Elsevier

The Lancet

Volume 388, Issue 10040, 9–15 July 2016, Pages 131-157
The Lancet

Articles
Indigenous and tribal peoples' health (The Lancet–Lowitja Institute Global Collaboration): a population study

https://doi.org/10.1016/S0140-6736(16)00345-7Get rights and content

Summary

Background

International studies of the health of Indigenous and tribal peoples provide important public health insights. Reliable data are required for the development of policy and health services. Previous studies document poorer outcomes for Indigenous peoples compared with benchmark populations, but have been restricted in their coverage of countries or the range of health indicators. Our objective is to describe the health and social status of Indigenous and tribal peoples relative to benchmark populations from a sample of countries.

Methods

Collaborators with expertise in Indigenous health data systems were identified for each country. Data were obtained for population, life expectancy at birth, infant mortality, low and high birthweight, maternal mortality, nutritional status, educational attainment, and economic status. Data sources consisted of governmental data, data from non-governmental organisations such as UNICEF, and other research. Absolute and relative differences were calculated.

Findings

Our data (23 countries, 28 populations) provide evidence of poorer health and social outcomes for Indigenous peoples than for non-Indigenous populations. However, this is not uniformly the case, and the size of the rate difference varies. We document poorer outcomes for Indigenous populations for: life expectancy at birth for 16 of 18 populations with a difference greater than 1 year in 15 populations; infant mortality rate for 18 of 19 populations with a rate difference greater than one per 1000 livebirths in 16 populations; maternal mortality in ten populations; low birthweight with the rate difference greater than 2% in three populations; high birthweight with the rate difference greater than 2% in one population; child malnutrition for ten of 16 populations with a difference greater than 10% in five populations; child obesity for eight of 12 populations with a difference greater than 5% in four populations; adult obesity for seven of 13 populations with a difference greater than 10% in four populations; educational attainment for 26 of 27 populations with a difference greater than 1% in 24 populations; and economic status for 15 of 18 populations with a difference greater than 1% in 14 populations.

Interpretation

We systematically collated data across a broader sample of countries and indicators than done in previous studies. Taking into account the UN Sustainable Development Goals, we recommend that national governments develop targeted policy responses to Indigenous health, improving access to health services, and Indigenous data within national surveillance systems.

Funding

The Lowitja Institute.

Introduction

International studies investigating health and social outcomes for Indigenous and tribal populations across two or more countries (hereafter referred to as Indigenous peoples) provide important insights into public health. Previous studies have revealed disparities for Indigenous populations relative to benchmark populations. However, these studies have been restricted in the number of countries examined and the range of health and social indicators reported. Reliable data are needed to monitor health outcomes and develop policy and service responses.

Peoples who are described as Indigenous, or who identify as such, are found in nearly all regions of the world. In 2009, a UN report estimated that there were Indigenous peoples in 90 countries worldwide.1 The most recent published estimates put the total world population of Indigenous peoples at 302·45 million.2 China and India have the largest total populations of Indigenous peoples of any single country, with estimates of 106·40 and 104 million, respectively.2, 3

A policy definition developed by the International Labour Organisation in 1989 characterises Indigenous peoples as: tribal peoples in independent countries whose social, cultural, and economic conditions distinguish them from other sections of the national community and whose status is regulated wholly or partly by their own customs or traditions or by special laws or regulations; and peoples in independent countries who are regarded as indigenous because of their descent from the populations who inhabited the country, or a geographical region to which the country belongs, at the time of conquest or colonisation or the establishment of present state boundaries and who, irrespective of their legal status, retain some or all of their own social, economic, cultural, and political institutions.4

Research in context

Search strategy

The objective of our search strategy for previous studies was to identify reports that included data for Indigenous health outcomes from two or more countries. We searched the PubMed database from Jan 1, 1982, to Dec 30, 2015, using the terms “population groups” OR “continental population groups” OR “indigenous” OR “aboriginal” OR “tribal” AND/OR “health outcome” OR “health outcomes” OR “health data” OR “health indicator” OR “health indicators” AND/OR “infant mortality” OR “maternal mortality” OR “life expectancy” OR “low birth weight” OR “high birth weight” OR “obesity” OR “educational attainment” OR “poverty” AND/OR “comparative study” [pt] AND “international” OR “cross-national” OR “cross-country” OR (“international”) AND (“comparison” OR “comparative”) AND/OR each of our contributor countries combined against each other. Our search was done in English and the literature identified spans 1982–2014, with a total of 39 journal articles and monographs identified and reviewed. As a quality measure we restricted our review to peer-reviewed journal articles and monographs with defined methods and health and social outcome data sources.

Added value of this report

Our study reports systematically collated health data from across a broader range of indicators and samples of Indigenous countries than in previous studies.

Implications of all the available evidence

These studies and our study report document evidence of poorer health and social outcomes for Indigenous populations than for benchmark populations, noting that there are exceptions in which health is better in Indigenous populations. Additionally, we document gaps in the availability of data. The geographical coverage of this report needs to be extended, as does the range of health indicators. Targeted policy responses are needed, including strategies to improve health-care access for Indigenous peoples and the availability of health data.

In a similar way, the UN Permanent Forum on Indigenous Issues (UNPFII) sets out seven characteristics to guide the identification of Indigenous peoples (described below). We use these seven characteristics as inclusion criteria for this study.5

The Lancet–Lowitja Institute Global Collaboration for Indigenous and Tribal Health is a research partnership drawing contributors from 23 countries, covering all WHO global regions and including Indigenous populations with diverse socio-historical characteristics. Our objective is to describe the health and social status of Indigenous and tribal peoples relative to benchmark populations without any attempt to make comparisons between Indigenous populations. We consider the implication of our findings in relation to the implementation of the UN Sustainable Development Goals (SDGs).

Section snippets

Overview

The project had three phases. In the first phase, we tested the feasibility of our approach with a preliminary sample of countries. In the second phase, we extended both the sample of countries and the selection of indicators in our data sample. In the third phase, we reviewed and analysed the data submitted.

Preliminary country sample and indicators

We identified a preliminary sample of countries with Indigenous populations. Indigenous peoples included in this preliminary (and subsequent) sample had at least six of the seven following

Results

Our sample of 23 countries (of a total of 90 countries with Indigenous populations) covers all WHO global regions. We had data for 28 populations, which encompass many distinct tribal or ethnic groups (Table 3, Table 4, appendix). We report systematically gathered health and social data from a total Indigenous population of 154 million people, constituting about 50% of an estimated global population of 302·45 million.2 Ten countries included are classified by the World Bank as high income, six

Discussion

A 2005 commentary published by The Lancet posed the question: “Indigenous peoples' health—why are they behind everyone, everywhere?”.26 Against available evidence this was a reasonable question. However, our findings require a more nuanced interpretation. First, although our data provide evidence of poorer health and social outcomes for Indigenous populations than their respective benchmark populations, this is not uniformly the case. For example, relative to their respective benchmark

References (105)

  • Y Paradies et al.

    Placing Aboriginal and Torres Strait Islander mortality in an international context

    Aust N Z J Public Health

    (2002)
  • AR Ruben

    Undernutrition and obesity in indigenous children: epidemiology, prevention, and treatment

    Pediatr Clin North Am

    (2009)
  • PS Shah et al.

    Pregnancy and neonatal outcomes of aboriginal women: a systematic review and meta-analysis

    Womens Health Issues

    (2011)
  • C Stephens et al.

    Disappearing, displaced, and undervalued: a call to action for Indigenous health worldwide

    Lancet

    (2006)
  • RA Montenegro et al.

    Indigenous health in Latin America and the Caribbean

    Lancet

    (2006)
  • N Ohenjo et al.

    Health of Indigenous people in Africa

    Lancet

    (2006)
  • DM Parkin et al.

    Part I: cancer in indigenous Africans—burden, distribution, and trends

    Lancet Oncol

    (2008)
  • M King et al.

    Indigenous health part 2: the underlying causes of the health gap

    Lancet

    (2009)
  • I Agyepong et al.

    Making sense of health estimates

    Lancet

    (2015)
  • UN. State of the world's indigenous peoples. New York: United Nations Department of Economic and Social Affairs,...
  • GH Hall et al.

    Indigenous peoples, poverty, and development

    (2012)
  • Census 2011 fertility tables (F1) for average children ever born per woman by 5 years reproductive age group 15–49

  • The concept of indigenous peoples

    (2004)
  • Who are indigenous peoples? Undated

  • Comparing life expectancy of indigenous people in Australia, New Zealand, Canada and the United States: conceptual, methodological and data issues

    (2011)
  • International Group for Indigenous Health Measurement, Canberra, 2006

    (2009)
  • WHO child growth standards: length/height-for-age, weight-for-age, weight-for-length, weight-for-height and body mass index-for-age. Methods and development

    (2006)
  • TJ Cole et al.

    Establishing a standard definition for child overweight and obesity worldwide: international survey

    BMJ

    (2000)
  • The sixth national population census 2010

    (2011)
  • Population and population growth 1901–2015 by time, type and place of birth

  • Noncommunicable disease risk factor survey Myanmar 2009

    (2011)
  • Annual report

    (2009)
  • Sami Parliament Act (1992:1433)

  • E Lund et al.

    Population based study of health and living conditions in areas with both Sámi and Norwegian populations—the SAMINOR study

    Int J Circumpolar Health

    (2007)
  • M Brustad et al.

    A population-based study on health and living conditions in areas with mixed Sami and Norwegian settlements—the SAMINOR 2 questionnaire study

    Int J Circumpolar Health

    (2014)
  • D Clayton et al.

    Statistical methods in epidemiology

    (1993)
  • UN. Manual X: indirect techniques for demographic estimation: United Nations publication sales number E.83.XIII.2,...
  • CJL Murray et al.

    WHO system of model life tables, GPE discussion paper series: number 8 (undated)

  • MORTPAK for Windows version 4.3. The United Nations software package for demographic measurement

    (2013)
  • ZW Zhai et al.

    Modern population analysis technology

    (1989)
  • OM Mendoza et al.

    A comparison of alternative variance estimators in demographic surveys

  • Dirección de Censos y Demografía—DCD. Nota metodológica: Cambio de la mortalidad infantile en la linea base 2005

    (2012)
  • Growth charts

  • MD Humphrey et al.

    Australian Institute of Health and Welfare. Maternal deaths in Australia 2008–2012: table 5.2. Maternal deaths series number 5. Catalogue number PER 70

    (2015)
  • Y Paradies et al.

    Racism as a determinant of health: a systematic review and meta-analysis

    PLoS One

    (2015)
  • J Freemantle et al.

    Indigenous mortality (revealed): the invisible illuminated

    Am J Public Health

    (2015)
  • J Smylie et al.

    Back to the basics: identifying and addressing underlying challenges in achieving high quality and relevant health statistics for indigenous populations in Canada

    Stat J IAOS

    (2015)
  • K Ahlm et al.

    Unnatural deaths in reindeer-herding Sami families in Sweden, 1961–2001

    Int J Circumpolar Health

    (2010)
  • L Omma et al.

    Suicidal expressions in young Swedish Sami, a cross-sectional study

    Int J Circumpolar Health

    (2013)
  • N Kaiser et al.

    Depression and anxiety in the reindeer-herding Sami population of Sweden

    Int J Circumpolar Health

    (2010)
  • Cited by (645)

    View all citing articles on Scopus

    Writing and review group

    View full text