Utz Wachil: Findings from an International Study of Indigenous Perspectives on Health and Environment

This article reports previously unpublished results of a collaborative study undertaken in 2003 by health workers of the UK-based organisation Health Unlimited, and by researchers of the London School of Hygiene and Tropical Medicine. This study marked the first of a series of collaborative activities aimed at highlighting the situation of Indigenous peoples, some in the most isolated ecosystems of the planet. While many researchers focus on quantitative analysis of the health and environmental conditions of Indigenous peoples, our 2003 study aimed at exploring the views of Indigenous peoples in isolated communities in five countries on their environment and their health. In this article we look closely at the web of knowledge and belief that underpins Indigenous peoples’ concepts of health and well-being, and their relationship to land and the environment. Although many Indigenous people have been forced off their traditional lands and live in rural settlements, towns, and cities, there are still a large number of people living in very small Indigenous communities in remote areas. This article focuses on 20 such communities in six countries. We explore traditional knowledge and practice and its relationship to Western medicine and services. The research findings highlight the importance of Indigenous knowledge systems for the emerging ecohealth community and suggest that we have much to learn from Indigenous peoples in our pursuit of a more holistic science. Utz Wachil is from the K’iche language originating in Totonicapan Department, Guatemala. It translates literally as “fine/well face-ness,” face meaning one’s aspect in general, not only physical appearance.     

Indigenous Cultural and Natural Resources Management and Mobility in Arnhem Land,Northern Australia

Many programmes formally engage Australian Indigenous people in land and sea management to provide environmental services. There are also many Indigenous people who ‘look after country’ without rewards or payment because of cultural obligations. We investigated how Indigenous peoples’ mobility in and around two communities (Maningrida and Ngukurr) is affected by their formal or informal engagement in cultural and natural resource management (CNRM). Understanding factors that influence peoples’ mobility is important if essential services are to be provided to communities efficiently. We found that those providing formal CNRM were significantly less likely to stay away from settlements than those ‘looking after their country’ without payment or reward. Paying Indigenous people to engage with markets for CNRM through carbon farming or payments for environmental services (PES) schemes may alter traditional activities and reduce mobility, particularly movements away from communities that extend the time spent overnight on country. This could have both environmental and social consequences that could be managed through greater opportunities for people to engage in formal CNRM while living away from communities and greater recognition of the centrality of culture to all Indigenous CNRM, formal or otherwise.     

The Contribution of Geography to Disparities in Preventable Hospitalisations between Indigenous and Non-Indigenous Australians

Objectives

To quantify the independent roles of geography and Indigenous status in explaining disparities in Potentially Preventable Hospital (PPH) admissions between Indigenous and non-Indigenous Australians.

Design, setting and participants

Analysis of linked hospital admission data for New South Wales (NSW), Australia, for the period July 1 2003 to June 30 2008.

Main outcome measures

Age-standardised admission rates, and rate ratios adjusted for age, sex and Statistical Local Area (SLA) of residence using multilevel models.

Results

PPH diagnoses accounted for 987,604 admissions in NSW over the study period, of which 3.7% were for Indigenous people. The age-standardised PPH admission rate was 76.5 and 27.3 per 1,000 for Indigenous and non-Indigenous people respectively. PPH admission rates in Indigenous people were 2.16 times higher than in non-Indigenous people of the same age group and sex who lived in the same SLA. The largest disparities in PPH admission rates were seen for diabetes complications, chronic obstructive pulmonary disease and rheumatic heart disease. Both rates of PPH admission in Indigenous people, and the disparity in rates between Indigenous than non-Indigenous people, varied significantly by SLA, with greater disparities seen in regional and remote areas than in major cities.

Conclusions

Higher rates of PPH admission among Indigenous people are not simply a function of their greater likelihood of living in rural and remote areas. The very considerable geographic variation in the disparity in rates of PPH admission between Indigenous and non-Indigenous people indicates that there is potential to reduce unwarranted variation by characterising outlying areas which contribute the most to this disparity.     

Strongyloides stercoralis: Systematic Review of Barriers to Controlling Strongyloidiasis for Australian Indigenous Communities

Background

Strongyloides stercoralis infects human hosts mainly through skin contact with contaminated soil. The result is strongyloidiasis, a parasitic disease, with a unique cycle of auto-infection causing a variety of symptoms and signs, with possible fatality from hyper-infection. Australian Indigenous community members, often living in rural and remote settings, are exposed to and infected with S. stercoralis. The aim of this review is to determine barriers to control of strongyloidiasis. The purpose is to contribute to the development of initiatives for prevention, early detection and effective treatment of strongyloidiasis.

Methodology/Principle Findings

Systematic search reviewing research published 2012 and earlier was conducted. Research articles discussing aspects of strongyloidiasis, context of infection and overall health in Indigenous Australians were reviewed. Based on the PRISMA statement, the systematic search of health databases, Academic Search Premier, Informit, Medline, PubMed, AMED, CINAHL, Health Source Nursing and Academic was conducted. Key search terms included strongyloidiasis, Indigenous, Australia, health, and community. 340 articles were retrieved with 16 original research articles published between 1969 and 2006 meeting criteria. Review found barriers to control defined across three key themes, (1) health status, (2) socioeconomic status, and (3) health care literacy and procedures.

Conclusions/Significance

This study identifies five points of intervention: (1) develop reporting protocols between health care system and communities; (2) test all Indigenous Australian patients, immunocompromised patients and those exposed to areas with S. stercoralis; (3) health professionals require detailed information on strongyloidiasis and potential for exposure to Indigenous Australian people; (4) to establish testing and treatment initiatives within communities; and (5) to measure and report prevalence rates specific to communities and to act with initiatives based on these results. By defining barriers to control of strongyloidiasis in Australian Indigenous people, improved outcomes of prevention, treatment of strongyloidiasis and increased health overall are attainable.     

Reconciliation and Australian Indigenous Health in the 1990s: A Failure of Public Policy

In 1991, the Australian Commonwealth Parliament unanimously passed the Council for Aboriginal Reconciliation Act 1991. This Act implemented a 10-year process that aimed to reconcile Indigenous and non-Indigenous people by the end of 2000. One of the highest priorities of the reconciliation process was to address Indigenous socio-economic disadvantage, including health, education and housing. However, despite this prioritising, both the Keating Government (1991–1996) and the Howard Government (1996–2000) failed to substantially improve socio-economic outcomes for Indigenous people over the reconciliation decade. In this paper, I examine one of the most prominent socio-economic areas, that of Indigenous health. First, I discuss the appalling levels of Indigenous health throughout the reconciliation decade by analysing a number of health indicators, including life expectancy, infant mortality rate, standard mortality ratios, hospital rates and health Infrastructure. This analysis reveals significant and often worsening disadvantage in these health indicators. Second, I analyse a number of policies and programs concerning Indigenous socio-economic disadvantage that were developed by Commonwealth Governments in the 1990s. I argue that these policies and programs largely failed to address Indigenous socio-economic disadvantage. I also discuss alternative policies and programs that could reduce the significant levels of socio-economic disadvantage suffered by Indigenous people.     

Parasitic diseases of remote Indigenous communities in Australia

Indigenous Australians suffer significant disadvantage in health outcomes and have a life expectancy well below that of non-Indigenous Australians. Mortality rates of Indigenous Australians are higher than that of Indigenous populations in developed countries elsewhere in the world. A number of parasitic diseases which are uncommon in the rest of the Australian population contribute to the high burden of disease in many remote Indigenous communities. High rates of infection with enteric parasites such as Strongyloides stercoralis, hookworm and Trichuris have been recorded and infection of the skin with the ecto-parasitic mite Sarcoptes scabiei is also a substantial problem. Secondary infection of scabies lesions, including with Staphylococcus aureus and group A Streptococcus, can produce serious sequelae such as rheumatic fever and post-streptococcal glomerulonephritis. Transmission of many parasites in many remote communities is facilitated by overcrowded living conditions and infrastructure problems which result in poor sanitation and hygiene. Improvements in environmental health conditions must accompany medical initiatives to achieve sustainable improvement in the health of Indigenous Australians.     

Long-distance travel for birthing among Indigenous and non-Indigenous pregnant people in Canada

BACKGROUND:For Indigenous Peoples in Canada, birthing on or near traditional territories in the presence of family and community is of foundational cultural and social importance. We aimed to evaluate the association between Indigenous identity and distance travelled for birth in Canada.METHODS:We obtained data from the Maternity Experiences Survey, a national population-based sample of new Canadian people aged 15 years or older who gave birth (defined as mothers) and were interviewed in 2006–2007. We compared Indigenous with non-Indigenous Canadian-born mothers and adjusted for geographic and sociodemographic factors and medical complications of pregnancy using multivariable logistic regression. We categorized the primary outcome, distance travelled for birth, as 0 to 49, 50 to 199 or 200 km or more.RESULTS:We included 3100 mothers living in rural or small urban areas, weighted to represent 31 100 (1800 Indigenous and 29 300 non-Indigenous Canadian-born mothers). We found that travelling 200 km or more for birth was more common among Indigenous compared with non-Indigenous mothers (9.8% v. 2.0%, odds ratio [OR] 5.45, 95% confidence interval [CI] 3.52–8.48). In adjusted analyses, the association between Indigenous identity and travelling more than 200 km for birth was even stronger (adjusted OR 16.44, 95% CI 8.07–33.50) in rural regions; however, this was not observed in small urban regions (adjusted OR 1.04, 95% CI 0.37–2.91).INTERPRETATION:Indigenous people in Canada experience striking inequities in access to birth close to home compared with non-Indigenous people, primarily in rural areas and independently of medical complications of pregnancy. This suggests inequities are rooted in the geographic distribution of and proximal access to birthing facilities and providers for Indigenous people.

Access to birth close to home, surrounded by loved ones, is taken for granted by most Canadians. The societal importance of family support during birthing has been highlighted during the severe acute respiratory syndrome and COVID-19 pandemics, despite the known and potentially fatal risks to hospital visitors, because people in labour have been one of the few patient groups exempt from visitor restrictions.^1,2 For residents living in rural areas of Canada, long-distance travel for birth is a reality that is becoming increasingly common in some regions because of closures of obstetrical services in smaller community hospitals.³ This is only partially mitigated by the revitalization of rural midwifery practice.^4,5Emerging evidence shows that the frequency of adverse medical events during labour and delivery for rural populations is similar for births that take place close to home and births for which people travel because of an absence of services close to home.^3,4,6 Less is known about the impacts of travel for birth on breastfeeding rates, maternal mental health and family functioning. Several studies have documented the negative impacts of birthing away from home with respect to maternal satisfaction and birth experience.^7–10 This evidence is particularly compelling for Indigenous populations for whom birthing on or near traditional territories in the presence of family and community is a long-standing practice of foundational cultural and social importance that contributes to well-being, cultural continuity and kinship.^7–12The striking isolation, family disruption and racism experienced by Indigenous people who are forced to travel alone for birth as a result of externally imposed federal “evacuation for birth” policies¹¹ has been met with a series of policy initiatives to support return of birth to rural and remote Indigenous communities. ^13–15 In April 2017, then federal Minister of Health Dr. Jane Philpott, committed to “a path to be able to return the cries of birth” to Indigenous communities and funding to support travel for a companion when Indigenous people living in rural and remote areas needed to travel away from home for birth.¹⁶ Before 2017, Indigenous pregnant people often travelled and birthed away from home alone without family or community support, because escorts were not deemed medically necessary. Although these initiatives have improved access to Indigenous perinatal programming and Indigenous birth attendant support in some local areas, over the past decade there has not been any substantial expansion of Indigenous birthing facilities outside of urban centres in Canada and at least 1 remote Indigenous birthing facility has closed.¹⁷Given this dynamic policy context, the national scope and Indigenous identifiers in the Canadian Maternity Experiences Survey (MES) provides a unique opportunity to quantify how often Indigenous and non-Indigenous people are travelling away from home for birth and to evaluate the association between Indigenous and non-Indigenous identity and distance travelled for birth in Canada.     

Factors Influencing the Health Behaviour of Indigenous Australians: Perspectives from Support People

Disparities between the health of Indigenous and non-Indigenous populations continue to be prevalent within Australia. Research suggests that Indigenous people participate in health risk behaviour more often than their non-Indigenous counterparts, and that such behaviour has a substantial impact on health outcomes. Although this would indicate that reducing health risk behaviour may have positive effects on health outcomes, the factors that influence Indigenous health behaviour are still poorly understood. This study aimed to interview people who support Indigenous groups to gain an understanding of their views on the factors influencing health behaviour within Indigenous groups in Western Australia. Twenty nine people participated in the study. The emergent themes were mapped against the social ecological model. The results indicated that: (1) culture, social networks, history, racism, socioeconomic disadvantage, and the psychological distress associated with some of these factors interact to affect health behaviour in a complex manner; (2) the desire to retain cultural identity and distinctiveness may have both positive and negative influence on health risk behaviour; (3) strong social connections to family and kin that is intensified by cultural obligations, appears to affirm and disrupt positive health behaviour; (4) the separation between Indigenous and non-Indigenous social connection/networks that appeared to be fostered by marginalisation and racism may influence the effect of social networks on health behaviour; and (5) communication between Indigenous and non-Indigenous people may be interrupted by distrust between the groups, which reduces the influence of some non-Indigenous sources on the health behaviour of Indigenous people.     

Rediscovering Nature in Everyday Settings: Or How to Create Healthy Environments and Healthy People

It is estimated that half of the world’s population now live in urban environments. Urban living necessitates a removal from nature, yet evidence indicates that contact with nature is beneficial for human health. In fact, everyday urban places, such as where people live, study, and work, provide opportunities to bring nature back into cities to contribute to positive, healthy environments for people and to foster the human–nature connection. The inclusion of more nature in cities could have additional environmental benefits, such as habitat provision and improving the environmental performance of built environments. In the context of climate change, outcomes such as these assume further importance. This article explores how common urban places can foster links between people and nature, and generate positive health and well-being outcomes. We achieve this by exploring nature in the everyday settings of schools and residential housing.     

The economic value of environmental services on indigenous-held lands in Australia

Australians could be willing to pay from $878m to $2b per year for Indigenous people to provide environmental services. This is up to 50 times the amount currently invested by government. This result was derived from a nationwide survey that included a choice experiment in which 70% of the 927 respondents were willing to contribute to a conservation fund that directly pays Indigenous people to carry out conservation activities. Of these the highest values were found for benefits that are likely to improve biodiversity outcomes, carbon emission reductions and improved recreational values. Of the activities that could be undertaken to provide the services, feral animal control attracted the highest level of support followed by coastal surveillance, weed control and fire management. Respondents' decisions to pay were not greatly influenced by the additional social benefits that can arise for Indigenous people spending time on country and providing the services, although there was approval for reduced welfare payments that might arise.     

Global Systematic Review of the Cost-Effectiveness of Indigenous Health Interventions

Background

Indigenous populations around the world have consistently been shown to bear a greater burden of disease, death and disability than their non-Indigenous counterparts. Despite this, little is known about what constitutes cost-effective interventions in these groups. The objective of this paper was to assess the global cost-effectiveness literature in Indigenous health to identify characteristics of successful and unsuccessful interventions and highlight areas for further research.

Methods and Findings

A systematic review of the published literature was carried out. MEDLINE, PSYCINFO, ECONLIT, EMBASE and CINAHL were searched with terms to identify cost-effectiveness evaluations of interventions in Indigenous populations around the world. The WHO definition was followed in identifying Indigenous populations. 19 studies reporting on 27 interventions were included in the review. The majority of studies came from high-income nations with only two studies of interventions in low and middle-income nations. 22 of the 27 interventions included in the analysis were found to be cost-effective or cost-saving by the respective studies. There were only two studies that focused on Indigenous communities in urban areas, neither of which was found to be cost-effective. There was little attention paid to Indigenous conceptions of health in included studies. Of the 27 included studies, 23 were interventions that specifically targeted Indigenous populations. Outreach programs were shown to be consistently cost-effective.

Conclusion

The comprehensive review found only a small number of studies examining the cost-effectiveness of interventions into Indigenous communities around the world. Given the persistent disparities in health outcomes faced by these populations and commitments from governments around the world to improving these outcomes, it is an area where the health economics and public health fields can play an important role in improving the health of millions of people.     

Building International Indigenous People’s Partnerships for Community-Driven Health Initiatives

In this article we present an international Indigenous people’s partnership project co-led by two Indigenous communities, Musqueam (Coast Salish, Canada) and Totoras (Quichua, Ecuador), as a community-driven health initiative. The Musqueam-Totoras partnership includes Indigenous organizations, universities, international agencies, government, and nongovernmental organizations to address Indigenous health concerns in both communities. Our collaborative approach provides a framework to (a) increase the development expertise of Indigenous people internationally, (b) increase skills among all participants, and (c) facilitate Indigenous knowledge mobilization and translation to promote cultural continuity. This international Indigenous people’s partnership between north and south reflects the diversity and commonalities of Indigenous knowledge, contributes to cultural revitalization, and minimizes the impact of assimilation, technology, and globalization. Indigenous people’s partnerships contribute to self-determination, which is a prerequisite to the building and maintenance of healthy communities and the promotion of social justice. The exchange of Indigenous knowledge upholds Indigenous values of respect, reciprocity, relevance, and responsibility. Given the history of colonization and the negligence of governments in the exercising of these values with respect to Indigenous communities, this contemporary exchange among Indigenous people in the Americas serves to reclaim these values and practices. International cooperation empowering Indigenous people and other marginalized groups has become fundamental for their advancement and participation in globalized economies. An international Indigenous people’s partnership provides opportunities for sharing cultural, historical, social, environmental, and economic factors impacting Indigenous health. These partnerships also create beneficial learning experiences in community-based participatory research and community-driven health initiatives, provide culturally sensitive research ethics frameworks, increase capacity building, and address basic human needs identified by participating communities.     

Intimacy and Distance: Indigenous Relationships to Country in Northern Australia

Among the strategies employed by colonial authorities to ‘manage’ Indigenous people, forced removal and centralisation to townships was a deliberate attempt to fragment relationships to home territories. For Yanyuwa, an Indigenous group in northern Australia, this meant being removed from their saltwater ‘country’ in the Gulf of Carpentaria and resettled 60?km inland. Despite this violent act Yanyuwa saltwater identity has remained strong. Whilst enduring, it has however undergone changes in the way relationships to place are established and maintained. Travelling through saltwater country with younger and middle generation Yanyuwa has revealed that sometimes relationships to place are marked by conditions of fear, nervousness and uncertainty. Not classically held to be dispositions of a ‘proper’ Indigenous person, these reveal that states of intimacy require time and certain conditions to flourish. So too, distance, signalled by fear and uncertainty, is a relational state that defines a vitally important relationship with country.     

Mansonelliasis,a neglected parasitic disease in Haiti

Reported in Haiti as early as 1923, Mansonella ozzardi is still a neglected disease ignored by the health authorities of the country. This review is an update on the geographic distribution of the coastal foci of mansonelliasis in Haiti, the epidemiological profile and prevalence rates of microfilariae in people living in endemic areas, the clinical impact of the parasite on health and the efficiency of the transmission of the parasite among three Culicoides biting-midge species identified as vectors in Haiti. Additionally, interest in establishing a treatment programme to combat this parasite using a single dose of ivermectin is emphasised.     

Ecological Aging: The Settings Approach in Aged Living and Care Accommodation

As the proportion of older people increases within populations, financial demands related to the cost of health service delivery threaten global stability. This population trend challenges the traditional approach to health service delivery to older populations. This article presents the Australian context as a case study to argue that the application of a health promoting settings approach to aged care may lead to improved well-being for older people to the extent that the periods of chronic morbidity often associated with aging can be compressed into an ever shorter period of time. Promoting an ecological perspective to aged care suggests that there is no need to manage older people in isolation, as is common practice, but as integral to the way society lives, works, and plays. The article maps parallels between characteristics of health promoting settings such as Health Promoting Schools and the aged living and care industry, arguing that the setting encompassing services for the elderly is a prime location for the establishment of a new health promotion setting. Supporting life opportunities for our aged is central to such an approach. More broadly, an ecological approach orients us toward the connection between environment and health, and encourages increased attention and action within the aged living and care sector on reducing environmental impacts of this growing population. As such, the application of this approach to the aged living and care sector has the potential to reduce the threat that a dependant older population has on global sustainability.     

Faith after an Earthquake: A Longitudinal Study of Religion and Perceived Health before and after the 2011 Christchurch New Zealand Earthquake

On 22 February 2011, Christchurch New Zealand (population 367,700) experienced a devastating earthquake, causing extensive damage and killing one hundred and eighty-five people. The earthquake and aftershocks occurred between the 2009 and 2011 waves of a longitudinal probability sample conducted in New Zealand, enabling us to examine how a natural disaster of this magnitude affected deeply held commitments and global ratings of personal health, depending on earthquake exposure. We first investigated whether the earthquake-affected were more likely to believe in God. Consistent with the Religious Comfort Hypothesis, religious faith increased among the earthquake-affected, despite an overall decline in religious faith elsewhere. This result offers the first population-level demonstration that secular people turn to religion at times of natural crisis. We then examined whether religious affiliation was associated with differences in subjective ratings of personal health. We found no evidence for superior buffering from having religious faith. Among those affected by the earthquake, however, a loss of faith was associated with significant subjective health declines. Those who lost faith elsewhere in the country did not experience similar health declines. Our findings suggest that religious conversion after a natural disaster is unlikely to improve subjective well-being, yet upholding faith might be an important step on the road to recovery.     

Universalising the particular? God and Indigenous spirit beings in East Kimberley

Some Aboriginal discourses in East Kimberley appear to indicate that Indigenous particularities are being universalised by evangelical Christianity. The aim of evangelical Christianity is to bring all peoples under the domain of one God. But counter statements by people of all ages reveal that the Christian universalising project in East Kimberley is an unfinished (and possibly unfinishable) project. Although Indigenous particularities contribute to generational conflict they are not disappearing, while Aboriginal people remain on or near the lands in which their stories are embedded. Locative traditions emphasise genealogical continuities between the living and the dead. Evangelical missionaries, however, direct spirits of the living to heaven and condemn spirits of the dead to follow Satan. One Aboriginal woman has reached a kind of resolution between God and Indigenous spirits: mamu and juwarri (spirits of the dead) are not evil spirits but sinners who will be redeemed in the Last Days. 1     

Impacto en residencias de la atención centrada en las personas (ACP) sobre la calidad de vida,el bienestar y la capacidad de salir adelante. Estudio transversal

IntroductionThe aging of the population has led to the introduction of qualitative and quantitative changes in healthcare resources, among which are the introduction of models of person-centred care (PCC), although there is a lack of information on their impact. The objective of this study is to assess the impact of a PCC model on the quality of life, well-being and thriving, in people living in nursing homesMethodsCross-sectional study. Population: all persons who lived indefinitely in the two participating centres that gave their consent. Impact of PCC vs. traditional model was assessed in terms of quality of life, well-being and thriving. Effect size was estimated with Cohen d adjusted for health problems, Charlson index, and presence of depression.ResultsOverall participation was 78% (59/77 persons from the conventional centre and 66/88 from the PCC). The people of the PCC centre had better well-being (d = 0.378) and thriving (d = 0.566). No differences were found in quality of life.ConclusionThe PCC model can have a positive impact on well-being and thriving in persons living in nursing homes.     

Health ethics and Indigenous ethnocide

In colonial societies such as Canada the implications of colonialism and ethnocide (or cultural genocide) for ethical decision‐making are ill‐understood yet have profound implications in health ethics and other spheres. They combine to shape racism in health care in ways, sometimes obvious, more often subtle, that are inadequately understood and often wholly unnoticed. Along with overt experiences of interpersonal racism, Indigenous people with health care needs are confronted by systemic racism in the shaping of institutional structures, hospital policies and in resource allocation decisions. Above all, racism is a function of state law – of the unilateral imposition of the settler society law on Indigenous communities. Indeed, the laws, including health laws, are social determinants of the ill‐health of Indigenous peoples. This article describes the problem of Indigenous ethnocide and explores its ethical implications. It thereby problematizes the role of law in health ethics.