The continuing need for a Day of Indigenous Peoples

Abstract

As if to provide a timely reminder of the atrocities experienced by Indigenous people, this UN International Day of the World's Indigenous Peoples (Aug 9) follows the horrifying discoveries of the remains of Indigenous children near to former residential schools in BC, Canada. Around 150 000 Indigenous children were forcibly taken from their families to attend these government-funded schools between 1883 and 1996, which aimed to strip them of their culture and subjected them to severe abuse and neglect. These findings confirm a long-suspected truth and represent just one chapter in colonialism's past and present of human rights violations, cultural erasure, and systematic discrimination against Indigenous people that is only now being validated by the dominant culture. According to the UN, more than 476 million Indigenous people live in 90 countries across the world: about 6·2% of the global population. In The Lancet Global Health, the poorer health outcomes experienced by these culturally, ethnically, and socially disparate communities relative to their non-Indigenous counterparts are clear. Last year, we published a systematic review and meta-analysis on the prevalence of pre-existing and gestational diabetes in pregnant women in Australia, Canada, New Zealand, and the USA, which found a higher prevalence of both conditions in Indigenous versus non-Indigenous women, with a prevalence odds ratio of pre-existing diabetes as high as 3·63 (95% CI 2·35–5·62) in Indigenous Australians. Across countries, these Indigenous women have little in common other than a shared experience of colonisation's legacy of discrimination and poverty, making socioeconomic factors the most likely causes of these differences. In addition to having a higher prevalence of several communicable and non-communicable diseases, Indigenous people also often face inferior outcomes of care. For instance, a study published in this issue evaluated the outcomes of percutaneous coronary intervention among Indigenous and non-Indigenous Australians in six tertiary hospitals. Indigenous heritage was independently associated with an increased risk of long-term mortality. At 30 days, Indigenous Australians were more likely to be taking optimal medical therapy, but follow-up was lower and persistent smoking was more common. These disparities in disease incidence and outcomes are multifactorial. They mostly arise from poor access to care, leading to delayed or no treatment—especially culturally safe and high-quality care—and less favourable social determinants of health in Indigenous people (such as a higher likelihood of being in precarious employment). A key solution in health care has been stated repeatedly: Indigenous communities need more services co-designed and led by the communities themselves. Community involvement should not be tokenistic, but truly engage with community members to create culturally adapted care. Such services have already proved successful. For example, a Birthing in Our Community service in Brisbane (QLD, Australia) was co-designed by local First Nations people, staffed by a First Nations workforce, and aimed to align with the Aboriginal worldview. A study on this service by Sue Kildea and colleagues found that, compared with standard care, First Nations women attending the service had greater odds of attending five or more antenatal visits and exclusively breastfeeding on discharge and lower odds of having a preterm infant. But health in these communities cannot truly match that in the dominant population without addressing the underlying contributors. In 2015, the Truth and Reconciliation Commission of Canada published bold recommendations, to begin to correct inequities. The commissioners suggested areas in which the Canadian Government should act to “close the gaps”, including working with Indigenous groups to eliminate differences in education, employment, imprisonment, and health; to appropriately represent their heritage in schools and museums; and to provide cultural training to those working in public roles. Many of these recommendations could apply elsewhere. The most pivotal aspects of these recommendations that should be replicated elsewhere are the emphases on amplifying the voices of Indigenous people and on these communities having a central role in deciding which actions are needed. Apologies are warranted and necessary. However, no apologies or reconciliatory efforts can completely recompense these communities for all that has been taken from and done to them. The least governments can now do is to implement the lessons learnt, to prevent the far-reaching outcomes of colonialism persisting into future generations.