Changing pattern of ill health for indigenous peopleBMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7412.406 (Published 21 August 2003) Cite this as: BMJ 2003;327:406
- Sunia Foliaki, Wellcome Trust visiting research fellow (, )
- Neil Pearce, director
- Centre for Public Health Research, Massey University, Wellington Campus, Private Box 756, Wellington, New Zealand
Control of lifestyle is beyond individuals and depends on social and political factors
Industrialising societies are said to have undergone various epidemiological transition stages, in which the transition from stage two to stage three involves a change from receding pandemics to lifestyle diseases.1 The dynamics of this transition, which took thousands of years in Western countries, have been unprecedented and greatly compacted in time in most indigenous populations. Rather than a transition we see the rise of lifestyle non-communicable diseases at a time when the receding pandemics have not yet receded.2 The pattern seems to be similar in indigenous people in their traditional lands, such as the Pacific, and in newly adopted metropolitan centres, such as New Zealand. We consider here the different dynamics of the epidemiological transition in indigenous people and argue that these are linked to socioeconomic transitions beyond their power and their borders. Thus individual lifestyle interventions cannot be naively transferred to indigenous populations. Rather, what is required is appropriate national and international social and political commitment to health protection, with the specific interventions to be identified and implemented primarily by indigenous people.
Even with “traditional” communicable diseases, the experience of indigenous people has differed from that of Western countries.3 In Western countries agriculture, domestication of animals, the adoption of a sedentary existence, and the accompanying population increase and density contributed to the emergence of epidemics of the major communicable diseases.4 The European colonisation of the Pacific and the Americas after 1492 saw indigenous populations decimated by imported communicable diseases.5 These effects were not uniform, depending highly on local conditions. For example, in the Pacific indigenous people experienced high mortality from imported infectious diseases mainly when their land was taken and their economic base, food supply, and social networks were disrupted. When land was not taken in large amounts by European settlers the death rate was relatively low.5 Similar social disruption resulting in increases in communicable disease has been seen more recently in eastern Europe.6
Just as the introduction of the major communicable diseases did not occur in a vacuum, neither has the rise of non-communicable diseases.7 For example, the Pima Indians of Arizona had their own way of life and economy until the late 19th century, when the new white settlers upstream diverted their water supply.8 This disrupted a 2000 year old tradition of irrigation and agriculture, causing poverty and starvation. The Pima then had to survive on lard, sugar, and flour supplied by the United States government, resulting in one of the highest rates of prevalence of diabetes in the world–a particularly graphic example of a population living with the consequences of decisions taken upstream.9
Such problems persist. In one Pacific country, fishing for food is illegal in front of certain villages, in an area recently leased to a commercial fishing company partly owned by a political leader. Inequitable land distribution in Pacific Island countries, deforestation in Asia by multinational companies, and mass purchasing of individual land for grazing and cash cropping in the Americas all continue to compromise the ability of indigenous people to grow food and sustain adequate nutrition. The use of the Marshall Islands by the United States for nuclear testing led to ecological destruction, making farming impossible and fish radiotoxic and resulting in whole populations being displaced and becoming economically dependent, with a diet now based on imported processed and canned foods.10
Vested political and commercial interests also affect trade policy. For example, in the Pacific, healthier low fat local sources of protein, such as fish, generally cost 15-50% more and are less accessible than imported fatty mutton pieces, chicken pieces, or tinned fish. Fiji's ban on the importation of mutton flaps immediately resulted in New Zealand threatening a complaint to the World Trade Organization,11 an action similar to the tobacco companies flooding of developing countries with their products.12
Although non-communicable diseases are often attributed to genetic factors or individual lifestyle, they are also caused by broader political and social factors needing social action.9 The World Health Organization's view that non-communicable diseases cannot be addressed by the medical profession alone, and require public, private sector, socioeconomic, and political involvement,13 is equally valid for indigenous people. Despite the best intentions of WHO the year 2000 has come and gone, and instead of “Health For All,” health care is increasingly being privatised–effectively putting health out of the reach of those most in need, while they face increasing socioeconomic pressures against healthy lifestyles. Most indigenous health infrastructures cannot accommodate expensive healthcare models designed to meet the needs of 3% of the population; however, they can easily deliver comprehensive primary health care to the other 97%. What is required, rather than the transfer of individual lifestyle oriented health promotion to indigenous people, is the active involvement of indigenous people in primary health care and in the planning and implementation of health protection programmes at the local, national, and international levels.
The Centre for Public Health Research is supported by a programme grant from the Health Research Council of New Zealand. SF is funded by a grant from the Wellcome Trust for epidemiology of asthma and other non-communicable diseases in the Pacific.
Competing interests None declared.