Misguided Medicine

The Lancet, Vol. 367, Issue Nos. 9524–9527, May 27, June 3, 10, and 17, 2006, London M

The Lancet, a 183-year-old peer-reviewed publication which boasts 37,500 print subscribers and more than a million registered online users, is typically lauded for printing groundbreaking scientific research. It also has a long tradition of controversy. In the 12 years since he’s been at the helm, Editor in Chief Richard Horton has attracted headlines by publishing articles at the intersection of politics, policy, and medicine. Most recently, The Lancet caused a stir when it published a report that 655,000 Iraqis had been killed since the United States invaded the country in 2003.

Last summer, Horton took up a new cause. He proclaimed "an overwhelming need for action" to better the health of the world’s indigenous peoples and published a series of six papers to document the crisis. Under the headline, "Indigenous peoples: time to act now for equity and health," Horton summed up their key findings: Compared to non-indigenous populations, life expectancy is lower, afflictions such as respiratory disease and diabetes occur more frequently, and access to health services and education is grossly inadequate for indigenous groups.

Unfortunately, Horton’s call to arms is both scientifically dubious and politically ill-advised. He claims there are 370 million indigenous people spread throughout 70 countries who account for 6 percent of the world’s total population. And yet, he never clearly defines who falls into the category of "indigenous." It is surely no small problem when you can’t quite say exactly what you are talking about, or whom you are counting.

The Lancet’s contributors would not speak of the French or the Dutch, for instance, as indigenous to their own countries. When talking about the Americas, Australia, and New Zealand, they have in mind the pre-colonial inhabitants of these regions. But who counts as indigenous in Africa and Asia, where there have been multiple waves of migration throughout history? Does the category exclude some ethnic groups that have lived in a region for hundreds of years? How does one distinguish whether someone is more or less indigenous than another?

All the papers in The Lancet’s series struggle inconclusively with this intractable question. If indigenous people are "nomads or hunting people," as former U.N. Secretary-General Boutros Boutros-Ghali once declared, that would exclude most of the populations that The Lancet writers call indigenous. Can they be defined by religion? Most of the subjects of The Lancet’s studies are Christians. Language? Many Australian Aborigines and Inuit speak only English, many Amazonian Indians only Portuguese or Spanish. Do they preserve the essential elements of a precolonial way of life? That would exclude most Native Americans. In one of The Lancet’s papers, the authors let themselves off the hook by citing a statement by the U.N. Permanent Forum on Indigenous Issues: "[I]n the case of the concept of ‘indigenous peoples’, the prevailing view today is that no formal universal definition of the term is necessary."

It is scarcely plausible that a category of people identified so vaguely should share common problems. In an overview of the six papers in The Lancet, Horton concludes that life expectancy is lower for indigenous peoples than others, citing three examples of special risks they face: "Maori (heart disease), Canadian First Nation peoples (intentional self-harm), and Native American and Alaskan Natives (assault)." Clearly these are not problems that go hand-in-hand with being indigenous. And there is no evidence that any of these afflictions are shared by all, or even many of the populations identified as indigenous. Nor is it apparent that the health problems of indigenous populations in any country are worse than, or even different from, those of other disadvantaged minorities — "untouchables" in India, or the Roma of Eastern Europe, for instance. The real causes of many public health problems are more likely to be social factors, such as poverty and discrimination. These are hardly unique to indigenous peoples.

The poor, the hungry, and the ill-served need attention, no matter what their ancestry. If a particular population is targeted on the basis of descent, priorities will inevitably be distorted in health spending. Why should special health services be allocated to Native Americans in the United States rather than to African Americans in rural Mississippi? Should every descendant of Native Americans receive special allocations regardless of his or her individual wealth and well-being? The issues are starker yet in poor countries that have meager health budgets. The government of Botswana, for example, has set up regional clinics that offer some emergency provisions to all comers in the Kalahari Desert. Does Horton think it should divert funds to provide more money for the Bushmen or some other ethnic group in the region?

But there is an even more fundamental problem. The Lancet struggles with the fact that no formal universal definition will fit all the indigenous cases the journal wishes to include. Instead, its contributors fall prey to a political definition that has been concocted only recently. In Europe’s older colonies — the Americas, Australia, and New Zealand — descendants of original inhabitants are minorities who have commonly suffered from discrimination. In the 1990s, they banded together in an international "indigenous peoples’ movement" and invited others from Asia and Africa to join. Appealing to post-colonial guilt, this movement has made remarkable political progress. The United Nations even established its Permanent Forum on Indigenous Issues six years ago. The lobby’s objectives have also been embraced by the green movement, which hopes that hunters and gatherers can live in harmony with nature if ancestral lands are restored to them.

It seems that these activists are in the thrall of Victorian anthropologists who patronizingly believed that there was a chain of "primitive peoples" in remote corners of the globe who all had the same customs and beliefs. In a revealing passage, one of the papers in The Lancet claims that "indigenous peoples have been the guardians of our environment and its medicines for thousands of years, built on a holistic communal view of humanity and its links to the ecosystem." In other words, wherever indigenous peoples are found they must have the same values. Yet the Pygmies of the Ituri have far less in common with the Inuit of Alaska than they do with their farming neighbors, whose language they share and with whom they have interbred for centuries. On most counts, the Maori are unlike Kalahari Bushmen and much more like white New Zealanders, who have a good reputation themselves for ecological sensitivity, social responsibility, and indeed medicine (or, at least, the kind of medicine that The Lancet usually promotes).

These romantic and unscientific notions do not provide a sound basis for much of anything, let alone analysis. The Lancet should determine its targets more carefully if it is truly interested in expanding its coverage from medicine to policy prescriptions.