The health of indigenous peoples globally is intricately related to their ecosystems and the complexities of their social and economic circumstances. All over the world, indigenous peoples often face extreme poverty with all its multiple dimensions and implications, that make them among the most marginalised and vulnerable human populations. And yet they control a wealth of knowledge of their ecosystems, including knowledge of their native foods, that merges with health and healing knowledge embedded in local culture and practice. This knowledge is a resource of truly global proportions to be used for their benefit. It also is of immense potential benefit to more economically privileged populations such as those in high-income countries that have lost touch with natural sources of food and their value and function in maintaining health and protecting against disease. Indigenous peoples have much to teach the industrialised world.
This paper describes how indigenous peoples and their academic partners in 12 rural regions (Fig. 1) think about protecting, using, developing and sustaining local food system knowledge for improving well-being and health in their communities, and thus also protecting their culture. It is a report of a meeting of partners held in the St. Lucia Futululu Centre as a Pre-Congress Safari of the International Congress of Nutrition in September 2005. The meeting was an activity of the Task Force on Indigenous Peoples' Food Systems and Nutrition of the International Union of Nutritional Sciences. The list of authors (Appendix) reflects the breadth of indigenous community and academic partners who contributed to the content.
Fig. 1 Location of indigenous peoples for case studies
In general, the nutrition and health of indigenous communities is among the worst of all communities, in any countryReference Stephens, Nettleton, Porter, Willis and Clark1. This situation is not helped by a rather over-simple view, among the public health authorities responsible for the health of indigenous peoples, that their nutrition-related problems are largely confined to stunting and micronutrient malnutrition in middle- and low-income countries, and to obesity, diabetes and its complications, and dental caries and tooth loss, in high-income countries. These problems do exist and are important, but are only one part of the story. Also, indigenous communities do have their own resources and knowledge that should be nurtured.
Our project proposes that the long-evolved food systems of indigenous peoples amount to a treasure of knowledge that is typically overlooked and undervalued; which has potential benefits for the well-being and health not only of indigenous peoples themselves, but also industrialised and other populations. This perception is now becoming more widely shared.
Thus, a principle suggested for ‘the new nutrition science’, an initiative of the International Union of Nutritional Sciences, is: ‘All nutritional theory, policy and practice should take into account, the diet-related evolutionary pressures that shaped the biological evolution of the hominid line and, eventually, Homo sapiens’. Another suggested principle, of direct relevance to long-evolved indigenous food systems, is: ‘Food and nutrition practices consistently followed in different cultures in history are probably valid – though not necessarily for the reasons given. They do not require proof to be accepted; they require disproof to be rejected’Reference Leitzmann and Cannon2.
Focus on the problems
The evidence base of the health status of indigenous peoples worldwide needs to be strengthened. Many middle- and low-income nations do not yet accrue health data by ethnic group. That said, data compiled for children in the Americas clearly show infant mortality 20 to 500% higher than country averages, and stunting 20–360% higherReference Damman, Eversole, McNeish and Cindamore3. In North America, Australia and New Zealand, obesity, diabetes and associated chronic diseases affect indigenous populations in higher proportions than the non-indigenousReference Ross and Taylor4–Reference Lee, Bailey, Yarmirr, O'Dea and Mathews7.
Reasons for these increased prevalences include changes in food, nutrition and physical activity levels and a general shift away from traditional ways of life. There is also evidence of accentuated genetic vulnerability.
Thus, in Canada since the 1940s, there has been an increase in permanent settlements for indigenous peoples, leading to a dependence on purchased ‘market’ and ‘store’ foods and a decrease in the importance of foods derived from hunting, fishing, gathering and traditional agriculture. Diets have become more energy-dense and higher in fats, sugars and salt contained, for example, in soft drinks and snack foodsReference Kuhnlein and Receveur8,Reference Ritenbaugh, Szathmary, Goodby and Feldman9.
Environmental, social and economic conditions profoundly impact the health of indigenous peoples. While life expectancy has improved for Canadian indigenous peoples in recent years, virtually all health status measures for every health condition are still worse for First Nations, Inuit and Métis than the overall Canadian population, with poorer conditions for education, employment and average income being key determinants10. Over 80% of Canadian First Nations and Inuit respondents to a health survey agreed that attention to and practice of traditional ways of life would help promote community well-beingReference Svenson and Lafontaine11, and that disconnection from health services must be remediedReference O'Neal, Leader, Elias and Sanderson12.
These well-attested concerns occur in the midst of global alarm about increasing obesity and chronic disease which affect rich and poor alike because of globalisation of food systemsReference Popkin and Gordon-Larsen13, and which can be triggered by foetal impairment in areas of poor nutritionReference Barker14. As the poorest of the poor in most nations, indigenous peoples are especially vulnerable to effects of the combination of foetal and infant undernutrition followed by energy-dense infant and childhood foods.
To develop strategies for prevention and management of conditions and diseases such as stunting, micronutrient malnutrition and diabetes and its correlates in indigenous populations, food security15 and health care must be improved. Indigenous peoples are themselves well aware of their risks for food insecurity. At an international meeting held in Atitlán, Guatemala in 2002, difficulties and frustrations with protecting their food environments and livelihoods were eloquently described by indigenous leaders, who called for global action to promote food sovereignty for indigenous peoples, and to protect traditional lands and food resources16,Reference Kuhnlein, Erasmus and Kalafatic17.
Indigenous communities contribute solutions
Our work addresses the local food systems and the well-being and health of indigenous peoples in 12 deliberately diverse settings, where undernutrition and/or overnutrition are of concern. It is concerned to find ways for community empowerment, development, and self-sufficiency to improve knowledge and understanding of good food, so that it becomes more available and accessible and used in ways that improve health.
The objectives universally embraced by community leaders in the group include the use of indigenous food resources to encourage, educate and build capacity for increasing dietary quality of youth, adults and elders; and working towards making local cultural food resources sources of community pride, pleasure and responsibility, thereby ensuring local determination and sustainability of intervention effort.
In areas where obesity and diabetes are common, increasing physical activity and reducing the purchase and consumption of poor-quality, imported and refined ‘market’ and ‘store’ food (refined foods oils, sugared beverages and other energy-dense processed foods, including those high in fat/sugar/salt content) are targets, as are improving knowledge of, access to and use of local cultural food.
The overall ultimate goal of the Task Force and the project is to provide evidence to show that indigenous peoples' local and traditional food systems are central to public health improvement, and require policies at local, national and international levels for protection of food environments to ensure food security and qualityReference Kuhnlein, Johns, Spigelski and Erasmus18,Reference Englberger, Marks and Fitzgerald19.
There is impetus for increasing knowledge of, access to and use of local food resources by indigenous peoples. This comes from the United Nations Human Rights CommissionReference Eide, Eide and Kracht20, the Permanent Forum on Indigenous Issues21 and the International Decade of the World's Indigenous Peoples and its renewal, and other sources22. Further, the United Nations' Millennium Development Goals urge attention to many principles affecting indigenous peoples (reduce hunger, sustainable development, child and maternal mortality, empowerment of women, access to nutritious food, etc.)23; and the UNEP Convention on Biological Diversity targets indigenous and local peoples' food systems for environmental protection24.
Such programmes address indigenous peoples' food security issues, but do not include any fully developed plans amounting to a blueprint on how to go about the basic, formative research and community-level education and development required for addressing these problems. Our Task Force and the meeting have accepted this challenge. This is to improve health and nutrition using a multidisciplinary, holistic approach grounded in collaboration with community leaders and women, who are the custodians and users of local food, and their academic partners. This paper is the result of extensive consultation among the 12 case studies of diverse cultures and ecosystems for a wide variety of community ideas and reflections on intervention activities and project evaluation. It presents needed perspective on how to go about improving nutritional health of indigenous peoples within local cultures and ecosystems.
This project evolved from the desperation expressed by indigenous peoples at the loss of food resources that are integral to their evolved cultures and ways of life. This cry, echoed by elders, leaders and youth, is that indigenous peoples can survive as cultures only with rights and access to their land and knowledge and ability to make full use of the food it provides.
Food relates to social needs and local economy. Indigenous peoples have their own unique perspectives on the relationships between environment and culture, and food, well-being and health, in many dimensions. This knowledge is precious to them. It also has many lessons for industrialised nations and populations.
There is a clear imperative to protect unique food resources and their diversity. There are 300–500 million indigenous peoples in more than 70 countries around the world, representing over 5000 languages and cultures on every continent, and each cultural food system may contain up to 250 species of traditional food alone (among additional bioresources for medicines and life ways). This knowledge base is a treasure worthy of global attention and protectionReference Kuhnlein and Receveur8,Reference Cobo25.
One way forward is to provide evidence and documentation of successful food-based interventions that have had and are having the effect of improving the well-being and health of indigenous peoples, especially in rural communities where indigenous foods and knowledge of its nature and value are still present, and where protection policies can be effective.
Our work deals with the holistic knowledge of and beliefs about food, well-being and health held by indigenous peoples. It recognises that food touches on the physical, psychological, social and spiritual dimensions of all age and gender groups in community life. Therefore, it is essential to build community support and action for sustainability and for self-determination that ‘makes sense to us’, and can build wellness and dignity to local ways of knowing what a valuable and healthy life is. The project strives to identify commonalities, differences, priorities and challenges in a diversity of communities wanting to increase knowledge of, access to and use of their local food. In this way it should be possible for individual communities to improve their well-being and health, and also make a contribution to the improved well-being and health not only of other indigenous communities, but also of industrialised populations.
Indigenous community and academic partnership
Each of the case study communities, containing 500–3000 members, have partnered with an academic in-country leader to contribute to two project phases. Phase 1 has been completed by all to date, and has resulted in documentation of the local food system using modifications to a methodology published on the website of the Centre for Indigenous Peoples' Nutrition and EnvironmentReference Kuhnlein, Smitasiri, Yesudas, Bhattacharjee, Dan and Ahmed26. Results show a staggering range of local food species and cultural styles and values for their use. (In addition to the 12 groups contributing here, the Phase 1 methods also had experience and input from the Mogh in Bangladesh, Miao in Sechuan Province of China, Aetas of Philippines, Hausas of Niger, the Zulu of South Africa, and 44 communities of Arctic Indigenous Peoples in CanadaReference Kuhnlein, Receveur, Soueida and Egeland27–Reference Kuhnlein and Pelto29).
As the current 12 case studies were completing Phase 1, plans took shape for the intervention phase (Phase 2). Ideas for interventions acceptable and appealing to communities developed first at the community level and were transmitted to the group in on-line meetings with academic partners and face-to-face meetings of the 12 indigenous community leaders and academic partners in Bellagio, Italy (2004), and during the workshop/safari in St. Lucia's Futululu Centre, South Africa (2005). To date, Phase 2 has been completed for two case studies and is in process for the others. Each indigenous community area plans interventions and measures based in local circumstances – giving an overall richness of knowledge of relevant activities that have appeal in indigenous areas. Obviously, with diversity in health conditions (e.g. micronutrient malnutrition vs. obesity/diabetes), not all activities and evaluation measures are appropriate for all case studies.
Case study partners collectively agreed that the best way to evaluate these kinds of interventions containing multiple activities is comparison of pre- and post-intervention measures. In most cases, control groups were not available with identical culture and ecological circumstances. Funding constraints also preclude working with reasonably small community collectives. This method does not permit evaluation of particular activities, but instead evaluates the entire community effort towards making a difference in health within their priorities. The ideas presented in Tables 1 and 2 are a straight compilation of point-form ideas contributed by case studies during the meeting. Although not an exhaustive list, these ideas are presented as a menu to choose from, that give insights on the breadth of activities mentioned that have appeal to indigenous communities for improving health through food access.
Table 1 Indigenous peoples' food system intervention ideas
NGO – non-government organisation.
Table 2 Indicators for measuring intervention success in indigenous communities
Successful public health work with indigenous communities depends entirely on good process. Techniques for development of community interest and participation in interventions is not the topic of this report, but it is essential for intervention success that the community informs and controls the research, and shapes it to its own prioritiesReference Ten Fingers30.
In each case, consent for the study and the project and its goals was obtained at three levels – from the collective, from each community and from participating individualsReference Erasmus, Kuhnlein, Vorster, Blaaum, Dhansay, Kuzwayo, Moeng and Wentzel-Viljoen31–33. Academic and community partners and their steering committees shared information and expertise to derive activities for interventions and evaluation measures that included both mainstream and indigenous forms of action and knowing, and that reflect community values.
In all case studies the interventions are rooted in local ecosystems and are community-driven, with inclusion of capacity building and empowerment, particularly of women, to guide strengthening of local food systems.
Ideas for interventions and their evaluation
Table 1 gives the ideas generated by participants in point form on how to improve food and nutrition circumstances in indigenous communities. It includes ideas about improving access to traditional food as well as (for higher-income regions) stimulating purchase of better-quality market food, and avoiding the pitfalls of ‘food colonisation’.
Considering the whole, it presents ideas that will likely have appeal and feasibility to indigenous peoples everywhere, although it cannot be considered a complete listing. Categories of activities are loosely grouped according to food system type, with separate categories for hunting/ gathering/fishing and agriculture-based food systems.
Table 2 presents evaluation measure ideas that evolved first from the academic partners and were explained, discussed and expanded with community leaders and health representatives. As stated earlier, the intent of the programme is to have similar pre- and post-intervention measurements, with the focus here for areas with micronutrient malnutrition and/or concerns for obesity, diabetes and related chronic diseases. In some cases consent was not given for human biological samples, because of cultural values and perceptions.
Consideration must be given to biological indicators if there is a high prevalence of malaria (cannot use ferritin) or HIV/AIDS (special blood handling requirements); in all cases consultation with public health officers is recommended before sampling. Dietary and food measures and process indicators are universally acceptable by the participants, if interview times are reasonably short. Both qualitative and quantitative data are seen as important to capture models of success in health evaluations of indigenous communities.
We offer this information for all who endeavour to improve food, nutrition, well-being and health in rural indigenous communities by emphasising food systems from the local culture and ecosystem.
Efforts to support and build local control of food resources are at the heart of the New Nutrition Science project, an initiative of the International Union of Nutritional SciencesReference Leitzmann and Cannon34.
Acknowledgements
Funding is acknowledged from the Canadian Institutes of Health Research, Institute of Aboriginal Peoples' Health and Institute of Population and Public Health, the International Development Research Centre, and The Rockefeller Foundation. We also thank Frances Davidson, Biplab Nandi, T Longvah, Siri Damman, Martina Schmid, Prasit Wangpakapattannawong, Verónica Vázquez-Garcia, Lizzy Shumba, Audrey Maretzki and Sakorn Dhanamitta for contributions to discussions. We are especially grateful to Geoffrey Cannon for editorial comments.
There is no conflict of interest.
Appendix – Full list of authors
Harriet Kuhnlein, Bill Erasmus, Hilary Creed-Kanashiro, Irma Tuesta, Lois Englberger, Adelino Lorens, Kiped Albert, Chinwe Okeke, Nkechi Ene-Obong, Igwe PE Eze, Camilo Correal, Natividad Mutumbajoy Janasoy, Hazel Nerysoo, Rose Hans, Nancy Turner, Gopa Kothari, Lalita Bhattacharjee, Motiram Chaudhary, Gail Harrison, Lindsay Allen, Salome Yesudas, PV Satheesh, Dina Spigelski, Joseph Ole Simel, Timothy Johns, Grace Egeland, Jonah Kilabuk, Laurie Chan, Masami Iwasaki-Goodman, Miwako Kaizawa, Suttilak Smitasiri and Sompop Sungklachalatarn.
