Traditional Medicine and Indigenous Health in Indigenous Hands
Abstract and Keywords
An estimated 370 million Indigenous people reside in 90 countries and make up 5% of the global population. Three hundred million Indigenous people live in extremely disadvantaged rural locations. Indigenous people have suffered from historic injustices due to colonization and the dispossession of their lands, territories, and resources, thus preventing them from exercising their right to development according to their own needs and interests. Across the board, Indigenous people have poorer health outcomes when compared to their non-Indigenous fellow citizens.
Cancer, respiratory disease, endocrine, nutritional, and metabolic disorders, primarily diabetes, affect Indigenous people disproportionately. Newborns of Indigenous women are more than twice as likely to be of low birth weight as those born to non-Indigenous women. Indigenous rates of suicide are the highest in the world.
For public health to be effective, a social determinants approach, along with health interventions, is insufficient to create lasting health impact. Partnerships with Indigenous organizations, Indigenous researchers, and the professionalization of health workers is essential. Integration of traditional medicine and traditional health practitioners can enable the Western biomedical model to work in partnership with Indigenous knowledge systems and become more locally relevant and accountable.
The Indigenous health workforce is increasingly using evidence-based, innovative approaches to address the shortage of health professionals as they move toward universal health coverage. Internet, mobile, and communication technologies are enhancing the mobilization of Indigenous health efforts and the support for health workers in rural locations. Presented are country examples of integrated medicine and Indigenous partnerships that effectively implement health interventions.
An estimated 370 million Indigenous people reside in 90 countries, approximately 5% of the global population. Approximately 300 million Indigenous people live in extremely disadvantaged rural locations, constituting 15% of the global poor (United Nations, 2013, 2017). Indigenous people have suffered from historic injustices due to colonization and the dispossession of their lands, territories, and resources, preventing them from exercising their right to self-determination and self-management. Under international law, Indigenous people also have exclusive rights to their traditional medicines to maintain their health practices, including the conservation of vital medicinal plants, animals, and minerals. As individuals, Indigenous people have the right to social and health services without discrimination.
In the African continent, there are an estimated 14.2 million Indigenous people who live in remote and inaccessible areas with poor infrastructure and harsh terrain. African states such as Kenya, Rwanda, Burundi, and the Democratic Republic of Congo are yet to acknowledge and recognize their Indigenous citizens who, as a result, are not represented in the database of international agencies or most national censuses (African Commission on Human and Peoples’ Rights, 2005; United Nations, 2017).
China has the world’s largest concentration of 105 million Indigenous people. The South Asian region has an Indigenous population of 95 million, where India alone has 84.3 million. There are an estimated 30 million Indigenous people in South East Asia, and 15 million in Western Asia (United Nations, 2017).
The Indigenous people who represent approximately 1.7% of the total population in the United States are known as American Indians, Alaska Native, and Native Hawaiians (United States Census Bureau, 2010).
In Canada, the collective term for Indigenous people is First Nations. The First Nation consists of distinct nations such as Metis and Inuit. The total number of Canadians who identify as Indigenous is 1.4 million and make up 4.3% of Canada’s total population of 30 million (United Nations, 2017).
The Indigenous people of the South American continent are subdivided into the Central, South American, and the Caribbean region, with a population of 45–50 million people. They make up almost 600 Indigenous groups who mostly reside in rural locations (United Nations, 2013, 2017)
In the Pacific region, the Australian Indigenous population in 2011 made up 669,900 of the total 24.6 million population (Australian Bureau of Statistics, 2014). In Aotearoa (New Zealand), there are 682,724 Maori or Pacific Islanders of the total 4.84 million population (Stats New Zealand, 2013). There are 8 million Indigenous people in Papua New Guinea, 850,000 Indigenous Melanesian Fijians, and 260,166 Indigenous Melanesians in New Caledonia (United Nations, 2013).
The Arctic region consists of the Inuit of Greenland and the Sami of the Sapmi traditional lands and the northern borders of the Russian Federation. Although statistical data are not conclusive, 20,000 Sami live in Sweden, 50,000–65,000 in Norway, 8,000 in Finland, and 2,000 in Russia (United Nations, 2013, 2017). The Inuit make up 56,000 of the 58,000 residents in Greenland.
In the following sections of this article, the public health status and the social determinants that affect Indigenous people are discussed, as well as how the Indigenous health workforce increasingly uses evidence-based, innovative approaches to address the shortage in health professionals as they move toward universal health coverage. The article also includes a section on the integration of Indigenous knowledge and traditional medicine (TRM) with the Western biomedical model for tackling health challenges at a local level.
Public Health Status of Indigenous People
A landmark study identified the variation of health status in the Indigenous population, describing the health and social status of Indigenous and tribal people relative to benchmark populations. Research from 28 communities across 23 countries showed poorer outcomes for Indigenous nations across the board (Anderson et al., 2016).
Indigenous infant mortality rates varied by state and ranged from a third higher to more than double the rate for non-Indigenous infants. Newborns of Indigenous women were more than twice as likely to be of low birth weight as those born to non-Indigenous women. The most moderate average birth weights for infants were those whose mothers used marijuana with tobacco or tobacco and alcohol. Overall, life expectancy was lower by 17 years for Indigenous women and men.
The leading cause of death among males and females in most nation-states was cardiovascular disease (CVD), with rates of up to 30% higher than the non-Indigenous population. The next leading cause of death for Indigenous males was injuries. These included automobile accidents, intentional self-harm, and assault (3.0 times that of the total male population). Cancer (1.3), respiratory disease (3.9), and endocrine, nutritional, and metabolic disorders, primarily diabetes (7.3), affect Indigenous people disproportionately. The most frequent causes of death for Indigenous women, after CVD, were cancer (1.6 times the total female population), endocrine, nutritional, and metabolic disorders (11.7), injuries (2.9), and respiratory diseases (3.6). Lung cancer is among the leading forms of cancer for Indigenous males and females, and cervical cancer is a significant cause of death for Indigenous women.
Leading infectious diseases among Indigenous people are tuberculosis, hepatitis A, B, and C, sexually transmitted infections, HIV–AIDS, Haemophilus influenza type b, pneumococcal disease, and meningococcal disease. Poverty, overcrowding, malnutrition, smoking, alcohol, and drug abuse are key risk factors for this constellation of communicable diseases.
Diarrheal disease and eye, ear, and skin infections are also significantly higher among Indigenous people, especially among young children. Levels of disability are estimated to be at least double that of the general population (Bodeker et al., 2018).
Despite uncertainty over definitions of mental health and mental illness and inadequate data on mental health problems, Indigenous people have high levels of mental health challenges and stress. A prominent manifestation of this is the rate of suicide. Based on sex-specific rates for the Australian population, suicide rates are more than 2.8 times for Indigenous males and 1.9 times more than expected for Indigenous females compared to the non-Indigenous people. MacRae et al. (2012) noted that these rates mask high youth suicide rates, where Indigenous to non-Indigenous ratios are 3.4 for males and 6.1 for females in the 15–24 age groups.
Health and environmental risk factors include tobacco, alcohol, and other drug use, poor nutrition, low income, limited education, high unemployment, high levels of stress, social marginalization, poor working conditions and housing, and gender-related challenges. These in turn interact with cultural and traditional factors to influence behavior, health status, and health outcomes.
Global Incidence of Indigenous Suicide Rates
A global estimate of 800,000 suicide deaths was recorded in 2016 (WHO, 2016) and is in the top three causes of death among males and females aged 15–44 years old, with an annual global age-standardized rate of suicide at 10.7 per 100,000 population. Studies from industrialized economies such as the United States (Herne, Bartholomew, & Weahkee, 2014), Canada (Macaulay et al., 2012), Australia (Pridmore & Fujiyama, 2009), Aotearoa New Zealand (Beautrais & Fergusson, 2006), and Norway (Silviken, 2012) have shown a consistent increase in suicide rates among Indigenous populations and a substantial proportion of disparities in comparison to non-Indigenous people. Colonial history, structural violence, and the forced removal of children to “weaken family ties and cultural linkages and indoctrinate children into a new culture—the culture of the legally dominant Euro-Christian Canadian society” (Truth and Reconciliation Commission of Canada, 2015, p. v) have given birth to a modern, socially engineered phenomenon. As a result, intergenerational trauma is a contributing factor to social and mental health problems.
A global and systematic investigation of suicide in Indigenous nations has revealed several pertinent issues (Pollock et al., 2018). Rates in high-income countries were highest among rural and sparsely populated Indigenous communities. The Palawan in the Philippines has the highest crude suicide rate (134 per 100,000) while Indigenous populations in Malaysia and Fiji are under seven per 100,000 population. The disparities between populations are more extensive in the measure of relative effect. In 102 Indigenous populations and 69 studies, Pollock et al. (2018) found rate ratios between China and Brazil or Canada to differ from 0.04 to more than 20. However, one study reported a suicide rate of zero for an urban Brazilian population compared to the general population rate of 4.8 per 100,000 in the same city (de Souza & Orellana, 2013).
Suicide rates have accelerated among the Inuit of Greenland (from 2.4 per 100,000 to 110.4 per 100,000) since the early part of the 20th century. An increase in suicides in the Aboriginal and Torres Strait Islander population in the Northern Territory, Australia (6.1 per 100,000 to 50.4 per 100,000) was noted between 1981 and 2002, and in the Micronesian islands (from 4.3 to 25.8 per 100,000) within a relatively short period of time between the 1960s and the late 1980s (Pollock et al., 2018).
There are many challenges for Indigenous people to access mental health care that is relevant and culturally appropriate, and is more often compounded by generalizable interventions from a “best practice” paradigm. Little importance is given to producing local Indigenous-led mental health programs that incorporate Indigenous knowledge, medicine, and culture. Despite clinical trials such as gatekeeper training (Sareen et al., 2013), hospital-based intervention programs (Hatcher et al., 2011), and mHealth applications (Tighe et al., 2017), “adverse and limited effects on suicide-related outcomes for Indigenous people” were reported (Pollock et al., 2018, p. 12).
Interventions designed with Indigenous knowledge systems specifically to address suicide that is integrated with evidence-based public health and clinical interventions were reported in countries such as Canada and in the Arctic region (Goebert et al., 2018; Rasmus et al., 2019). Pertinent outcomes of Indigenous-led interventions include the creation of supportive communities and resilient families who instilled a sense of pride in Indigenous identity and enhanced connections to people and place while inspiring hope. These results argue for a key theme in communities where self-management, self-policing, and culturally based solutions offer the most viable means of tackling socially based health problems. An example from Micronesia is a culturally based intervention which supports traditional practices that provide a pathway for the individual as well as the community. Social structures that influence individual outcomes in Micronesia include adhering to cultural protocols, respect for leaders, and sharing of resources at a communal level to help provide a pathway for an individual’s life. This does not mean that individual opinions are not welcomed but rather that they are considered in light of the standpoint of their traditional leaders and interpersonal sensitivities (i.e., gender, sexuality, and confidentiality) (Hezel & Francis, 2013).
The Social Determinants of Indigenous Health
The current public health status and health outcomes of Indigenous nations are intrinsically linked to the social determinants of health. Social determinants are related to how economic, social, and political policies are implemented to alleviate the burden of morbidity and mortality (Preda & Voigt, 2015). As a result of their poor social and economic status, the lack of culturally appropriate education, employment, and housing, as well as physical and environmental conditions widen the gap in health outcomes between Indigenous and non-Indigenous populations (De Andrade et al., 2015).
The Cuban Dengue Prevention Program and Eradication of Aedes aegypti is an example of a social determinants approach to tackling public health challenges underpinned by legislation. The program is an intersectoral collaboration and a community-based participatory model supported by public health policy collaboration between local government, community organizations, the Ministry of Public Health, medical doctors and health professionals, as well as water resources management and some civil society organizations. Outcomes from these efforts shed light on the lack of government organizations involved in multisectoral action and community partnerships. Partnerships that enhance local needs assessments are essential for an intersectoral move toward universal health coverage and sustainable development (De Andrade et al., 2015).
The impact of colonization and policies such as the Aboriginal Protection Act of 1869 in Australia were dimensions of a comprehensive scheme to control the lives of Aboriginal people. The continuing effect of such historical policies, the lack of reparation, and the lack of recognition of colonial impact continue to hurt programs designed to reduce health inequalities (Griffiths et al., 2016). Colonial methods of deconstructing cultures, systems, and structures have enabled an unequal distribution of power between Indigenous and non-Indigenous people. Therefore the devaluation of Indigenous ways of knowing and their traditional medicine persists in present-day society (2020). Griffiths et al. (2016) provide an example by drawing on the low uptake of Indigenous definitions of health in the administration of health systems designed specifically for Indigenous populations.
The global public health status of Indigenous people needs to be considered in the context of the environment, where an individual is born, grows, learns, plays, and works. An understanding of the lived experience of Indigenous people is a prerequisite for designing effective public health interventions. Collaborative approaches, the professionalization of the Indigenous workforce, and taking into account Indigenous knowledge systems may hold the key to improved health and well-being outcomes.
Indigenous Health Workforce Professionalization
The United Nations Declaration on the Rights of Indigenous Peoples (2007) emphasizes their right to education and health, including access to traditional medicine (TRM) and the utilization of traditional knowledge in promoting and maintaining their health and well-being. Indigenous communities have taken control of their health and have developed innovative public health programs. In this regard, many have included the custodianship of their traditional lands as a foundational step toward reconciliation. Increasingly, Indigenous young people are trained as community health workers, nurses, and doctors while maintaining their connection with traditional health practitioners. These integrated services are reporting positive outcomes.
There are six areas for development that participants in an Australian study described as challenges for public health to tackle in an Indigenous context (Kendall & Barnett, 2015), as follows:
• An overall aversion to Western medical systems and colonial history;
• Health care professionals insufficiently trained in cultural sensitivity or cultural competence may alienate Indigenous people from health services;
• A prevalent “colonial” or top-down communication style may impede building trust and rapport in the community;
• A dissonance between the collective nature of health and well-being from an Indigenous standpoint and the individualistic processes of the Western biomedical model may add to the problem; and
• The challenge for public health practitioners to understand that the holistic Indigenous approach to health is more than a medical or somatic condition.
• Personal information from physicians in the Pacific who are active in primary health care indicates that they may face professional liabilities in not prescribing pharmaceuticals that are known to address health problems and in trying to address them with lesser-tested or regulated traditional remedies.
Some evidence of efficacy, known safety, cultural acceptance, lower cost, and widespread availability of traditional remedies are factors that have led to standardized traditional medicines taking a place alongside mainstream medicine when safety and efficacy are known (see Willcox et al., 2015).
A key theme in communities is that self-management, self-policing, and culturally based solutions offer the most viable means of tackling socially based health problems. Since WHO’s Alma Ata Declaration of Primary Health Care (WHO, 1978), traditional health systems have been a formal focus of policy development at both the international and the national level. The Alma Ata Declaration (WHO, 1978), adopted by WHO and UNICEF, stated that primary health care (PHC) is an essential element of health care based on practical, scientifically sound, and socially acceptable methods, supported by technology made universally accessible to individuals and families in the community through their full participation and at an affordable cost. PHC engages with the population of interest through community health workers (CHW), as well as through physicians, nurses, midwives, and traditional medicine practitioners who are socially and technically trained to work as a team and to respond to the expressed health needs of the community.
Who are these CHWs and what are their characteristics? CHWs live locally, typically have completed their secondary education, and are trusted members of the community. They often debut as volunteers before gaining employment. The professionalization of CHWs only began in the early 2000s, and since 2005, a key development hs been the ubiquity of mobile phone coverage into remote, rural, low-income localities (Huang et al., 2018). Mobile technology has enabled supportive supervision, real-time data monitoring, and expert system guidance. More online tools from 2010 coincided with the emergence of smartphones that enabled new public health applications such as Dimagi’s CommCare (Mishra et al., 2018).
The effectiveness of CHWs has been increased through rapid diagnostic technology. For example, in malaria testing and treatment, the efficacy of the Millennium Villages Project relied heavily on the new roles of CHWs in 10 sub-Saharan African countries. CHWs are remunerated, trained, supervised, and provided with mobile technology, information systems, and backpacks with medical kits. The Ebola epidemic that severely impacted countries such as Sierra Leone, Guinea, and Liberia in 2014 was found to be due to a lack of CHWs as well as a lack of trained professionals with local contextual knowledge and skills to act in the early phases of the disease. In the context of Indigenous communities, traditional health practitioners (THPs) constitute an on-the-ground resource for CHWs capable of mobilizing around public health issues and participating in integrated health service development despite the lack of systematic and continuing professional development from government programs (Huang et al., 2018).
Incorporating Traditional Medicine in Indigenous Health Interventions
Most traditional medicine (TRM) systems have a theoretical basis, a materia medica, a range of therapeutic modalities, an empirical approach to treatment, and a tradition of training. Extensive scientific research has been conducted and published on TRM. Some TRM has been proven to be safe and effective through controlled clinical trials. Some TRM practices are dangerous (e.g., hepatotoxicity or herb–drug interactions) or ineffective.
A key point is that in both rural and urban areas, there is a demand for TRM and patients seek guidance in selecting from traditional and modern healthcare options. Given the trust of local communities in TRM and its practitioners, partnerships with THPs is warranted and is based on mutually respectful exchange. Increasingly, in line with WHO’s policies, partnerships have been developed between modern and THPs.
The World Health Organization’s Global Atlas on Traditional, Complementary and Alternative Medicine (Bodeker & Ong, 2005) provided the first global overview of utilization and policy development in the TRM sector. Half of the world’s population uses these approaches regularly and pay out of pocket to do so. By this standard, there is nothing “alternative” about these approaches to healthcare. Instead, they constitute a collective majority body of health practices.
In Africa, regular use of TRM is assessed at around 80% of the population. In Asia, more than half of the population uses it, with variations across urban and rural areas (i.e., higher use in rural areas) and across educational levels (i.e., a bimodal curve exists, with high use at low educational and income levels and at the highest educational and income levels).
The World Health Organization produced a strategy on Traditional and Complementary Medicine (T&CM), which looks ahead to the year 2023 (WHO, 2014). WHO’s Traditional Medicine Strategy 2014–2023 has two key goals:
1. To support member states in harnessing the potential contribution of T&CM to health, wellness, and people-centered health care; and
2. To promote the safe and effective use of T&CM through the regulation of products, practices, and practitioners.
WHO has outlined three strategic objectives for meeting these goals:
1. Building the knowledge base and formulating national policies;
2. Strengthening safety, quality, and effectiveness through regulations and support testing; and
3. Promotion of universal health coverage through the integration of T&CM services and self-health care into national health systems.
According to WHO, TRM not only maintains its function in primary health care in developing countries (70–80% of the population in India and Ethiopia still depend on TRM and practitioners for primary health care), but its use has expanded widely in many developed countries, and is referred to as Complementary or Alternative Medicine (CAM). For instance, 70% of the population in Canada and 80% of people in Germany have used TRM as CAM treatment.
Much of the use of TRM by those with higher levels of income and education is for health promotion and disease prevention, widely referred to as wellness.
The editorial in the September 2018 edition of Bulletin of the World Health Organization, titled “Healthy living, well-being and the sustainable development goals,” and coauthored by Amina Mohammed, Deputy Secretary-General of the United Nations, and WHO’s Director General, Tedros Adhanom Ghebreyesus, identified three strategic priorities:
1. universal health coverage;
2. health security; and
3. improved health and well-being.
While these priorities are laudable, there is a growing concern about the viability of some of these sustainable development goals, particularly universal health coverage. WHO’s Assistant Director-General for Special Initiatives, Ranieri Guerra, wrote in August 2018 that:
There is general agreement that the over-optimistic assumptions of the SDGs are now passing through a reality check that indicates where we need to re-prioritise and move resources accordingly. According to progress reports so far, it is insufficient to meet the goals and targets set for 2030.
(Guerra in Bodeker et al., 2018, p. 5)
Integrating Indigenous Knowledge With Modern Healthcare Practices: Country Studies
The Arctic Region: Norway and Fennoscandia
Sami people of the Arctic region still have a long and continuous relationship with traditional healers, even after the first district medical doctor scheme had been established there in 1836. With a distance of at least 125 miles from local communities, the high cost of traveling made modern health care inaccessible. Traditional healers, however, were local, free, and culturally sensitive (Langås-Larsen et al., 2018). The study by Langas-Larsen and colleagues (2018) found that family networks (family, kin, friends, and neighbors) held an important role in patient management and especially in the maintenance of health and well-being. This network has been responsible for offering help with practical tasks and with supporting close kin. In some cases, they may be asked to contact traditional healers for providing their services in the hospital.
The Sami residing in Fennoscandia use a cultural form of singing called “yoik.” Singing in general has been found not only to be a form of self-expression but a tool that enables self-regulation with music therapy, promising therapeutic potential in neurological and psychological disorders (Hämäläinen et al., 2018). Yoik therefore can be a means for emotion regulation and stress relief for individuals. As a cultural artifact, such cultural practice has promoted sociocultural resilience and reinforced Indigenous identity.
The prevention and control of the HIV epidemic in Myanmar requires regular engagement at a local level, particularly with men who have sex with men (MSM) and transgender women (TW). This public health challenge affects some Indigenous and diverse gender and sexual identities among same-sex attracted men. Despite the known risk to the MSM and TW community, less than half reported in 2016 receiving an HIV test in the prior 12 months (as reported by the National AIDS Program, 2016). Nondisclosure of MSM to family and friends is a strategy to avoid stigma and discrimination. Adding to the latter is the criminalization of homosexual acts through anti-homosexual legislation, resulting in a reduced level of access to health services among MSM and TW (Arreola et al., 2015; Veronese et al., 2019). However, according to Veronese et al. (2019), the National AIDS Program is addressing the structural and social stigma of this community through a call for their engagement through a discreet use of peer-based outreach and digital health promotion.
Grameenphone (GP) has introduced a mobile phone-based health service delivery model that builds on the capabilities framework pioneered by Amartya Sen (Meier & Stiglitz, 2002). The service has over 74 million subscribers and has increased access to services for Indigenous people who could not afford to consult a registered doctor face to face. The social impact of the GP project has been further illustrated by the experience of an Indigenous secondary school girl who called the Healthline service (the service has been rebranded to “Tonic”) and developed a better understanding of her body (Palas et al., 2017).
The following is a short account of the teenager’s experience, using a pseudonym:
Radhika declined her grandmother’s offer of a traditional method of protection for her menstrual cycle. Traditional methods often utilize old cloths, cotton, or tissue. These items are repeatedly used without cleaning, drying, or laundering, and 90% of the time they are stored in an unhygienic, hidden place (Mondal et al., 2017). From Radhika’s reading of her home economics textbook, she learnt that the traditional method was a health hazard and a risk factor for urinary tract cancer. Her body was going through changes, which caused much physical pain and discomfort during her periods. It took her several months to muster the courage to speak of this with a female teacher. Radhika said, “the first experience of my period was very challenging and I was too shy and confused as to what to do.” The teacher provided Radhika with the number of Healthline. Radhika called and described her concerns to a doctor who not only suggested to use sanitary napkins but also prescribed some medicine. Radika recalled her kind female doctor in her own words and said that as a result, “I did not hesitate to discuss my problem with her which I could not discuss with anyone else before.”
(Palas et al., 2017, pp. 73–74)
The story of Radhika offers a cameo of a teenage girl overcoming cultural and societal barriers to improve her well-being through the use of an online service, namely Healthline. Even though she was interviewed by a male, according to Palas et al. (2017), her ability to speak without fear or shame was due to her behavior change outcomes as a result of being supported by women in talking about her issues openly through her interaction with Healthline.
A high turnover of health professionals is one of the challenges of health care provision in regions with vast distances between remote localities and urban centers. The Nunavik in the region of Northern Quebec have looked at the use of social media as a means to promote health information and to address the need for community engagement in remote locations. Although young people are the primary users of social media, a wide variety of age groups utilize Facebook, including unilingual Inuktitut speaking elders. The Inuit elders have integrated Facebook and traditional methods of communication into their routines to ensure that the younger generation may benefit from traditional knowledge and culture.
Despite the prohibition by the Quebec health system on the use of Facebook, community social and health workers who work directly under the Nunavik health system, found a way to work around this rule and engage with the Indigenous community outside of their regular working hours. The “Feeding My Family” Facebook page is an example of integrating technology and health promotion into the discourse of health in the community. The members of this page, numbering more than 20,000 as of 2019, first began to show concern over the effects of high food prices on family health. These online posts of photos and comments slowly evolved into a community action rally or protest in several localities. The use of Facebook to generate full community participation grew into a robust regional effort to transform the Western biomedical model and health services as well as to advocate for an integrated model prioritizing Inuit values and knowledge (Diamond & Starks, 2018).
The Yukon, a region of Canada’s northwest, has a population of 38,455 and is home to 14 First Nations communities (Yukon Bureau of Statistics, 2017). The Council of Yukon Indians inspired the diversifying of professional health training by stating “the whole Yukon is our school. In the past, we learned from our surroundings” (Council for Yukon Indians, 1973, p. 21, in Diamond & Starks, 2018). By decolonizing, indigenizing, and making reconciliation efforts, Yukon College is striving to put health professional training into Indigenous hands.
Nation Initiative staff also deliver a short workshop on competencies related to understanding First Nations heritage, culture, governance, and contemporary challenges through their worldview. Students have an opportunity to learn collaboratively about traditional foods, Indigenous epistemology, and the importance of ceremony related to end of life. As a result, students can provide more meaningful interactions with their future clients and respect traditional knowledge and Indigenous perspectives on health and well-being (Diamond & Starks, 2018).
Researchers Airhihenbuwa and colleagues argue that “to change negative health behaviors, one must first identify and promote positive health behaviors within the cultural logic of its context” (Airhihenbuwa, Ford, & Iwelunmor, 2013, p. 78). The Center for Alaska Native Health Research designed an intervention program based on Indigenous knowledge called the Qungasvik (ph. Kung-as-vik/Toolbox) Training and Teachings manual. This training package is delivered by Native Alaskans who are leading the development and evaluation of strengths-based and protective factors to reduce the risk for Alaska Native suicide and alcohol abuse. The men’s communal house, or “qasgiq,” which in one of its possible meanings is “to encircle,” is a living space used for an extended kinship structure among men during the winter months. The qasgiq process, led by elders, is based on community action and promotes equality in the community. The intervention includes planning, reflection, and a series of activities during a 3-year time frame, targeting young people and their development and the need to be exposed to Native values, knowledge, and practice, as well as to live the customary yuuyaraq, or “way of life” (Rasmus et al., 2019).
What is prominent about this intervention is the use of Alaska Native knowledge on space, symbols, and metaphors, where the qasgiq is a place to learn essential survival skills in a postcolonial world. Healing is embedded in the qasgiq, through re-establishing “collectivity, interdependence, equanimity, and encircling.” The program aims to enable youth to gain positive wellness outcomes (Rasmus et al., 2019, p. 49).
The focus on culture was historically reduced in importance during the intervention design phase. But increasingly, Indigenous frameworks and paradigms are translated into interventions that complement and strengthen Western ideas of public health. In turn, the growth of the Qungasvik and the success of the qasgiq model will influence self-determination in health services and public health research among Alaska Natives (Rasmus et al., 2019).
A randomized controlled intervention was implemented as part of the Tribal Health and Resilience in Vulnerable Environments study. The researchers partnered with tribally owned and operated supermarkets in the Chickasaw Nation and Choctaw Nation of Oklahoma. The goal was to increase the purchase of healthy foods, fresh vegetables and fruits, as well as to reduce food insecurity in the community (Blue Bird Jernigan, D’Amico, & Keawe’aimoku Kaholokula, 2018). The collaborative relations with tribal commerce leaders involved co-developing all aspects of the study that included designing a specific store assessment tool, testing the right food for taste and acceptability, and designing the marketing and signage. As a result, the tribal commerce leaders greatly enhanced the external validity of the evidence-based healthy retail strategies and augmented self-reported survey data with objective store-level measures, including food costs and sales (Blue Bird Jernigan et al., 2018).
Studies that focus on internal validity, such as randomized control trials, lack the translation and dissemination of learning to real-world settings with high variabilities, such as in Indigenous contexts, where culture, Indigenous medicine, knowledge, and acceptability are complex issues. The National Institutes of Health has brought critical attention to the importance of translational research and has identified external validity as key to the problem of utilization of evidence- based practice. Efficacy trials must include greater diversity in participants, especially Indigenous participants, and hand back intervention design and implementation in collaborative practice to balance the internal and external validity issues in interventional studies (Blue Bird Jernigan et al., 2018).
Community Mental Health: Projeto Quatro Varas
An influential and innovative community mental health model in Fortaleza-Ceara, northeast of Brazil, called Projeto Quatro Varas, was co-founded by Adalberto Barreto, a psychiatrist and mental health researcher, and his brother, Airton Barreto, a lawyer. Adalberto Barreto generated the community therapy (CT) methodology to provide community care grounded in both societal and academic understanding. He developed the CT program initially in the favela of Fortaleza after carrying out research showing that local curanderos, who use herbs and other traditional cultural remedies, have a positive impact on community health (Neville, 2008).
The CT program consisted of a range of components, including collective therapy circles, “living pharmacies” (i.e., herbal medicines), and curing houses with complimentary treatments. He studied the importance of parteiras (traditional female obstetricians), the value of razeiros and rezadeiras, and the cultural treatment of death, marital conflicts, and neighborhood disputes.
The CT approach has now become widely diffused throughout Brazil and is used among many different groups and populations, mainly through formal partnerships established between the Universidade Federal do Ceara and various levels of federal, state, and municipal health services. In research conducted in 10,000 community therapy circles and 100,000 consultations, 88% of attendees had experienced improvement through community therapy and its support system. Based on these research findings and the success of more than 600,000 therapeutic sessions, Barreto managed to get CT approved as national public health policy and trained 1,100 government public health and social assistance employees (Barreto & Grandesso, 2010).
Other countries in the region as well as countries in Africa and cities in France have built relationships with the CT movement and Barreto, establishing community mental health programs based on the principles of a local therapist, traditional knowledge, self-help, mutual support, and program evaluation (Ashoka Foundation, 2018).
The Matses Traditional Medicine Encyclopedia
A tribe called the Matses in the Amazon (Brazil and Peru) are trying to protect their language, knowledge, stories, and culture from extinction through the production of a comprehensive 500-page encyclopedia. The encyclopedia, a combined effort and a first of its kind by shamans of an Amazonian tribe, is written in their language to protect their medicinal knowledge from appropriation by researchers and corporations. The encyclopedia, written from the perspective of the Matses shamans, incorporates flora and fauna into the nature of diseases of their people. Although this is a historical and pertinent production, the long-term benefits of such an effort must be supported by long-term apprenticeships and experience, which pose a challenge in the recruitment of participants.
The encyclopedia is a resource to train new shamans and mentor them in their youth with the knowledge of experienced shamans before they pass on, as well as to preserve their way of life and the medicinal plant knowledge of their people. The encyclopedia, which took 2 years to compile, includes an entry on Matses master healers. Each entry is sorted by disease name, an explanation on how to identify its symptoms, its etiology, and the preparation processes and plant sources to be used to address the illness. It also includes alternative therapeutic options. The Matses also use photos to accompany each entry in the encyclopedia. Preservation of traditional healthcare practices, however, requires a specific plan, and maintenance of traditional methods with the help of mentors, as suggested here, is essential for the continuity of a culture and of Indigenous knowledge.
Makere University and PROMETRA Uganda: Partnership for the Scientific Investigation of Important Traditional Medicines
Uganda has a long history of research in TRM. As far back as the 1960s, a government team began documenting the traditional medicinal knowledge of many of Uganda’s 111 districts. A monumental task, this national ethnomedical survey continued for almost 30 years and resulted in a comprehensive written record of the national TRM heritage. The document is stored as a set of typed volumes at both Makere University and at the National Chemotherapeutics Research Institute, both of which are in the capital, Kampala.
In a collaboration as part of the European Union-funded Multi-University Initiative on Traditional Healthcare (MUTHI), Uganda’s Makerere University in Kampala, Mbarara University in Southwest Uganda, and PROMETRA Uganda created a legal framework to partner in investigating essential traditional medicines for scientific evaluation (Bodeker, Weisbord, et al., 2018).
Several people involved in herbal medicine as well as groups of traditional healers were invited to a meeting at Makerere University. Most THPs were ready to work with the Makarere team. However, they did harbor fears that the researchers could steal their medicinal formulae and profit from them, as is an often realistic concern of traditional knowledge holders in general.
The Makerere team expressed interest in the partnership and assured the THPs that the main objective of the project was to contribute to improving TRM, mainly herbal medicine, and to place safe and standardized herbal medications, registered with the National Drug Authority, on the open market.
The Department of Traditional Medicine
Mali benefits from an unusually high level of government support for research and development of TRM. The Department for Traditional Medicine (DMT) within the National Institute for Research on Public Health (part of the Ministry of Health), was founded in 1968. Since 1979, one of its aims has been the development of standardized “medicaments traditional ameliorés,” or improved traditional herbal medicines (Willcox et al., 2012; Willcox et al., 2015).
In Mali, the objective to develop phytomedicine for home-based management of malaria (HMM), with the aim of symptomatic improvement and prevention of severe malaria, was seen as an effective and innovative public health policy. If the preventive population-based treatment were found to be effective, the plant would be cultivated and prepared locally as a first-line treatment for presumed malaria.
The primary outcome measure in this research program was “clinical recovery” on Day 28, without the need for second-line treatment. An important secondary outcome measure was the incidence of severe malaria, which is a crucial outcome in public health terms. Large numbers of patients were needed to demonstrate non-inferiority because severe malaria is a relatively rare event. Another approach is to see whether the incidence of severe malaria is kept below a pre-specified level in both groups. A previous study in a similar context showed that age-specific incidence (age <5 years) of severe malaria in untreated patients with presumed malaria was about 11%, and in patients treated at home with chloroquine (the standard treatment at that time) was about 5% per month (Sirima et al., 2003). The aim was therefore to keep the age-specific incidence of severe malaria (in patients aged <5 years) below 10%, and ideally, at ≤5% in both groups.
Over 28 days, second-line treatment was not required for 89% (95% CI 84.1–93.2) of patients treated with the locally used herbal antimalarial Argemone mexicana versus 95% (95% CI 88.8–98.3) treated with artesunate-amodiaquine (ACT). The observed age-specific incidence of severe malaria (in children aged 0–5 years) was 1.9% in both groups (A. mexicana and ACT) over the first 28 days of follow-up. The follow-up was extended to 3 months and, over this time, the age-specific incidence of severe malaria was 2% per month in the herbal group and 1% per month in the ACT group. With 95% confidence, the age-specific incidence of severe malaria in both groups was <6% per month (Willcox et al., 2011).
The research team has documented a 3.5-fold increase in the use of A. mexicana for the treatment of uncomplicated malaria and an 8-fold decrease in the consultation of traditional healers for severe malaria (Graz et al., 2010). The research team is working to scale this program up, leading potentially to substantial reductions in mortality from malaria and delays in the appearance of resistance to conventional drugs such as artemisinin combination therapies.
As a challenge to public health, malaria was overcome with sustainable efforts, especially in the area of indigenous malaria. Sustained surveillance and expedited responses for each malaria foci achieved such results, particularly in achieving zero reported cases of indigenous malaria in 2017 (Feng et al., 2018).
A robust policy and a centralized approach for malaria control and elimination was guided by three strategic guidelines, seven national criteria, and five technical plans. This multipronged approach mobilized social resources (Feng et al., 2018) and the achievement is partly owned by the malaria training programs held from the provincial to the village level. Health workers from higher up in the health system were more interested in the technical aspects of malaria prevention, while township and village health workers trained in fieldwork coordination and targeted public health interventions better suited for the context in regard to case detection and investigation (Lu et al., 2018). China has demonstrated that the incorporation of health workers at all levels of government, especially those on the ground in rural and remote villages, was crucial to prompt prevention, detection, and treatment of cases.
The Institute of Applied Dermatology, Kerala
In the traditional medicine sector, skin and wound treatments were estimated to account for approximately one third of all traditional medicines (Balick & Cox, 1996). This figure may not include the natural products regularly applied to healthy skin in many parts of the world to promote hygiene, such as “soap plants” and emollients.
Community dermatology is a concept that extends the focus of care delivery from the individual patient who comes to see the doctor about a skin problem to a proactive intervention to improve the care of skin and treat diseases that present with skin signs in the broader communities in which people live (Ryan, 2015). Programs that use local health care workers, those that use traditional practices, and those that involve other groups such as burn care experts are all manifestations of the same basic principle for achieving the best results; teams are usually multidisciplinary and sensitive to local practices and needs.
The Institute of Applied Dermatology (IAD) was founded in 1999 by dermatologist S.R. Narahari along with nine other interdisciplinary senior medical professionals. In 2014, the Government of Kerala established its Center for Integrated Medicine and Public Health in the IAD under public–private partnership for furthering activities of research, development, and operations related to community dermatology. The IAD is collaborating with seven institutions and universities to enhance the evidence, application, and impact of integrated medicine in dermatology.
The IAD, a not for profit organization in Kasaragod, Kerala, devised a suitable program that employs locally available supervisors and user-friendly technology at low cost. In 2004, the IAD launched an integrated treatment protocol to reduce lymphatic filariasis morbidity by combining Ayurveda, yoga, and compression therapy supplemented, when necessary, with modern dermatology drugs to treat bacterial entry points.
Narahari et al. (2013) designed a treatment that included skin wash, phanta soaking (an Ayurvedic infusion made of Rubia cordifolia in hot water), yoga and breathing exercises before and after Indian manual lymph drainage (limb massage against the direction of hair growth using an oil specially prepared for lymph drainage), compression therapy, and bacterial entry points using pharmaceutical medicines. A total of 730 patients completed the 3.5-month follow-up. Inflammatory episodes decreased from 37.5% to 28.3% in one district and from 37.6% to 10.2% in the second district. A lymphatic filariasis-specific quality of life questionnaire revealed an overall improvement in all domains.
The authors note that this cost-effective integrative treatment protocol has adapted all the principles of primary healthcare, namely community participation, intersectoral coordination, user-friendly technology, and equitable distribution, which may be adapted globally.
In the 11th annual Closing the Gap report on the health of Aboriginal Australians, little progress was shown and only two of the seven targets were met to reduce inequalities for Aboriginal and Torres Strait Islander peoples’ social determinants (The Lancet, 2019). The report’s editorial called for a complete overhaul of the national strategy and focus on equitable expenditure, with a particular emphasis on putting Aboriginal health in Aboriginal hands. From social marketing to clinical practice, Indigenous knowledge systems and collaborative research methods need to be front and center of the Closing the Gap strategy.
Indigenous health workers from Aboriginal and Torres Strait Islander nations in Australia are actively engaged in oral health interventions across the lifespan in their localities. Training programs have varied from a three-module program delivered in a classroom with a 60-hour on-the-job training component to a 1- or 2-day workshop on oral health education and hygiene, and training with an early childhood oral health screening tool (Villarosa et al., 2018).
The Kaholo Project incorporated a traditional Hawaiian dance in hula to prevent cardiovascular disease in Native Hawaiians with hypertension. While historically the traditional hula dance was prohibited by Christian missionaries and later by legislation, the hula remains a popular and acceptable dance among Native Hawaiians and is woven into the context of community life, where behavior change is possible and more efficacious. Kahalokula et al. (2017) found the dance as a form of physical activity effective in reducing systolic blood pressure and in improving social functioning.
Palau is an archipelago of over 500 islands, part of the Micronesia region in the western Pacific Ocean. Around 70% of deaths in the Pacific are due to non-communicable diseases (NCDs) such as cancer, diabetes, and cardiovascular and respiratory ailments, according to the Pacific Islands’ Non-Communicable Disease Roadmap (2014).
Medicinal plants are widely used in the Pacific, and Palau specifically, for the management of common ailment and NCDs. The Palau Primary Health Care Manual is a compilation of traditional ethnomedical information about plants, presented by the authors within the context of Western medicine. The Manual offers data on the traditional use, pharmacology, and toxicology of a wide range of plants in treating common ailments and injuries and for women’s and men’s health, as well as for managing NCDs (Dahmer et al., 2018).
In subsequent research, a “reverse pharmacology” study published in the Journal of Ethnopharmacology found that seven out of ten people in Palau self-prepared a medical concoction using Morinda citrifolia L. for diabetes and Phaleria nishidae for obesity. These are the two most frequently used medicinal plants in the archipelago. Researchers reported that for excess weight, M. citrifolia L. was associated with better outcomes than P. nishidae Kaneh. (p = .05). In the case of diabetes, when comparing P. nishidae and Morinda citrifolia, the former was statistically more often associated with a reported outcome of “lower blood sugar” (p = .01). The researchers noted that while statistical association of some 30 plants and their reported outcomes were not proof of effectiveness or safety, this approach can help local researchers identify further studies of plants or methods that can bring the most benefit to the population (Graz, Kitalong, & Yano, 2015; Kitalong et al., 2017).
Papua New Guinea
Family planning studies in Papua New Guinea (PNG) have often overlooked the importance of Indigenous knowledge and cultural systems, especially the views of Indigenous women (Hinton & Earnest, 2011). However, since the 1970s, village birth attendants (VBA) and village child health workers (VCHW) have been able to bridge this gap as part of a complex socioeconomic policy process. This resulted in the reduction of PNG’s maternal mortality, with “an estimated 250 deaths per 100,000 live births (down from 733 per 100,000), and reported infant mortality of 48 deaths per 1,000 live births (a reduction from 65 deaths per 1,000 live births) between 2009 and 2012” (Kampblijambi et al., 2018, p. 18).
In comparing the shift in community knowledge and the impact on living standards, the VBAs and VCHWs, both female and male, observed that there had been many positive outcomes. One of the changes in the community as a result of the education and training of VBAs and VCHWs was the reduction of blame for deaths to witchcraft and sorcery and an increase in awareness of the real causes of deaths in the community (Kampblijambi et al., 2018).
Another example of the impact on training local health workers was that mothers saw the importance of reducing the size of their family. While women often turn to traditional medicine for contraception, there has been an increase in acceptance of vasectomy in Goroka, in the highlands of PNG. However, these great efforts on the part of volunteer health workers could be threatened by a lack of financial incentives and support from organizations and the government due to its “voluntary” aspect (Kampblijambi et al., 2018).
Aotearoa New Zealand
In Aotearoa, the use of funding contracts as an incentive is to clarify roles and create transparency in the process of aligning goals between government agencies (as funders) and health care providers. These funding contracts bring with them unique challenges to Maori health providers.
The He Pinkinga Waiora (Enhancing Well-being) Implementation Framework is a planning tool used for funders and policymakers to collaborate with Maori health organizations in assessing the effectiveness of services and innovative interventions. As Maori health organizations are better equipped to implement services that target long-term conditions such as diabetes, a consistent method is applied to implement systems-thinking interventions with intersectoral integration of health and social services. This systems-thinking approach is aligned with Maori knowledge systems in health care delivery mentioned elsewhere as whanau- and client-centered care (Oetzel et al., 2017).
The Impact of Traditional Medicine in Addressing the Social Determinants of Indigenous Health
The approach of health interventions that tackle the social determinants of Aboriginal and Torres Strait Islander health, such as education, poverty, and housing, has received criticism for its top-down policy approach (Senior & Chenhall, 2013). There is little room for discussion on the way individuals and indigenous communities engage with health determinants at the micro level to create change from their standpoint. In a study of Aboriginal health beliefs in a remote community in the Northern Territory of Australia (Senior & Chenhall, 2013), researchers understood from their participants that the first course of action was to seek out bush medicines (traditional medicine) when ill. It is common to find some Aboriginal people underutilizing health services despite the provision of education or the implementation of health promotion campaigns. This interrelationship between some Aboriginal people and health service providers is a freedom that some must exercise as a pathway to self-determination, just as it is recognized and accepted in non-Indigenous or Anglo-European societies that resist coercion to be healthy.
In Canada, the First Nations have for thousands of years extensively utilized plant resources in traditional midwifery practice. Traditional midwifery proliferation into the greater community of North America has brought with it dignity and much-needed respect for traditional methods of birthing. The traditional knowledge of the First Nations is incorporated into modern midwifery through collaborative efforts under a framework that states the following:
. . . respect for, and use of, Indigenous knowledge and practices in the development and implementation of public health programs can only hope to succeed if the holders of that knowledge are allowed to define (the parameters) of its utilisation . . .
The re-establishment of Indigenous midwifery in North America, including the licensing of modern midwives and the construction of traditional Aboriginal birthing centers, was an achievement born from grass-roots efforts of the First Nations communities.
The Internet, Social Media, and Mobile Phones in Indigenous Health
The exponential growth of social media sites such as Facebook, Twitter, Instagram, YouTube, and the relatively newer Snapchat and WhatsApp has had a significant impact on the way people communicate and consume media, making it a ubiquitous source of information and a platform for knowledge exchange (Anderson & Perrin, 2017). Social media creates enormous potential for health organizations to engage, connect, and communicate with their target audiences. The often hard-to-reach population of Aboriginal and Torres Strait Islanders are among the most common adopters of social media (60% of Indigenous population used Facebook compared to 42% of non-Indigenous Australians) (Hefler et al., 2018).
The online content analyzed by Hefler et al. (2018) ranged from common health-related topics such as mental health, nutrition, exercise, and tobacco cessation and are generally visually prominent online and offline as a result of health promotion and social marketing activities. In addition, a broad discussion of the social determinants of health includes the importance of maintaining Aboriginal culture and language, connection to land and bush tucker, and the reinforcement of Aboriginal identity (Hefler et al., 2018).
The use of technology or media to create, share, and comment on stories and metaphors on health-related topics enables Indigenous epistemology and knowledge construction. According to Torres Strait Islander scholar Martin Nakata, knowledge construction is embedded in a variety of ways such as “storytelling, memory making, narrative art and performance; in cultural and social practices, of relating to kin, of socializing children in ways of thinking [and] transmitting knowledge” (Kariippanon & Senior, 2018, p. 34).
Research conducted on the role of the internet and communication technology in raising a new consciousness among Indigenous people in Bangladesh, referencing Amartya Sen’s five freedoms (political freedom, economic freedom, social freedom, transparency guarantees, and protective security), found compelling positive results (Ashraf, Grunfeld, & Quazi, 2015). The Grameenphone Community Information Center’s (GPCIC) programs, for example, created new opportunities in “income generating activities, education, health, improved transparency and disaster warnings” (Ashraf et al., 2015, p. 12). A young man from the GPCIC program shared his view of how the program benefitted his single mother:
My mother runs the family since my father passed away many years ago. She is the only earning source of our family who makes and sells handicraft goods. Since she is getting older, I thought to help her by any means. One of my friends from GPCIC told me that an Internet website could be an alternative way to sell handicraft goods. I joined GPCIC, learned website designing, and used this skill in selling the products. This helped me boost sales and thereby enabled me to better help the family.
(Ashraf et al.,2015, p. 9)
In Australia, through a culturally sensitive and appropriate process of engagement and sampling of study participants in a remote locality in the Northern Territory, insights into the interaction between technology and Indigenous people can reveal how digital public health interventions are perceived (Kariippanon & Senior, 2017). The potential of digital public health interventions is often limited by a lack of dialogue between health services and target audiences. Health service providers discreetly fear online discussions, as they may provide an uncensored platform for critique, which may hurt the reputation of the health service provider (Kariippanon & Senior, 2018). When public health content is designed to factor in a conversational process by using new methods, such as ethnographic filmmaking which captures interactions, discourse, performance, narratives, body language, culture, law, and ceremony, the messages are found to be better suited to Indigenous populations in a culturally relevant manner.
Ethics of Conducting Research With Indigenous People
The history of research with Indigenous people was historically a tool and strategy for colonization (Tuhiwai-Smith, 1999). Unsustainable developments have historically plagued Indigenous people, and Grenier (1998) suggests that this is due to a lack of Western researchers consulting with stakeholders and incorporating Indigenous knowledge.
The use of community-based participatory research (CBPR) and tribal-driven participatory research (TDPR) methods in the Indigenous context has become a highly sought after method that acknowledges the different ways of being and knowing while being flexible in its approach to the evaluation of interventions (Richmond, Peterson, & Betts, 2008; Wilson, 2008; Thomas, Donovan, & Sigo, 2010).
The Australian Institute of Aboriginal and Torres Strait Islander Studies’ guidelines for ethical research urge researches to consider nine main categories when designing research initiatives in partnership with Indigenous people or Indigenous organizations. Researchers must provide clear explanations in their research protocol on how these requirements are met. The categories are as follows: consultation, negotiation, mutual understanding, respect, recognition, involvement, benefits, outcomes, and agreement (AIATSIS, 2018). The Canadian approach is similar to the Australian process in that a comprehensive ethical framework for research is provided. The need for community-informed consent, research agreements, and protection of communities’ cultural and sacred knowledge are front and center of the framework. Ethical guidelines also include stem cell research and best practices for research involving children and adolescents (Government of Canada, 2019).
Research partnerships with Indigenous communities can be complex and require transparent, long-term relationships where trust-building and rapport are established before any research is conducted. The intricacies of building trust with the Native American communities in Montana, for example, involves sharing power while embracing a mix of stakeholders such as tribal members, health care professionals, and Native and non-Native researchers (Christopher et al., 2011). Tribal governments are now in a viable position to conduct and manage their research agenda to achieve their goals. Their efforts are consistent with the core principles of TDPR, which must involve a full partnership between researchers and the community of interest through the life of the project,, from planning through implementation and evaluation (Mariella et al., 2009).
In distinguishing generic research from TDPR, or CBPR, a typical research program involves the approach of “experts” who come into a community to gather information and leave (helicopter research) or where outside researchers visit a community, gather limited information, and leave with their data as “trophies” (safari research) (Mariella et al., 2009).
The International Society of Ethnobiology (ISE), cited by Willcox et al. (2015), provides a set of questions for researchers to reflect upon at each stage of the research process. According to Willcox et al. (2015, p. 285), respecting “intellectual property rights is possible even in a context where the knowledge is not owned by a clearly identified person or group of people, and when plants are not being developed for commercial purposes.” Mutual trust is essential between researchers and the communities through the use of agreements on benefit sharing. A brief overview of the ISE Code of Ethics is provided here. Further details can be found in Bodeker, van ‘t Klooster, and Weisbord, (2014, pp. 817–818):
1. Prior rights and responsibilities;
4. Traditional guardianship;
5. Active participation;
6. Full disclosure;
7. Educated prior informed consent;
10. Active protection;
12. Reciprocity, mutual benefit, and equitable sharing;
13. Supporting Indigenous research;
14. The dynamic interactive cycle;
15. Remedial action;
16. Acknowledgment and due credit; and
Recognition of community values and goals, particularly regarding collective harm, and the development of full partnerships between institutions and communities is essential to keeping with the core principles of CBPR and TBPR. Along with these, encouraging community participation in all aspects of the research through skills transfer and building research capacity would ensure that research and its findings are sustainable, beneficial to the community, and conducted respectfully (Mariella et al., 2009).
A common pattern is observed when studying the variety of country cases that have implemented an integrated approach to healthcare provision vis-à-vis the inclusion of Indigenous voices and knowledge of traditional and complementary medicine. The integration of traditional and complementary medicine ranges from organizational or high-level policy implementation to community-led grass-roots efforts, with assistance from a range of diverse professionals, both Indigenous and non-Indigenous. A research gap that may potentially be of importance is in regard to the development of small- to medium-scale business models that can be sustainable and generate income for Indigenous communities globally as well as enhance their contribution to the local economy. The impact of social entrepreneurship on health outcomes manifests itself through capacity building and strengthening local agents of social change to act where governments and not-for-profits have not been successful. The small- to medium-scale business models utilize an interdisciplinary framework to solve complex health and socioeconomic problems. Some entrepreneurs still rely partly on philanthropic funding but the aim is to become self-sustaining and to create employment while raising social and human capital in resource-poor settings (Hsiao, Lee, & Chen, 2016; Lim & Chia, 2016)
The advancement of the global public health status of Indigenous people lies in the self-management of Indigenous health services. It includes the employment and training of a skilled local health workforce. Indigenous people have a right to incorporate and determine what are culturally appropriate and sensitive public health interventions as well as health services that are relevant to their local context. Professionalization of the Indigenous health workforce and a more nuanced local approach to public health interventions have resulted in raising a positive community identity of self-determined Indigenous nations. A flow-on effect of self-management has resulted in many Indigenous-led designs of interventions, health education resources, online communications, and the use of the internet and mobile technology to engage with hard-to-reach populations.
A call for Western biomedical frameworks to seek out and enable partnerships with Indigenous knowledge systems, as well as integration of traditional medicine as part of these partnerships’ core business is becoming a common phenomenon in many Indigenous contexts. The employment of youth as peer outreach and health workers, equipped with smartphones and in-depth knowledge of the culture, tradition, and language of their people, as well as possessing evidence-based medical skills, is becoming an increasingly common practice in many countries.
The Indigenization of the concept of well-being has implications for future research. In the future, it will be important that Indigenous-led research investigates local meanings of well-being in order to create more complex public health planning that incorporate Indigenous knowledge systems and cultural aspirations. Such research is respectful and beneficial to Indigenous people only when done in partnership and involving multiple stakeholders, particularly Indigenous researchers and their governing organizations.
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