153
Indigenous Peoples’ access to Health Services
nomic and physical environments. The social determinants of health are the conditions in which
people are born, grow, live, work and age. These circumstances are shaped by the distribution of
wealth, power and resources at global, national and local levels.
445
,
446
“The inequity is systematic,
produced by social norms, policies and practices that tolerate or actually promote unfair distri-
bution of and access to power, wealth and other necessary social resource(s)”.
447
This statement
by Michael Marmot acknowledges that there are larger “causes of causes”, or distal determinants,
of unhealthy life conditions. At an International Symposium on the Social Determinants of In-
digenous Health,
448
it was demonstrated that the determinants of indigenous health dier from
those of the mainstream population. This is in part due to how health is conceptualized amongst
indigenous peoples compared to Western, biomedical definitions
Indigenous populations were relatively large prior to contact with European settlers but conflict
and diseases led to sharp declines in the numbers of indigenous peoples, especially those living
in New Zealand, Australia and Hawaii, threatening the very existence of indigenous peoples. The
increase in population numbers has led to the revival of interest in their languages and cultures
and interest from the wider society within all three countries. Loss of languages and cultures were
a result of intentional and unintentional actions by the colonizers, often with oppressive regula-
tions and legislations aimed at assimilation into the body politic of the developing nation states.
While some aspects of indigenous cultures are being celebrated, they continue to experience
the poorest health status with higher rates of preventable disease and disability and premature
death in the Pacific region.
Universal access to health care services in New Zealand is an integral part of the welfare and
health policies but the Maori peoples have had generally low access to health care at all levels.
Successive New Zealand Health Surveys have shown that Maori generally have lower access to
health care despite having higher health needs. The establishment of Maori health care providers
has improved the availability of primary and community health care services, but the impact on
health outcomes remains unclear and needs to be carefully evaluated. Most Maori peoples continue
to receive health care from mainstream health care providers. Early indications are encouraging
in that 65 per cent of the caseload for Maori health providers is regarded as high need compared
with mainstream providers where their “high needs” population base is 26 per cent. There is
evidence of improved access to primary and community health care services primarily as a result
of the changes to the criteria for universal access and availability of low-cost clinics, for example;
Maori health providers also have a strong presence in rural communities where the majority of the
resident population tends to be Maori.
449
445
Commission on Social Determinants of Health retrieved 10/10/2013 from
http://www.who.int/social_determinants/the commission/en/index.html.
446
Social determinants of health, retrieved 10/10/2013 from http://www.who.int/social_determinants/B_132_14-en.pdf.
447
Commission on Social Determinants of Health retrieved 10/10/2013 from http://www.who.int/social_determinants/the
commission/en/index.html.
448
Social determinants and Indigenous health, retrieved 10/10/2013 from http://www.who.int/social_determinants/re-
sources/indigenous_health_adelaide_report_07.pdf.
449
Ellison-Loschmann L, Pearce N. Improving access to health care among New Zealand’s Maori population. American
Journal of Public Health. 2006;96:612-617.
154 ξ Chapter 6
State of the World’s Indigenous Peoples
The relatively profound socioeconomic disadvantage experienced by indigenous peoples in Aus-
tralia compared to non-indigenous people places them at greater risk of exposure to behavioural
and environmental health risk factors. Indigenous peoples also do not enjoy equal access to pri-
mary health care services and health promotion and disease prevention public health community
level infrastructure including safe drinking water, eective sewerage systems, rubbish collection
services and healthy housing. The Royal Australasian College of Physicians describes these health
inequities as “both avoidable and systematic”.
450
The Native Hawaiian Health Care Improvement Act (NHHCIA), as amended is a Congressional
Special Initiative with the purpose of improving provision of comprehensive disease prevention,
health promotion, and primary care services to Native Hawaiians in Hawaii. The NHHCIA authoriz-
es funding opportunities for the following activities:
ɜ Service grant to Papa Ola Lokahi (POL) for the activities described in the NHHCIA, includ-
ing the coordination of the health care program and services provided to Native Hawaiians;
ɜ Service grants to the five recognized community-based Native Hawaiian Health Care Sys-
tems (NHHCS) to provide a full range of services identified by the legislation and tailored
to fit the needs of their respective island communities.
The Hawaii Health Authority (HHA), which was established by the Hawaii Legislature as part of
the state’s Department of Budget and Finance and tasked with being “responsible for overall
health planning for the state”, in 2011.
451
The HHA is expected to demonstrate how to get from the
present health care situation in Hawaii to an ecient, cost-eective universal health care system,
and is intended to provide health policy guidance to both the administration and legislature over
the next several years.
In addition to the health status and health services for indigenous peoples in the developed coun-
tries in Pacific region, there are targeted programmes for advanced health research in Australia,
New Zealand and USA (Hawaii). There are clear national, state and local policies and programmes
designed to improve access to health services by and for indigenous peoples in these countries.
Indigenous peoples are also actively involved in research, policy development and service delivery
incorporating traditional health concepts into ways of explaining health phenomenon and service
delivery. In some programs, armative action policies operate, particularly at training institu-
tions
452
and research funds are available for research by indigenous and non-indigenous people
into the health issues of indigenous peoples. At the same time, while the data and information
are available and policies are oered, indigenous people continue to have the poorest health in-
dicators and social conditions.
In all settings, including small island nations of the Pacific, colonialism seems to be universally
identified as having a profound and long-lasting influence on the health status of indigenous
peoples. In the past and continuing to the present day, colonialism impacts negatively on many
450
Inequity and Health: A Call to Action—addressing health and socioeconomic inequality in Australia. Royal Austral-
asian College of Physicians 2005.
451
“About Hawaii Health Authority”. Department of Budget and Finance. N.p., n.d. Web. 28 Feb. 2014. http://hawaii.gov/
budget/hha/hha-meetings-and-minutes.
452
Sowell, Thomas, Armative action around the world: an empirical study. New Haven: Yale University Press, 2004. Print.
Chapter 6 ξ 155
Indigenous Peoples’ access to Health Services
aspects of the health and well-being of indigenous peoples, including a dramatic decline in pop-
ulation numbers at first contact with settlers, due to the introduction of unfamiliar diseases,
loss of languages and cultures, marginalization and discrimination often supported by legisla-
tion. It seems the forces of missionary-style religion, pursuit of trade and commerce and fueled
by the European expansionist doctrine of Manifest Destiny converged in the Pacific region, as it
did across the globe, to marginalize indigenous peoples in their homelands. The Pacific region
experienced myriad loss of cultures and traditions that were aggravated by the introduction of
Christianity which led to the systematic destruction of Pacific cultural practices and symbols. The
Pacific was also a region of intense military strategic importance thus laid claim to by a variety of
European nations. It is dicult to quantify the impact of colonization and Christianity and other
forces on the health status of indigenous peoples in the Pacific. Nonetheless, it is clear that the
process of colonization destroyed and undermined not only the external expression of indigenous
cultures, but their inner sense of self-belief and confidence as distinct cultural groups. Increased
prevalence of stress and mental disorders and social problems manifested as higher incarceration
rates in indigenous peoples in all regions relative to the non-indigenous people living the same
environment and is further evidence of the long-lasting and pervasive negative consequences of
colonization and destruction of cultures.
Government policies and programmes can perpetuate historical practices which further aggravate
the inequalities that exist between indigenous and non-indigenous peoples. For example, social
housing policies often create communities consisting mainly of low-income families who are
located in neighbourhoods with limited access to services. These neighbourhoods often do not
have good educational institutions and children do not get a good start in life. Poor educational
achievement inevitably limits employment prospects for young people and many resort to antisocial
behaviours, which further limits their opportunities for maintaining health and well-being. These
situations often create a never-ending vicious circle where socioeconomic disadvantage becomes
intergenerational and children grow up in environments into which employment prospects are
limited and risks are inherited by the next generation. Promising practices need to be shared and
implemented to stem this pattern of trauma.
At the present time, the most important determinant of poor health among indigenous peoples
relates to their socioeconomic situation and poverty. Poor education and low income are univer-
sally associated with poor health and they are clearly connected. The evidence suggests that the
income gap between the rich and poor has a far greater negative impact on health, rather than
the absolute level of income. For example, studies have shown that market economies such as
the USA, Australia and New Zealand have much greater income inequalities than other jurisdic-
tions.
453
Consequently, the health inequalities and social problems between low income (including
indigenous peoples) and high income groups are more pronounced.
454
Socioeconomic disadvan-
tage is a consequent of low educational achievement by indigenous children and young people.
While children and their families are often blamed for poor performance, the education system in
453
Whiteford, Peter, Australia: Inequality and Prospersity and their impacts in a radical welfare State, March 2013 p. 76,
https://crawford.anu.edu.au/public_policy_community/content/doc/Australia_Inequality-and-Prosperity_final-15-
March-13.pdf.
454
Rowlingson K. Does income inequality cause health and social problems? retrieved 14/10/2013 from
http://www.jrf.org.uk/sites/files/jrf/inequality-income-social-problems-full.pdf.
156 ξ Chapter 6
State of the World’s Indigenous Peoples
many developed countries does not cater well for the needs of indigenous children. Improvements
in educational achievement are essential for improvements in indigenous health.
Policies and programmes to improve indigenous peoples’ health have been in place in developed
countries (Australia, New Zealand and USA (Hawaii) in the Pacific for some years. These initiatives
involve both adjustments to mainstream funding and delivery of health services as well as sup-
port for indigenous health programmes. Adjustments to mainstream provision include funding
incentives to improve to health services by removing financial barriers to access as well as train-
ing for non-indigenous health workers in cultural competency. Indigenous programmes include
the delivery of conventional primary health care and community services targeting indigenous
peoples, which are owned, governed and managed by indigenous peoples themselves. Some of
these services include complementary traditional healing practices which are incorporated into
the range of services provided by the medical clinic.
While there are number of initiatives under way in developed countries deigned to improve ac-
cess to and impact of health care services, there is limited information on the impact of these
programmes. In New Zealand, research is under way to determine the impact of the participation
of Maori health providers on access to and the quality of services received. There are encouraging
signs that health initiatives provided “by indigenous for indigenous people” is improving access to
services, but somewhat too early to assess the impact on their health status.
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Appendix
Pacific Island Countries and Territories (excluding Australia, New Zealand, and Hawaii):
455
ɜ American Samoa
ɜ Cook Islands
ɜ Federated States of Micronesia
ɜ Fiji
ɜ French Polynesia Guam
ɜ Kiribati
ɜ Marshall Islands
ɜ Nauru
ɜ New Caledonia
ɜ Niue
ɜ Northern Mariana Islands,
ɜ Palau
ɜ Papua New Guinea
ɜ Pitcairn Islands
ɜ Samoa
ɜ Solomon Islands
ɜ Tokelau
ɜ Tonga
ɜ Tuvalu
ɜ Vanuatu
ɜ Wallis and Futuna
455
“Members”. Secretariat of the Pacific Region. N.p., n.d. Web. 26 Feb. 2014. http://www.spc.int/en/about-spc/members.
html.
UN Photo
Chapter 7 ξ 159
Indigenous Peoples’ access to Health Services
Chapter Seven
Access to Health Services
by Indigenous Peoples in the
Russian Federation
By Oksana Buranbaeva
UN Photo
160 ξ Chapter 7
State of the World’s Indigenous Peoples
Chapter Seven
Access to Health Services
by Indigenous Peoples
in the Russian Federation
By Oksana Buranbaeva
Introduction
This chapter will focus on indigenous peoples’ access to health services in the Russian Federa-
tion. First, this paper will provide background information by defining health and reviewing rel-
evant international and national legal frameworks regarding health care guarantees. Secondly,
the paper will review the analytical frameworks relevant to understanding access to health care
and factors aecting indigenous health. Third, the paper will examine the overall public health
situation in the Russian Federation and give a summary of the general health care access situ-
ation in the country. It will then discuss problems in indigenous peoples’ health and the causes
of these problems, and examine indigenous peoples’ access to health services. Finally, the pa-
per will present promising examples of practices or interventions that are helpful in alleviating
barriers to health care.
What is health?
In 1948, the World Health Organization (WHO) defined health as “a state of complete physical,
mental and social well-being and not merely the absence of disease or infirmity”.
456
This definition
was included in the Preamble to the Constitution of the WHO in 1946 and remains unchanged
since 1948. The WHO has been requested to amend the definition of health by including the spiri-
tual component. For indigenous peoples, health is a broad and holistic concept encompassing the
spiritual, the intellectual, physical and emotional dimensions. Essential is the coexistence of the
past, present and future, ensuring an intergenerational continuum, including both individual and
communal perspectives. There is a respect for nature that seeks to achieve balance or sense of
equilibrium between the needs of indigenous peoples for their health and survival with sustain-
able environmental stewardship, which includes “interaction with life processes and the natural
laws that govern the planet, all life forms, and spiritual understanding”.
457
Health is seen by indigenous peoples as fundamental to well-being and critical to the broad-
er idea of expanded human capabilities.
458
A healthy person is better able to attain a higher
quality of life by achieving better social integration, both gaining from and giving to his or her
456
WHO (1948), p. 1.
457
WHO (1999), The Geneva declaration on the health and survival of indigenous peoples.
458
Sen (1985, 1999), Nussbaum (2000).
Chapter 7 ξ 161
Indigenous Peoples’ access to Health Services
community. A healthier person is preconditioned to attain better education, greater longevity
and increased livelihood.
459
International and national legal frameworks
The right to health is enshrined in international and regional human rights treaties, such as the
Universal Declaration of Human Rights, the International Covenant on Economic, Social and Cul-
tural Rights (ICESCR), the Convention on the Elimination of All Forms of Discrimination against
Women (CEDAW), the Convention on the Rights of the Child (CRC), the European Social Charter
and the Constitution of the Russian Federation. The right to health in these documents is applied
at the level of the individual. The UN Declaration on the Rights of Indigenous Peoples (UNDRIP),
adopted by the UN General Assembly in 2007, stands out for its recognition of collective rights.
460
The WHO Constitution states that “the enjoyment of the highest attainable standard of health is
one of the fundamental rights of every human being without distinction of race, religion, political
beliefs, economic or social condition”.
461
The right to health means that governments are responsible
for creating conditions in which everybody can achieve the highest attainable standard of health.
This right encompasses “access to timely, acceptable, and aordable health care of appropriate
quality”,
462
as well as healthy and safe working conditions, adequate housing and nutritious food.
The Universal Declaration of Human Rights (Article 25) states that “everyone has the right to a
standard of living adequate for the health and well-being of himself and of his family, including …
medical care and necessary social services”.
463
ICESCR (Article 12) states that the realization of the right to health includes those actions that
reduce infant mortality and ensure the healthy development of the child, improve all aspects of
environmental and industrial hygiene, prevent, treat and control epidemic, endemic, occupational
and other diseases, and create conditions to ensure access to health care for all.
464
In 2000, the
UN Committee on Economic, Social and Cultural Rights, a body that monitors compliance with
this agreement, adopted a General Comment on the Right to Health. The Comment postulates
that “the right to health extends not only to timely and appropriate health care but also to the
underlying determinants of health, such as access to safe and potable water and adequate sani-
tation, an adequate supply of safe food, nutrition and housing, healthy occupational and environ-
mental conditions, and access to health-related education and information, including on sexual
and reproductive health”.
465
According to the Comment, the right to health compels states to respect (do not harm); protect
(ensure that non-state actors do not infringe upon the enjoyment of the right to health), and ful-
459
Wilkinson, R. and Marmot, M. (2003). Social determinants of health: The solid facts. Geneva: World Health
Organization.
460
UNPFII (2009), p. 158.
461
WHO (1948), p. 1.
462
WHO (2012).
463
The Universal Declaration of Human Rights (1948), Article 25.1.
464
ICESCR (1966), Article 12.2.
465
WHO (2012).
162 ξ Chapter 7
State of the World’s Indigenous Peoples
fil (take positive steps to realize the right to health, such as ensuring that proper legislation and
finance mechanisms are in place). The General Comment obliges states to have a national public
health strategy that addresses the health concerns of the whole population, giving particular at-
tention to all vulnerable and marginalized groups.
466
The United Nations Declaration on the Rights of Indigenous Peoples, which incorporates the con-
cept of collective rights, includes government obligations to provide indigenous peoples’ access
to health services and to respect indigenous health systems. Article 24 states that “indigenous
individuals have the right to the enjoyment of the highest attainable standard of physical and
mental health” and that “states shall take the necessary steps with a view to achieving progres-
sively the full realization of this right”.
467
“Indigenous peoples have the right to their traditional
medicines and to maintain their health practices, including the conservation of their vital medic-
inal plants, animals and minerals. Indigenous individuals also have the right to access, without
any discrimination, to all social and health services”.
468
In accordance with Article 29, “States shall
also take eective measures to ensure, as needed, that programmes for monitoring, maintaining
and restoring the health of indigenous peoples, as developed and implemented by the peoples af-
fected by such materials, are duly implemented”.
469
Furthermore, Article 23 states that indigenous
peoples have the right to be actively involved in developing and determining health programmes
aecting them and to administer such programmes through their own institutions.
470
The right to health care and medical assistance is guaranteed in Article 41 of the Constitution
of the Russian Federation.
471
The Article also guarantees that medical assistance shall be made
available by state and municipal health care institutions to citizens free of charge, with the mon-
ey from the relevant budget, insurance payments and other revenues.
472
The Article states that
“The Russian Federation shall finance federal health care and health-building programmes, take
measures to develop state, municipal and private health care systems, encourage activities con-
tributing to the strengthening of human health, to the development of physical culture and sport,
and to ecological, sanitary and epidemiologic welfare”.
473
Article 42 guarantees everyone’s right to
a favourable environment, reliable information about its condition and to compensation for dam-
age inflicted to his or her health or property by ecological violations.
474
While the Constitution
does not specifically mention the right to health guarantees for people with disabilities, children
and youth, it states that fundamental rights and freedoms shall be inalienable and shall belong
to everyone from birth (Article 1),
475
and it contains a special clause stating that men and women
shall have equal rights and freedoms as well as equal opportunities for their pursuit (Article 19).
476
466
WHO (2012).
467
United Nations Declaration on the Rights of Indigenous Peoples, Article 24.2.
468
United Nations Declaration on the Rights of Indigenous Peoples, Article 24.1.
469
United Nations Declaration on the Rights of Indigenous Peoples, Article 29.3.
470
United Nations Declaration on the Rights of Indigenous Peoples, Article 23.
471
Russian Constitution, Article 41.
472
Russian Constitution, Article 41.
473
Russian Constitution, Article 41.
474
Russian Constitution, Article 42.
475
Russian Constitution, Article 1.
476
Russian Constitution, Article 19.
Chapter 7 ξ 163
Indigenous Peoples’ access to Health Services
Article 19 additionally guarantees the equality of human and citizen rights and freedoms, regard-
less of gender, race, nationality, language, origin, property and ocial status, place of residence,
attitude to religion, convictions and membership of public associations or other circumstances.
The Article forbids any restrictions of citizen rights on social, racial, national, linguistic or religious
grounds.
477
With health care coverage in the Russian Federation being guaranteed as a constitu-
tional right, universal and free (under mandatory medical insurance), the responsibility for enforc-
ing this right is shared between central, regional and local authorities.
478
With Russian as the state language throughout the territory of the Russian Federation (Article
68),
479
Article 26 of the Constitution guarantees the right to use one’s native language as well as
to choose freely the language of communication, upbringing, education and creative work.
480
The Russian federal law On Fundamental Principles of Health Care in the Russian Federation (21
November 2011) states that territorial state guarantee programmes providing free medical care
shall take into account the climate and geography of a particular region and the transport avail-
ability of medical organizations (Article 81).
481
This is particularly relevant for indigenous people
in remote locations.
In 1999 the Russian Federation issued the federal law On Guarantees of Rights for Indigenous
Numerically Small Peoples of the Russian Federation. Article 8 of this law entitles indigenous
people to free medical care in state and municipal health care facilities within the framework of
the Programme of state guarantees for mandatory health insurance.
482
As described above, the
legal framework is comprehensive and includes specific provisions for indigenous peoples’ access
to health services.
Analytical frameworks
To examine indigenous peoples’ access to health services in the Russian Federation, it is use-
ful to review three existing analytical frameworks, which inform the following sections. The first
framework focus is on the core elements of the right to health; the second on the core elements
of health care access; and the third on the determinants of indigenous health.
Analytical framework 1: The four components of the right to health
According to the aforementioned General Comment on the Right to Health, the right to health
contains four core elements, namely, availability, accessibility, acceptability and quality. Availability
refers to the provision of a sucient quantity of functioning public health and health care facilities,
goods, services and programmes. Accessibility implies that health facilities, goods, services and
programmes must be accessible to everyone without discrimination. They must be accessible from
477
Russian Constitution, Article 19.
478
Popovich (2011), p. 19.
479
Russian Constitution, Article 68.
480
Russian Constitution, Article 26.
481
The Russian Federation (2011), On fundamental principles of health care in the Russian Federation. Article 81.4.4.
482
The Russian Federation (1999), On guarantees of rights for indigenous numerically small peoples of the Russian Fed-
eration. Article 8.9.
164 ξ Chapter 7
State of the World’s Indigenous Peoples
a physical point of view, aordable and that information about them also must be accessible.
Acceptability implies that health services, goods, services and programmes should respect medical
ethics, be sensitive to gender and life-cycle requirements and be culturally appropriate. Quality
refers to the medical and scientific appropriateness of health facilities, goods and services.
483
Analytical framework 2: Access barriers to health services
484
Table 1: Overview of identified access barriers along supply and demand sides and four dimen-
sions of access
485
Supply-side barriers Demand-side barriers
Geographic accessibility
Service location (in relation to the house-
hold)
Indirect costs to household (e.g. transport
and accommodation expenses)
Means of transport available
Availability
Unqualified health workers, sta absentee-
ism, opening hours
Waiting times
Motivation of sta
Drugs supply and other consumables (e.g.,
medical supplies, assistive devices and
equipment)
Non-integration of health services
Lack of opportunity (exclusion from services)
Information on health care services/providers
Education
Aordability
Costs and prices of services, including infor-
mal payments
Private-public dual practices
Household resources and willingness to pay
Opportunity costs
Cash flow within society
Acceptability
Complexity of billing system and inability for
patients to know prices beforehand
Sta interpersonal skills, including trust
Household’s expectations
Low self-esteem and little assertiveness
Community and cultural preferences
Stigma
Lack of health awareness
483
General Comment No. 14 (2000), Normative Content of Article 12.
484
Jacobs, et al. (2011), pp. 1-11.
485
Jacobs, et al. (2011), p. 4.
Chapter 7 ξ 165
Indigenous Peoples’ access to Health Services
While there is no agreed-upon definition of access to health services,
486
one way to describe
such access is “the timely use of service according to need”.
487
Scholars identify four dimensions
of access to health care - geographic access, availability, aordability and acceptability
488
-
and state that barriers to health care access can stem from both supply and demand sides.
489
Supply-side barriers (see table below) are the barriers that are inherent to the health system
and have a negative eect on the uptake of health services at the individual, household or
community level. Demand-side barriers (see table below) are barriers that hinder individuals’,
households’ or communities’ ability to use health services. Supply- and demand-side barriers are
not necessarily mutually exclusive. They may influence each other
490
and should be addressed
simultaneously.
491
Analytical framework 3: Cultural and socioeconomic determinants of indigenous health and ac-
cess to health services
492
Indigenous peoples worldwide face challenges in achieving optimal health health that is exacer-
bated by inadequate access to health services due to their socioeconomic and cultural contexts
as well as some distinctive factors that are specific to indigenous peoples’ culture, history and
political connectedness to the dominant culture. These include issues such as indigeneity, the
impacts of colonial and post-colonial experience, and often a lack of government recognition.
Scholars Sheikh and Islam identify the following factors aecting indigenous health and how they
determine health via access, directly or indirectly:
ɜ geographic location and rural lifestyles;
ɜ ethnicity/indigenous identity;
ɜ dispossession and dislocation from the land;
ɜ housing;
ɜ level of education;
ɜ income;
ɜ employment and occupation;
ɜ environmental factor;
ɜ lack of data.
486
Oliver and Mossialos (2004), pp. 655-658.
487
Peters et al. (2008), pp. 161-171.
488
O’Donnell (2007), pp. 2820-2834.
489
Ensor and Cooper (2004), pp. 246-256 and O’Donnell (2007), pp. 2820-2834.
490
James et al. (2006), pp. 147-153.
491
O’Donnell (2007), pp. 2820-2834.
492
Islam and Sheikh (2010), pp. 263-273.
166 ξ Chapter 7
State of the World’s Indigenous Peoples
Health status and access to health services in the Russian Federation
Overall population health in the Russian Federation
Despite the stabilization trends in recent years, the health of the general population of the Rus-
sian Federation remains poor relative to other WHO European Region
493
and other G8 countries.
494
Certain indicators, such as mortality rates for men, are very high compared to countries at similar
development and income levels.
495
In the 1990s, the whole of the Russian Federation experienced a dramatic decline in life expec-
tancy due to social and political transformation and to soaring poverty rates resulting from the
economic collapse following the dissolution of the Soviet Union. Such a striking rise in Russian
mortality was beyond the experience of industrialized countries, with a five-year decline in life
expectancy.
496
In Moscow life expectancy decreased by 7.7 years over a period of four years from
1990 to1994; and in the whole of Russia by 6.4 years.
497
Changes in life expectancy were due to
many factors including economic and social instability, high rates of tobacco and alcohol con-
sumption, poor nutrition, depression and deterioration of the health care system.
498
For example,
cigarette consumption increased by 81 per cent between 1990 and 2000.
499
The decline was particularly sharp in the life expectancy of men of working age, especially those
in lower socioeconomic groups within regions experiencing a particularly rapid economic transi-
tion.
500
Traditionally responsible for family income, men found themselves under extreme pres-
sure, leading to soaring rates of depression, alcohol and drug use, accidents and suicide.
501
The top three killers in Russia today are cardiovascular disease, cancer and external causes. In
addition to the abovementioned problems, Russia has one of the highest vehicular fatality rates
in Europe.
502
Whereas chronic conditions and external causes are leading causes of premature
death and disability, communicable diseases, particularly multidrug resistant tuberculosis and
the tuberculosis epidemic intersected with HIV/AIDS also pose a considerable threat to health
and well being.
503
Female mortality is significantly lower than male mortality, with female rates
117 in 1990 and 144 per 1,000 in 2009, while male mortality was 318 in 1990 and 391 in 2009,
504
but
disability-adjusted life expectancy data point to the fact that even though women live consider-
ably longer, their overall quality of life and health status is poor.
505
493
Popovich et al. (2011), p. 12.
494
Popovich et al. (2011), p. 175.
495
Popovich et al. (2011), p. 11.
496
Notzon et al. (1998).
497
Leon and Shkolnikov (1998), p. 790.
498
Notzon et al. (1998)
499
Danishevski et al. (2007), pp. 276-83.
500
Leon and Shkolnikov (1998) p. 790.
501
Abryutina (2012), p. 215.
502
Popovich et al. (2011), p. 12.
503
Popovich et al. (2011), p. 12.
504
WHO (2012) World Health Statistics.
505
Popovich et al. (2011), p. 12.
Chapter 7 ξ 167
Indigenous Peoples’ access to Health Services
Having reached 148.3 million in 1992,
506
Russian’s population declined to 142.9 million in 2010
507
and increased to 143.6 million in October 2013, due to immigration.
508
The context of mainstream
Russian health challenges is important for framing the health of indigenous peoples’ because as
will be shown indigenous peoples are among the poorest of the poor with the greatest health
challenges in the country.
Overall access to health services in the Russian Federation
Universal access to primary health care, the principle guiding health care in the Soviet Union, is
still central to the discourse and practices in the health care system of the Russian Federation.
With independence, Russia inherited a centralized health care system boasting an extensive net-
work of medical facilities and a high number of physicians per capita.
509
The system had substan-
tial overcapacity and patients were largely guaranteed free treatment.
510
While the guiding principle of universal free access to primary care has remains unchanged, the
governance and the organization of the health care system have evolved.
511
Facing severe bud-
getary constraints, two years into independence the Russian Federation adopted a mandatory
health insurance system designed to open up an earmarked stream of funding for health care.
512
Today health care financing in the Russian Federation comes more or less evenly from compulsory
sources such as general taxation and payroll contributions for mandatory health insurance and
out-of-pocket payments. The range of benefits covered is comprehensive and all basic care is pro-
vided free.
513
All patients except vulnerable groups, such as veterans or disabled individuals must
pay for outpatient prescription drugs.
514
The comprehensiveness of the benefit package is however,
undermined by the persistent scarcity of resources and reported generalized informal payments.
515
Since 1991, the number of physicians per capita has grown and is now one of the highest in the
WHO European Region,
516
though there are few indigenous doctors.
517
Since independence, as a
result of budgetary constraints, as well as the policies linked to the introduction of mandatory
health insurance, there has been a decrease in the number of both hospital and outpatient facili-
ties as well as a reduction in preventive services. The vast majority of small village hospitals have
closed since 2000.
518
A particular challenge is the maintenance of health facilities in some rural
areas which are lacking such basic services as adequate sanitation or hot water. Poor communi-
506
Popovich et al. (2011), xv.
507
Russian Population Census 2010.
508
Federal State Statistics (2013).
509
Popovich et al. (2011), xviii.
510
Popovich et al. (2011), xviii.
511
Popovich et al. (2011), xiii.
512
Popovich et al. (2011), xiii.
513
Popovich et al. (2011), xvii.
514
Popovich et al. (2011), xvii.
515
Popovich et al. (2011), xvii.
516
Popovich (2011), xix.
517
Kozlov and Lisitsyn (2008), p. 99.
518
Popovich (2011), xix.
168 ξ Chapter 7
State of the World’s Indigenous Peoples
cations including lack of telephone connections contributes to undermine the development and
maintenance of information systems.
519
According to the OECD, enhancing access, restoring the
capacity of the health care system to provide quality care, and reducing mortality through pre-
ventative interventions are among the top five policy priorities at the national level.
520
Indigenous peoples’ health status and access to health services in the Russian Federation
Data availability
According to the Federal law On Guarantees of Rights for Indigenous Numerically Small Peoples
of the Russian Federation, the indigenous are the numerically small peoples living on the terri-
tories of traditional residence of their ancestors, adhering to their original way of life, trades and
crafts, and believing themselves to be independent ethnic entities; their total number in Russia
is less than 50,000 people.
521
Nearly all the peoples currently recognized as indigenous live in
the North.
522
Between 1926 and 1993 the ocial list of indigenous peoples included 26 peoples occupying the
vast territory of over 9 million square kilometres stretching from the Kola Peninsula to Chukotka.
The government has been expanding the list since 1993. Forty groups were recognized by 2000,
523
many of the newly recognized indigenous groups were residing in the southern parts of Siberia.
At the same time, some of the groups that had been previously recognized as distinct indigenous
groups were merged.
524
The current ocial list of indigenous peoples living in the Russian Feder-
ation consists of 47 groups;
525
almost all of them live in the northern regions of the country. They
are highly diverse in their origins, cultures and languages.
526
According to the census conducted in
2010, there are 316,000 indigenous people living in 23 subjects of the Russian Federation.
527
In the
period between the two most recent censuses (2002 and 2010) the number of indigenous peoples
of the North increased by 5.7 per cent.
However, the censuses showed a reduction in the absolute population numbers of some indigenous
peoples. For example, the census conducted in 2002 revealed that 10 groups of indigenous peoples
decreased in numbers and the census conducted in 2010 showed that 24 groups of peoples de-
creased in numbers.
528
The North is also home to ethnic minorities that are not considered numeri-
519
Popovich (2011), p. 20.
520
OECD (2012), p. 59.
521
Russian Federation, On Guarantees of Rights for Indigenous Numerically Small Peoples of the Russian Federation,
Article 1.
522
Russia’s southern Republic of Dagestan, one of the most ethnically diverse places on earth, is developing a list of
indigenous peoples for inclusion in the ocial list of indigenous peoples compiled by the government of the Russian
Federation.
523
Young (2008), Circumpolar health indicators: sources, data, and maps, 21.
524
Young (2008), Circumpolar health indicators: sources, data, and maps, 21.
525
Federal State Statistics Service (2010d).
526
Kozlov et al. (2007, p. 13
527
Federal State Statistics Service (2010d).
528
Bogoyavlensky (2012).
Chapter 7 ξ 169
Indigenous Peoples’ access to Health Services
cally small or indigenous such as the Komi, the Komi-Permyaks, the Yakuts and the Buryats.
529
One
interesting aspect is that the ocial policy definition for recognition of indigenous peoples does
not include minorities with a population over 50,000 people which seems arbitrary and counter
to the notion of rebuilding healthy, viable and economically sustainable indigenous communities.
Complete and accurate current medical and demographic data on the indigenous peoples of the
Russian North are lacking.
530
The Soviet Union collected information about indigenous peoples,
and this information could be accessed for professional or academic purposes. Available statis-
tics demonstrated positive dynamics in indigenous peoples’ health. However, the restructuring
of the health care system in the 1990s, as well as the abolition of ethnic identity in the Russian
passport in 1997, led to the gradual end of the centralized collection and systematization of
statistical information on indigenous peoples of the North.
531
Countrywide reports by interna-
tional organizations such as WHO,and the OECD do not pay specific information on indigenous
peoples. Therefore, while specific information on indigenous peoples’ health and access to health
services is available from discrete research initiatives, the routine use of regular statistical meth-
ods to capture and evaluate indigenous peoples’ health and health services on a large scale is
no longer possible.
532
Health and demographic information about the peoples who have been
recognized as indigenous only recently is particularly scarce. Therefore this report also has to
rely on older data sources.
Rapid changes in the twentieth century
In the twentieth century, the indigenous peoples living in the Russian Federation faced rapid so-
cial, economic and cultural change. The inflow of migrants from Russia’s central regions to the
“regions of new development” quickly turned indigenous peoples into minorities in their home-
lands. Between 1926 and 1935, under a decade, the share of indigenous peoples in the districts
with indigenous populations in the northern parts of Russia fell from 56 per cent to 35 per cent. It
further decreased to 15 per cent in 1970 and 4.4 per cent in 1989.
533
The Soviet policies focused on integrating indigenous peoples into mainstream Soviet society,
combining the communist ideology with an ethnic policy corresponding to the “all-European
outlook” of the epoch”.
534
Traditionally, the economy of indigenous northerners was based on
animal resources. They practised reindeer herding, fishing and hunting in taiga
535
and tundra. From
the beginning of the twentieth century, indigenous peoples were subjected to collectivization,
industrialization, forced migration to urban centres and sedentarization, all of which failed to
take into consideration indigenous cultures and ways of life. Rapid industrialization led to the
contamination and devastation of landscape and wildlife and decreased access to indigenous
self-subsistence activities. Collectivization destroyed indigenous community-based economies.
529
Kozlov et al. (2007), p. 12.
530
Abryutina (2012), p. 212; Snodgrass (2013), p. 74.
531
Abryutina (2012), p. 213.
532
Abryutina (2012), p. 213.
533
Kozlov and Lisitsyn (2008), p. 86.
534
Cheshko (2000) in Kozlov and Lisitsyn (2008), p. 87.
535
A sub-Arctic, evergreen coniferous forest of northern Eurasia located just south of the tundra, dominated by firs and
spruces.
170 ξ Chapter 7
State of the World’s Indigenous Peoples
Forced migration to cities and towns caused indigenous peoples, who lacked the skills necessary
for survival in urban settings and could not rely on their usual family and social networks, to be
pushed to the bottom of the social ladder.
536
The introduction of mandatory boarding schools had the most pronounced consequences. In the
1950s, the children of nomadic hunters and reindeer herders received education for several months
a year in large settlements; a decade later, this was replaced by a system of boarding schools,
which became mandatory for both nomadic and settled populations in the North and were fi-
nanced by the state. Education was delivered in Russian by non-indigenous teachers. Indigenous
languages were taught only as a separate subject in elementary grades. Boarding schools did
not take into consideration indigenous cultures, indigenous physiology or psychology. Education
in Russian and extended stays far away from family resulted in the gradual replacement of the
mother tongue with Russian, created a generation gap, had a negative eect on family cohesion
and led to psychological deprivation.
537
Boarding school diets did not take into account indige-
nous physiology: for example, indigenous children were regularly given milk, though it has been
proven that 50-90 per cent of northern indigenous children are unable to digest milk sugar and
should, therefore, exercise caution with the consumption of whole milk.
538
The policies that the Soviet Union adopted vis-à-vis indigenous peoples had both negative and
positive consequences. Withdrawal from family and social networks and the disruption of cultural
transmission mechanisms resulted in the loss of the mother tongue, traditional skills and indige-
nous healing practices. The reduction in traditional nomadic migration resulted in some consan-
guineous marriages, a practice leading to genetic disorders. Stress and psychological deprivation
contributed to alcohol abuse. On the positive side, indigenous peoples received equal rights with
non-indigenous peoples, secure employment and income, literacy, access to medical care and
preservation of indigenous traditional diet, as well as access to non-indigenous food.
539
Indigenous peoples’ health status
The health of indigenous peoples in northern Russia is extremely poor, and there are clear
dierences with Russia as a whole.
540
Rapid social transformation and transition from traditional
to new occupations, as well as dietary changes, led to a high incidence of diseases that were rare
in indigenous peoples in the past.
541
New health problems include myopia, myocardial infarction,
ischaemic heart diseases and hypertension, the latter two problems being particularly explosive.
542
Indigenous peoples of the North have unusually high rates of oesophageal cancer: in 1976-1990,
incidence in the Chukchi, Koryak
543
and Taimyr
544
autonomous districts was 4-12 times higher than
536
Nettleton et al. (2007), p. 63.
537
Kozlov and Lisitsyn (2008), p. 86.
538
Abryutina (2012), p. 213.
539
Abryutina (2012), p. 213.
540
Snodgrass (2013) p. 79.
541
Medvestnik (2008).
542
Medvestnik (2008).
543
Note that the Koryak autonomous district ceased to exist as a distinct federal subject as of 1 January 2007.
544
Note that the Taimyr autonomous district ceased to exist as a distinct federal subject as of 1 January 2007.
Chapter 7 ξ 171
Indigenous Peoples’ access to Health Services
the average in Siberia and the Far East.
545
Parasite infections in the North are twice as common
as in the general Russian population.
546
Among the indigenous peoples of the Yamal-Nenets
autonomous district, the incidence of parasitic infections was 3.5 times the average district rate.
547
Tuberculosis incidence among indigenous northerners is several times the Russian average.
548
For
example, in the Koryak autonomous district, tuberculosis incidence was almost 7 times higher at a
rate of 444.6 per 100,000 of population compared to 67 per 100,000 in the Russian Federation.
549
The incidence of death from infectious diseases, mainly from tuberculosis, is more than twice higher
in indigenous northerners as in the general Russian population. Generally, the data available from
1998-2007 reveal the deterioration of indigenous peoples’ health over this period.
550
Table 2: Summary of the health information and key risk factors for selected indigenous peoples
in northern Russia
551
552553
Indigenous people Overall health and key health challenges Main lifestyle, innate?
Evenki, Khanty,
Mansi, Yakut
552
Overall poor health; pronounced disparities com-
pared with non-native population
Life expectancy lower by approximately 10 years
(but Russia is low in general)
553
High infant mortality rate
High cardiovascular disease burden (especially
stroke) but relatively low type 2 diabetes
Moderate obesity levels and very high
hypertension rates
Modestly elevated infectious disease burden
Very high rates of alcoholism, suicide and vio-
lence
Dietary change
Low activity levels
High smoking levels
Very high rates
of alcoholism
Psychosocial stress
Pollution
Poor living conditions
Climate change
Adaptive pattern that
may predispose to high
blood pressure
The life expectancy of the indigenous people living in the North of Russia is considerably lower
than the overall life expectancy in the Russian Federation. Indigenous northerners can expect to
live 10-11 years less and non-indigenous northerners 3-4 years less than the overall average Rus-
sian population. Indigenous men live 14 years less than women,
554
which generally correspond to
545
Choynzonov et al. (2004), p. 51.
546
Abryutina (2012), p. 211
547
Russian Federation (2002), The concept of a complex district target programme of socioeconomic development of
indigenous numerically small peoples of the North of the Yamal-Nenets autonomous district for 2003-2005.
548
Abryutina (2012), p. 211.
549
Abryutina (2012), p. 211.
550
Manchuk and Nadtochiy (2010), pp. 24-32.
551
Adapted from Snodgrass (2013), p. 75.
552
The Yakut are a Turkic minority mainly residing in the Republic of Sakha (Yakutia).
553
According to federal statistics, the average life expectancy in Russia was 70.24 in 2012. Average male life expectancy
in the same year was 64.56 and the average female life expectancy 75.86 years.
554
Stepanovskaya et al. (1998), p. 9.
172 ξ Chapter 7
State of the World’s Indigenous Peoples
overall Russian dierences between male and female life expectancy. For example, in the Berezo-
vo region of the Khanty-Mansi autonomous district, in the late 1990s the average age at death
was 48 for men and 60 for women.
555
Table 3: Life expectancy at birth in 2000
556
Numerically small peoples
of the North
All-Russian average
Male 45 61
Female 55 74
Another important indicator for access to health services is infant mortality rates, which have
been consistently high. In 2003-2004 the infant mortality rate was 20 per live births among in-
digenous peoples in the North, compared with the Russian average of 13.3 per 1,000 live births.
557
Table 4: Selected demographic indicators of the northern indigenous population (crude birth rate,
crude death rate, and natural increase per 1,000: infant mortality rate per 1,000 live births.
558
Period Crude Birth Rate Crude Death Rate Natural increase Infant mortality rate
1984-1988 30.2 10.5 19.7 41.1
1989-1993 25.7 10.8 14.8 30.4
1994-1998 19.8 12.6 7. 2 32.5
1999-2002 17.6 11.7 5.9 27.6
Table 5: Infant mortality in the Taimyr autonomous district559 in 1990-1992
(expressed as per 1,000 livebirths)
560
Year Indigenous people Non-indigenous people
1990 27.7 15.8
1991 29.2 19.9
1992 67.6 40.5
There is a strong sex-ratio imbalance: in all indigenous nations but one, the Aleuts, the number
of women greatly exceeds the number of men. The Even male-female ratio is 1,000:1,469; Veps,
1,000:1,450; and Saami 1,000:1,300.
561
The urban-rural comparison of sex ratio suggests that this
sex-ratio imbalance is driven by the migration of indigenous women to urban areas. The sex-ratio
555
Kozlov and Lisitsyn (2008), p. 95.
556
Based on data from Northern Practical Dictionary (2005) as quoted in Kozlov et al. (2007), p. 29.
557
Kozlov and Lisitsyn (2008), p. 93.
558
Estimated by Bogoyavlensky (2004). Quoted in Kozlov and Lisitsyn (2008), p. 93.
559
Note that the Taimyr autonomous district ceased to exist as a distinct federal subject as of 1 January 2007.
560
Kozlov et al. (2007), p. 32.
561
Russian Population Census (2013), Press Kit, 9.
Chapter 7 ξ 173
Indigenous Peoples’ access to Health Services
imbalance among indigenous urban dwellers is particularly striking, with male-female ratio be-
ing 1,000:1,805 among the Even; 1,000:1,690 among the Dolgan; and 1,000:1642 among the Ket
people.
562
On average, the number of indigenous women in urban areas exceeds the number of
indigenous men by a third.
Alcohol and its impact on mortality
Rapid social changes, poverty and uncertainty have resulted in high levels of stress, sub-
stance abuse, accidents, violence and suicide. The shift away from the typical protein-lip-
id diet of indigenous northerners which leads to the reduction of stress-relieving hormone
corticosteroid,
563
have resulted in high levels of anxiety and higher alcohol consumption.
564
Poisonings from low-quality alcohol are also frequent. Although alcohol abuse has a major
impact on the mortality pattern of northern regions in general, it has had a particularly signif-
icant impact on indigenous peoples, with levels of alcohol use atypically high among women.
For instance, in the Berezovo region of the Khanty-Mansi autonomous district, in 1996-1999,
out of 362 deaths among indigenous peoples excluding infants, one third were associated
with alcohol, while the rate of alcohol-related deaths was 15 per cent in non-indigenous popu-
lation. Alcohol-related deaths in women were five times higher among the indigenous peoples
than among Russian northerners.
565
In the Chukchi autonomous district, alcohol caused 42 per
cent of indigenous women’s deaths, while alcohol caused 19 per cent of deaths of non-indig-
enous women.
566
Even when it does not end in human losses, alcohol consumption leads to
economic losses which directly or indirectly decrease life quality. The rate of death resulting
from external causes among indigenous northerners is more than twice the Russian average.
At 100 cases per 100,000, indigenous suicide rates exceeded 2.5 times the national average
and five times the critical threshold for suicide rates established by the WHO. The incidence of
violent deaths is 70 per 100,000 compared to 27 per 100,000 overall in Russia.
567
In the early
1990s, 73 per cent of murders, 55 per cent of suicides, 64 per cent of accidental injuries among
indigenous northerners occurred in a condition of medium or strong alcoholic intoxication.
568
After a steady increase during Soviet times, the growth of indigenous populations in Russia
slowed down during the last two decades of the twentieth century due to the decline in the birth
rate and an increase in the death rate.
569
Consequently, the average age of indigenous northern-
ers remains considerably lower than that of the general population of the Russian Federation,
with the median age of most indigenous peoples of the North between 21 and 29 years.
570
The
median age of the general population of the Russian Federation is 38 years. The overall number
562
Russian Population Census (2013), Press Kit, 9.
563
Panin (1987)
564
Borinskaya et al. (2009) pp. 126-127
565
Data from Kozlov and Vershubsky (1999) as quoted in Kozlov and Lisitsyn (2008), p. 98.
566
Data from Kozlov and Vershubsky (1999) as quoted in Kozlov and Lisitsyn (2008), p. 98.
567
Bogoyavlensky (2012).
568
Data from Kozlov and Vershubsky (1999) as quoted in Kozlov and Lisitsyn (2008), p. 98.
569
Kozlov and Lisitsyn (2008), pp. 92-93.
570
Russian Population Census (2013), Press Kit, 9.
174 ξ Chapter 7
State of the World’s Indigenous Peoples
of indigenous peoples in the Russian Federation increased by 9,567 between the 2002 and 2010
censuses. However, population increase occurred only in 16 out of 47 indigenous groups.
571
Organization of health care provision in the North of the Russian Federation
Russia’s North has the same formal structure of health care services as the rest of the country
and, in addition, it practises the use of mobile health teams. Small rural villages are serviced by
medical aid stations equipped with a few beds. These stations are staed by medical assistants
and midwives and report to local hospitals. The latter are equipped with clinical laboratory and
radiology units and have one or more physicians, a surgeon and a gynaecologist. The closer to
administrative centres, the more specialized is the level of facilities and sta. The system includes
specialized medical dispensaries for certain diseases, such as tuberculosis, cancer, sexually trans-
mitted infections, psychiatric disorders and skin diseases. Emergency evacuation from remote
villages is usually conducted by regular light planes and helicopters at the request of hospitals.
572
Russian federal legislation guarantees indigenous peoples’ access to free medical care in state and
municipal health care facilities within the framework of the programme of state guarantees for
mandatory health insurance.
573
Regional programmes of state guarantees of provision of free health
services may exceed federal standards set at the national level. This allows regional programmes
to take into consideration the climate and geography of the region and other specific features.
574
Thus, a distinctive feature of health care provision in the Russian North are mobile health care
teams. The decision to create such teams rests with the health authorities at the district level. There
are no set standards regarding these teams’ size, personnel, functions or equipment. Whereas some
mobile teams are staed with one medical assistant and nurse, other mobile teams may be staed
with medical specialists providing more complex diagnostic and treatment services, such as, for
example, lung examinations by fluoroscopy.
575
While many medical assistants and nurses in pre-
dominantly indigenous areas are indigenous, most doctors are not. Although indigenous peoples
rarely face language problems in their communication with doctors, there is a need for doctors to
have better knowledge of the indigenous cultures.
576
Physicians training at medical universities are
neither exposed to course on “northern medicine” nor trained to work with indigenous peoples.
577
Key factors influencing indigenous peoples’ access to health services
Environmental factor: pollution and degradation
It is necessary to bear in mind that the simple provision of health services, while essential, will
not solve indigenous peoples’ health problems; there is an urgent need for action to protect the
environment in which indigenous peoples live. Environmental pollution is one crucial factor that
571
Russian Population Census (2013), Press Kit, 8.
572
Kozlov and Lisitsyn (2008), p. 99.
573
The Russian Federation (1999), On Guarantees of Rights for Indigenous Numerically Small Peoples of the Russian
Federation. Article 8.9.
574
The Russian Federation (2011), On fundamental principles of health care in the Russian Federation.
575
Kozlov and Lisitsyn (2008), p. 99.
576
Kozlov and Lisitsyn (2008), p. 99.
577
Kozlov and Lisitsyn (2008), p. 99.
Chapter 7 ξ 175
Indigenous Peoples’ access to Health Services
undermines indigenous peoples’ health. Indigenous northerners in the Russian Federation live
in regions with rich natural resources, among them oil, gas and gold, and extractive industries
contribute to ecological destruction. The environment is contaminated with petroleum products,
radioactive fallout from nuclear testing and fallen rocket debris. About 40 per cent of reindeer
pastures are no longer usable.
578
Lack of sewage facilities in the North adds to water pollution.
Toxic chemicals are a major source of environmental pollution and causal factor in poor health.
Among the most dangerous of these toxins are persistent organic pollutants (POPs)—pesticides,
industrial chemicals and by-products—that have a particular combination of physical and chem-
ical properties that, when released into the environment, remain intact for years. They become
widely distributed as a result of natural processes involving soil, water and air. POPs accumulate
in the fatty tissue of living organisms are more concentrated higher in the food chain and are
toxic to both humans and wildlife. POPs end up in the Arctic through the “grasshopper eect”, a
process by which pollutants released in one area are transported to far-removed regions by way
of continuous evaporation and condensation in the atmosphere. POPs also concentrate in living
organisms through bioaccumulation process through which pollutants are absorbed and stored in
fatty tissue. Fish, predatory birds, mammals and humans, all of which are high in the food chain,
absorb the greatest concentrations of pollutants. As a result, POPs are found in people and ani-
mals living in the Arctic, thousands of kilometres from any major POPs source.
579
Today, then, indigenous northerners’ diet consists of either expensive commercial processed foods
high in sugar and salt or cheaper traditional foods containing dangerous contaminants. The ef-
fects of POPs on human health can include allergies, immune system disruption, damage to the
nervous system, reproductive disorders and cancer.
580
POPs are transferred from mother to foe-
tus in utero, which can lead to the development of new pathologies.
581
One of the most dangerous
POPs is DDT, widely used in the past for pest and disease control. DDT remains in the soil 10-15
years after application and long-term exposure is associated with chronic illnesses.
582
Indigenous
northerners also used DDT for cleaning, treating their homes and even washing.
583
Empty DDT
containers were used for storing water, making dough and brewing alcohol. In addition, indige-
nous peoples used DDT for processing reindeer hides and meat, and often did so on the banks of
rivers and lakes from which they took drinking water.
584
Among other toxic substances present in Russia’s North are heavy metals such as mercury, lead
and cadmium. The quantity of mercury released into the environment in the Yamal-Nenets and
Taimyr autonomous districts
585
reaches 15 tons a year; polychlorinated biphenyls, 3.2 tons. In a
number of coastal regions of the Russian Arctic, the blood of the indigenous residents has con-
578
Novikova (2008), p. 283.
579
Stockholm Convention on Persistent Organic Pollutants.
580
WHO Glossary: Persistent Organic Pollutants (POPs).
581
Abryutina (2012), p. 217.
582
The 12 initial POPs under the Stockholm Convention. Stockholm Convention on Persistent Organic Pollutants (POPs).
583
Abryutina (2012), p. 217.
584
Abryutina (2012), p. 217.
585
Note that the Taimyr autonomous district ceased to exist as a distinct federal subject as of 1 January 2007.
176 ξ Chapter 7
State of the World’s Indigenous Peoples
centrations of polychlorinated biphenyls, hexachlorocyclohexane, DDT, lead and mercury 10 times
higher than that of the residents of Russia’s large urban centres.
586
Indigenous peoples are highly dependent on natural foods, in part out of necessity due to poverty
but also for biological and cultural reasons. Today, however, the consumption of meat and fat from
certain species of birds, fish and animals can present danger, particularly to pregnant and nursing
women and to children. Indigenous northerners have a tradition of breastfeeding for up to seven
years,
587
but this can be harmful under current conditions, as milk is rich in fats containing toxic
chemicals.
588
Research shows that 75 per cent of infant mortality of indigenous peoples is caused
by genetic diseases or diseases that cause foetal changes in infants.
589
The level of environmental
pollution correlates positively with rates of stillbirths, mental disorders and cataracts.
590
Some adaptive mechanisms acquired over centuries of exposure to harsh climatic conditions may
have adverse eects in current environmental conditions. Indigenous northerners have developed
a peculiar breathing pattern which protects them from extremely cold air: a very brief inhalation
is followed by a long exhalation. This breathing pattern may, however, be harmful with the current
state of environmental pollution, as toxic substances are held longer in the lungs, leading to a
whole range of respiratory and pulmonary diseases, including lung cancer.
591
Geographic factor: remote and rural locations, vast territories and low population density
Many indigenous peoples in the North of Russia continue to lead rural and nomadic lifestyles in
their traditional environments. Harsh climatic conditions, vast territories, extremely low popula-
tion density and remote locations hinder access to health services. “In the 2002 Census, only 28
per cent of indigenous peoples within the territories of their primary residence were classified as
urban, a proportion similar to that of the total USSR population in the 1930s, compared with 73
per cent in the Russian Federation in 2002”.
592
Although an increase in energy prices on world
markets resulted in greater macroeconomic stability and better living standards across Russia,
there is a clear urban-rural divide throughout the country. Poverty is now a predominantly rural
phenomenon, and indigenous northerners experience particularly severe hardship. As previously
mentioned, there has been a sharp drop in the number of rural hospitals since the collapse of the
Soviet Union. Both indigenous and non-indigenous rural populations have poorer health and less
access to health services than urban residents. Rural indigenous northerners tend to demonstrate
lower satisfaction with their ethnic origin than their urban counterparts.
593
Population density in indigenous territories is extremely low: it is 0.07 per 1 square kilometres in
the Chukchi autonomous district, 0.31 in the Republic of Sakha and 0.7 in the Yamal-Nenets auton-
omous district. Russia’s northern regions occupy 53.4 per cent of the country’s territory but only
586
Institute of Professional Environmental Practice.
587
Abryutina (2012), p. 217.
588
Abryutina (2012), p. 217.
589
Naroditsky et al. (1995), pp. 62-7.
590
Naroditsky et al. (1995), pp. 62-7.
591
Sedov (1988), pp. 12-23.
592
Kozlov and Lisitsyn (2008), p. 95.
593
Kozlov and Lisitsyn (2008), p. 95.
Chapter 7 ξ 177
Indigenous Peoples’ access to Health Services
5.7 per cent of the country’s total population.
594
Even if, as Table 1 shows, the number of medical
personnel per 10,000 population in indigenous areas is close to the Russian average, reaching
small, widely scattered communities in remote areas with harsh climate is a challenge, and more
resources are required for the provision of health services under such conditions in comparison to
areas with higher population densities and milder climates. According to the OECD, northern dis-
tricts have some of the highest public health expenditures per capita.
595
Although the government launched a number of federal-level health programmes to improve
primary-care provision in rural areas, indigenous nomads’ access to timely and comprehensive
health services, particularly prevention services, remains limited. The dissolution of the Sovi-
et Union in 1991, lead to an exodus of professionals, including doctors, from Russia’s Arctic re-
gions.
596
The practice of mobile health teams has declined since the collapse of the Soviet Union
and is irregular. Reindeer-herding communities depend on unreliable communications networks
and air ambulance not only for emergencies but also for primary care services. In some areas, ra-
dio communication is possible only a couple of times a day, and even this depends on the weather.
Thus, even if air ambulance is located in the same district, uses the shortest flying routes and runs
around the clock, access to health services is undermined by limited communication networks.
The diculty of obtaining health care pushes elder nomads to move into villages.
Socioeconomic factor: level of education, employment and occupation, income
The social fabric of the Soviet Union provided indigenous peoples with a certain safety net that
guaranteed employment and income. The reforms of the 1990s led to massive abandonment of
reindeer herding, fishing, hunting and other traditional activities. Few communities worldwide ex-
perienced such a rapid shift from stability to a complete economic breakdown. To this day unem-
ployment rates are high among indigenous northerners, particularly men, and ocial numbers are
likely conservative, as data reflect only the number of people who voluntarily register as unem-
ployed. Few indigenous peoples are employed in the formal sector, which means that few have
access to the potential health benefits that work in the formal sector provides.
In 10 of the 15 northern regions of the Russian Federation, GRP per capita is higher than the
national average. However, there is a marked gap in income levels between indigenous and
non-indigenous populations. “According to local surveys carried out among the Khanty-Mansi
population in 1999, the per capita monetary income for rural Khanty and Mansi … amounted to
only 15 per cent of the regional average. All the surveyed indigenous peoples lived below the
ocially established monthly subsistence wage for this region”.
597
Low income forces indigenous
peoples to turn to a subsistence economy, which has a negative eect on nutrition and health.
598
Additionally, low income may lead to decreased health care access in situations where out-of-
pocket payments are required, for example, if they travel to larger residential areas. According
to the global corruption watchdog Transparency International, the Russian health care system
suers from corruption, and those who cannot aord to pay or bribe may not receive proper care.
594
Akopov and Gadzhiev (2008), p. 481.
595
OECD (2012), p. 37.
596
Kozlov and Lisitsyn (2008), p. 100.
597
Kozlov and Lisitsyn (2008), p. 88.
598
Kozlov and Lisitsyn (2008), p. 89.
178 ξ Chapter 7
State of the World’s Indigenous Peoples
“According to a summer 2006 study commissioned by the group, 13 per cent of 1,502 respondents
who had sought medical help during the previous year had to pay an average of $90 under the
table, out of wages averaging $480 a month”.
599
Rural residents bear a double burden as they not
only lack access to health care services, but are less able to aord the costs of illness, including
the loss of work days and, if they have to travel to obtain health care services, out-of-pocket
payments for transportation, accommodation and food.
Another important factor increasing indigenous peoples’ chances of achieving better health is
education. The level of education among indigenous people is generally lower than that of non-
indigenous populations.
600
Lower education levels have a negative impact on health and contribute
to a cycle of poor health. Education increases access to health care and successful education
relies on adequate health. Health is a crucial factor in school attendance and performance.
Healthier individuals learn more eciently and they are more able to productively use education
at any point in life.
601
Improved education and health help to break cycles of poverty and have
multiplied eects for subsequent generations. Education is a precondition for training as a nurse
or doctor (as mentioned above, while there are indigenous mid-level medical sta, there are few
indigenous doctors). Educated parents are better able to attend to their children’s health and
nutritional needs and educated people are better able to come up with innovations that benefit
their communities.
602
While education and income levels have an impact on health, health also
has a significant impact on education and income levels.
The study comparing health indicators of nomadic indigenous, sedentary indigenous and non-
indigenous women in the Far North of the Krasnoyarsk Krai showed that nomadic indigenous
women living in the tundra are in better health than sedentary indigenous women in small towns
and settlements, which demonstrates two things. On one hand, having left their traditional
lifestyle in the tundra for urban settlements, they may not have been able to adapt well to the new
living conditions.
603
It may be that with no family support the urban based sedentary indigenous
women have higher levels of smoking and alcohol consumption and abuse.
604
On the other hand,
the fact that nomadic indigenous women are in better health but their infant- and child-mortality
rates are higher can be accounted to lower living standards in the tundra, lack of sanitation, delays
in seeking medical care as well as access to health services due to remote locations and a lack of
means of communication.
605
599
New York Times (2007).
600
Russian Population Census (2013), Press Kit, 13.
601
Todaro and Smith (2006), p. 366.
602
Todaro and Smith (2006), p. 369.
603
Zakharova et al. (2012) p. 50.
604
Zakharova et al. (2012) p. 50.
605
Zakharova et al. (2012) p. 50.
Chapter 7 ξ 179
Indigenous Peoples’ access to Health Services
Table 6: Comparison of health indicators of nomadic indigenous sedentary indigenous and
non-indigenous women in the Far North of the Krasnoyarsk Krai
606
(per cent)
Pathologies
Indigenous
nomadic
Indigenous
sedentary
Non-indigenous
Diseases of the circulatory system 2.0 7. 3 7. 3
Diseases of the respiratory system 6.7 13.3 8.7
Diseases of renal and urinary systems 10.0 20.0 26.0
Disorders of fat metabolism 4.0 5.3 9.4
Thyroid disease 4.0 17. 3 12.7
Diseases of the digestive system 2.0 3.3 5.3
Gynaecological diseases 64.0 67. 3 74.7
Harmful habits
Smoking 32.7 58.0 46.0
Alcohol consumption 8.0 10.0 7. 3
Alcohol abuse 0.7 2.0 1.3
Child mortality
Women who lost one infant 7. 3 6.0 2.7
Women who lost two infants 1.3 0.7 0.0
Women who lost three infants 0.7 0.0 0.0
Women who had one stillbirth 2.7 2.0 0.0
Women who had two stillbirths 1.3 0.0 0.0
This finding underlines the importance of ensuring indigenous peoples have access to health care
in their natural environment and of supporting them in attaining the highest possible health stan-
dards wherever they live.
Interventions to alleviate access barriers to health services can be both demand-side and
supply-side oriented, with the most eective interventions being those that address the two
simultaneously, e.g., provision of services combined with raising awareness and social marketing.
Some of the priority areas for targeting improvements are primary care, prevention, psychological
counselling services, and the identification of environmental risks.
The mobile health teams have been a successful model in bringing health care to indigenous
northerners, whether they are nomadic reindeer herders and fishermen or simply live in remote
villages. Suciently outfitted, the teams have proven that they can provide direct health services
and raise awareness about prevention.
606
Adapted from Zakharova et al. (2012), pp. 47-48.
180 ξ Chapter 7
State of the World’s Indigenous Peoples
Such interventions in remote northern areas require financial commitments that take into account
geographic characteristics and can make a real contribution to the health status of indigenous
peoples. When planning the allocation of resources, the social justice goals of preserving unique
ethnic groups collective identities and ancient ways of knowing—rather than purely economic
considerations—should be taken into account. Described below are some of the most successful
models of health service provision to northern indigenous communities.
Delivery of health services in the tundra: Red Tent
607
In 2008, the Yasavey Association of the Nenets peoples and medical specialists from Arkhan-
gelsk implemented a project called “Kanin Red Tent”, a revival of an old practice used by the
Soviet authorities in the 1930s. A doctor and a cultural worker travelled for nine weeks around
the settlements in the Kanin tundra, working with the families of nomadic reindeer herders
of the Kanin peninsula. They covered 10 groups of nomadic reindeer herders of a total of ap-
proximately 250 individuals, a third of them children. The work of the mobile health team was
divided into four parts. First, in order to fill existing information gaps, they took a medical
and social inventory of the nomadic population covered by the project. Second, using special
equipment allowing assessment of 40 dierent parameters, they tried to get a picture of how
indigenous nomads cope with infections, climatic and meteorological conditions and changes
in daily rhythms. Third, they taught reindeer herders basic first-aid techniques to be used in
cases of high fever, food poisoning, etc., and provided each group of herders with a first-aid
manual. Finally, having taken stock of the most frequent health problems, they prescribed
medications and selected patients to receive in-depth specialized health care services at hos-
pitals of dierent levels. With hypertension being a major health problem among indigenous
nomads, the doctor provided herders with blood pressure monitors and trained them to use
them. The “red tent” provided emergency aid, including emergency dental care, physiothera-
py services and medications, and provided supervision to two pregnant women. In addition,
medical sta provided veterinary services to over 50 reindeer. Finally, the health team devised
policy recommendations for preventing disease and promoting health in the conditions of the
tundra. In the future, “red tents” could include nurses to deliver primary health care including
vaccination. This project appears to be one of the most successful approaches to bringing
health care services to indigenous northerners.
607
Zubov and Sovershayev (2008).
Chapter 7 ξ 181
Indigenous Peoples’ access to Health Services
Awareness Raising: Persistent toxic substances (PTS), food security and indigenous
peoples of the Russian North.
608
The project Persistent Toxic Substances, Food Security and Indigenous Peoples of the Rus-
sian North was a joint project established by the Association of Indigenous Peoples of the
North, Siberia and Far East of the Russian Federation (RAIPON), the Arctic Monitoring and
Assessment Programme (AMAP) and the Global Environmental Facility (GEF). The project was
implemented in 2001-2005 in four Arctic regions: Murmansk oblast and the Nenets, Taimyr
609
and Chukchi autonomous districts. AMAP Assessments had documented how PTS have a ten-
dency to be transported to, and accumulate in, the Arctic region. Arctic indigenous commu-
nities have some of the highest exposures to PTS of any populations on Earth due to cold
Arctic climate, lipid-rich food chains, and lifestyles of indigenous people and their reliance on
traditional food. The economic changes of the 1990s resulted in increased consumption by
indigenous people of traditional food rich in PTS. The project aimed at assisting indigenous
peoples of the Russian north in developing appropriate remedial actions to reduce the health
risks associated with contamination of their environment and traditional food sources. The
project distributed accessible information materials about PTS and ways to reduce health
risks through modified cooking practices for traditional foods and use of imported, “European”
foods, as well as the disposal of hazardous materials. The project also attempted to address
root causes and advocated for the Russian Federation to join existing international agree-
ments concerning measures to reduce the use of PTS, and to increase its involvement in the
work of the Arctic Council to reduce emissions of PTS. The project put special emphasis on
empowering indigenous peoples to participate in these negotiations.
Conclusion
This chapter has highlighted the health challenges faced by the indigenous peoples living in the
North of the Russian Federation and drawing on analytical frameworks, identified the most rele-
vant factors aecting indigenous peoples’ access to health services in the North of the Russian
Federation. Rural poverty, lack of economic opportunity, environmental degradation, adverse ge-
ography and insucient allocation of resources for health care in rural and remote locations sig-
nificantly aect indigenous peoples’ access to health services and put their health at risk.
The available data suggest that indigenous peoples’ health status merits special attention, and
there is a need for the development of specific health care concepts and targeted interventions
tailored to the needs of northern indigenous populations. A comprehensive strategy is needed and
should be developed in partnership and consultation with indigenous peoples and draw on the ex-
perience of other Arctic countries in enhancing access of indigenous peoples to health services. The
strategy could include 1) prioritizing the collection and analysis of disaggregated demographic and
health data, 2) providing resources to ensure aordable, culturally capable health care access where
people live, e.g., through mobile health teams with knowledge of indigenous culture and health, 3)
implementing awareness and prevention programs and (iv) ensuring access to specialised care and
treatments including emergency care, e.g. through evacuations,when needed. These specific mea-
608
GEF, UNEP, AMAP, RAIPON (2004).
609
Note that the Taimyr autonomous district ceased to exist as a distinct federal subject as of 1 January 2007.
182 ξ Chapter 7
State of the World’s Indigenous Peoples
sures need to be accompanied by urgent local, national and international action to address the root
economic, social and environmental causes impacting on indigenous peoples’ health.
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