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J R Soc Med. 2007 May; 100(5): 248–250.
PMCID: PMC1861414

Of indigenous people and their health

‘Indigenous’ is the politically correct version of the word ‘native’, used by the white man in reference to the peoples he ‘discovered’ upon exploring and subsequently colonizing the globe. The word native had, until the middle of the 20th century, the connotation of primitive and uncivilized people, recognizable by virtue of skin pigmentation. The replacement word, indigenous, came into use during the independence movement and has acquired several new connotations. The indigenous have suffered and continue to suffer injustice, they are disadvantaged, ‘challenged’, and must be helped to attain the ‘civilized’ status of Western man, as measured by means constructed by Western man—such as the human development index, the Disability Adjusted Life Years (DALY) rates, and ultimately, life expectancy at birth. Indigenous people should attain equity in all the ‘civilized’ achievements.

Western man has bestowed his technology upon mankind, yet this must not be done in a coercive manner, for indigenous cultures are precious and their survival must be guaranteed.

For millennia, health was a matter of luck: good genes, adequate and appropriate nutrition and a low risk environment were the guarantors of a low DALY rate and long life. In the contemporary world, health is a function of wealth, and except in a few countries where the welfare state is reasonably functional, the poor are disadvantaged. The indigenous (except for the predatory elite that rule them) are poorer than the poor living in the western world.

Culture is the uniquely human continuation of evolution: the ability to formulate concepts, to organize and to invent technologies. The purpose of culture is to enhance the chances of survival, to live longer and better. Western man—or rather, Northern man, for what applies to the whites applies to the Chinese as well—largely because of the challenges and the opportunities presented in the ecological niche that became available upon the retreat of the ice, developed a culture that, principally because of its technology and organization, and probably because of its aggressive religion, eventually conquered the world.

In terms of political power, the conquest was short lived: the very ideas and religions Western man was disseminating among the indigenous defeated his attempts to lord over them.

In some parts of the world, Western man settled and mixed with the indigenous, for example in South America, where he also imported Africans; in others he tried to exterminate the locals, for example North America and Australia, where the indigenous population survived until lately, a neglected minority; in other places again, where the natives had overwhelming numbers, he tried to maintain a separation of races, for example Africa and Asia.

The indigenous do partake of the blessings of Western culture, and even if they profess to despise it, most of them covet Western technology and crave education and medical care. Most of them have a longer life expectancy than they had before the arrival of the conqueror, bearing his gifts. Among these gifts were the secrets of reducing child mortality. In consequence, among the indigenous, the rate of population growth has accelerated and the demographic composition of the population changed dramatically, posing an enormous hurdle for development.

The disadvantages of the indigenous are many and varied; chief among them are the ecological niche in which they developed, pre-colonial history (a sequence of invasions and colonization by others, not classified as indigenous), colonial history, the presence or otherwise of natural resources, geographical position, the degree of discrimination and humiliation they have experienced and still experience, and their own culture. With the exception of the cultural constraints, the other factors hindering equity of access to education and medical care—given good will, ingenuity and investment—could be eliminated.

One would have thought that if the indigenous people wanted to partake in the ‘civilized’ achievements of Western culture as represented by the life indices, they should pursue their integration into Western culture with vigour and discard their cultural heritage, or at least those elements of their cultural heritage which have lost their survival value and have become maladaptive.

Many of the indigenous do not want to integrate into Western culture; they want to maintain their identity and adhere to their customs and rituals, their heritage. There are several reasons for this attitude, among them conservationism, the abhorrence of change; the permanence of ancient power structures; the still-surviving slogans from the days of the struggle for independence; the anti-colonialism campaign; post-modernist ideology both in the West and among the indigenous; official UNESCO policy; and the concept of multiculturalism. The fact is that many of the indigenous are disadvantaged, not because of the deprivations caused by the conquest of Western culture, but because of their adherence to their cultural heritage.

Westerners often romanticize indigenous cultures. Presently the East African pastoralists are the most admired (the Masai, Samburu, Rendile, Turukana). No doubt, for thousands of years the nomadic pastoralist cultures were the most successful in Africa: storing wealth on the hoof and following the storm cycles over hundreds of miles was superior to farming because predation, including parasites and microbes, was less severe; food security was easier to achieve; the people had access to much more protein than did settled farmers; bones, sinew and hides were readily available for use in arms and armour; and the social organization and availability of a class of warriors allowed large scale raids.

The nomadic pastoralist cultures were almost entirely destroyed by the missionaries, the creation of boundaries (international or internal), the provision of abundant water at fixed points (the convergence of large numbers of stock devastated the land surrounding the watering point), and many other developmental activities, including schools.

Many of the pastoralists try to adhere to their culture and do not notice that many of their customs have become maladaptive. In terms of health, life expectancy and DALY, adherence to customs is a much greater problem than is access to medical care. The umbilicus of the newborn is covered with cow dung, as are all manner of wounds. The body hygiene of children is appalling even when water is not a problem. Dogs are allowed—sometimes even encouraged—to lick children clean. Circumcision of boys may have fatal consequences. Female genital mutilation may also be fatal, but it certainly causes anaemia, infection, and scarring, and can cause urethral and vaginal obstruction. The instruments used for circumcision may transmit infection, including HIV. Pregnancy and childbirth in adolescent girls carries a high complication rate, including vesicovaginal fistula. The licensed promiscuity among the young is responsible for the high rate of STDs and HIV. Competitions bravely indulged in by the young warriors lead to foolhardy risk taking. All work not related to domestic animals is the exclusive responsibility of women: they have to find the food, other than milk and blood (and the occasional meat); they carry water and fuel; cook; build the dwellings; pack and load and carry belongings. The contemporarily pastoralists also cherish the tradition of raiding and cattle rustling practices, which at one time, when killing and being killed was limited to warriors, were adaptive, but when carried out with Kalashnikovs and with the aid of pick-up trucks and mobile phones, amount to high tech, brutalized—if still ritualized—large scale mayhem.

There are countless examples of the counter-productivity of many indigenous cultures. ‘Saving’ cultures does not save people, does not save lives, and does not help to prevent disease. Westerners have discovered that if they want to avoid chronic degenerative disease and live longer than they presently can expect, they have to change their lifestyle. If the pastoralists of East Africa, the Bushmen of the Kalahari, the Pygmies of the Ituri forest, want to adopt the human development index and want to improve their position according to that scale, they have to change their lifestyle.

All the indigenous peoples of the world covet Western technology and try to incorporate that technology into their cultures, but will resist adopting the thinking and the attitudes without which that technology would not have been invented.

No doubt the indigenous are disadvantaged, at least according to the measuring systems invented by Western man, but the lack of equity in the matters of education and health does not arise from the failure of social justice alone, and hence the matter is not solely a moral issue. It will be argued that stubborn adherence to customs that have lost their survival value, and may never have been adaptive, is in itself the result of poverty and a lack of education. This is only partially true. Moreover, the lack of education may in itself be the result of adherence to custom!

Pastoralist boys learn to look after goats and sheep from the age of five and six. This may be regarded as child labour, and is abhorred by the very same Westerners who want to save cultures and save children. The pastoralists look upon these boys as apprentices who are undergoing intensive training in traditional animal husbandry and associated matters such as weather forecasting, botany, animal behaviour, wildlife, veterinary problems and the use of weapons (traditional and modern). Whilst the boys tend to livestock, the girls are engaged in the household. Looking after the cattle requires but a few men. The rest of the men, if not engaged in ceremonies or raids, have nothing to do. The elders oppose education for they know that education will lead to integration into a ‘Westernized’ culture, and that this will erode the ancient structure of power.

Politicians talk about cultural heritage and value systems superior to Western culture, and about cultural identity, but they also talk about development, health centres, schools, abundance of water, veterinary services, roads, mobile telephone network and security. The Western-inspired developmental agencies are split into two groups: integrators and developers. Integrators believe that the old pastoralist culture, together with population increase and the increase of the herds, is responsible for environmental degradation—desertification of the Sahel and the Horn of Africa. They think that land use has to change, and that there is no room for the old culture. They think that indigenous cultures hinder human development, and that the warriors would make good night watchmen, policemen, soldiers, truck drivers, pilots and could be an asset to the national economies. Many of these integrators are of indigenous origin: they are educated, westernized and often unwelcome at home. The developers, on the other hand, are mostly young Westerners. They would like to provide health services and education, but at the same time would like to preserve the culture which awes and fascinates them. The developers often behave like conservationists, who want to save a certain species—say the rhino—in its natural habitat; for this purpose they create a fenced sanctuary, but at the same time supplement nutrition and provide veterinary services.

In the meantime, the East African pastoralists have been discovered by the tourist industry. Ethno-tourism is popular. A good safari is not only a matter of big game, but also of Masai dancers. Visits to manyattas (from which the most ubiquitous artefact of the contemporary world, plastic, has been carefully removed) are key. ‘Pichurrure! Pichurrure!’ shout the culture hawkers, and the girls baring their bosoms charge a premium.

There is nothing wrong with ethno-tourism per se. Tourists flock to Buckingham Palace to see young men wearing bearskin headgear, to Holland to see buxom maidens with wooden clogs dancing, and to Cherokee in the Smoky Mountains to see a venerable redskin decorated with eagle feathers. Everyone knows that this Cherokee, the Dutch ladies and the guardsmen arrived by car, bus or tube at their place of work and changed into cultural gear at their workplace. Perhaps this is the way forward for the Masai... to be videoed when shooting an arrow into a neck vein of a bullock and collect blood in a gourd, whereas normally they use a razor blade, made in China, and a plastic jerry can; or to be filmed when labouring with sticks of wood to make fire, when they actually have a lighter in their pocket. Looking at it from this angle, the exhibition of elements of picturesque and exciting indigenous cultures does have survival value: it can be sold.

The guardsmen and the Dutch girls do enjoy equity in access to education and health care. The old Cherokee may be less lucky, but even he looks upon the display of the defunct culture as a job. They do not identify with the cultures which they are paid to exhibit. The post-modernist dictum is that without the culture of the Masai, the Pygmies, the Bushmen, the Amazonian Indians, the Eskimo, the Papuans, the Maori and the varied Australian Aborigines, the world would be impoverished. So it may be. But keeping cultures alive, cultures that have failed in the struggle for survival—even if this was the result of invasion—impoverishes the people representing that culture, may perpetuate discrimination and will prevent equity in education and medical care even in the face of a new wave of moral rearmament.


Since writing this article, Dr Loefler has sadly passed away.

Articles from Journal of the Royal Society of Medicine are provided here courtesy of Royal Society of Medicine Press