Given Australia and New Zealand have now adopted the Declaration (New Zealand also has obligations under the Treaty of Waitangi), how are the indigenous peoples of these countries faring with regard to health outcomes?

Differences in life expectancy are considered a ‘high level’ measure of health inequalities. The gap in life expectancy between Indigenous and non-Indigenous Australians in 2010–2012 was10.6 years for males and 9.5 years for females². In New Zealand the gap in life expectancy between Māori and non-Māoriin 2013 was 7.3 years for males and 6.8 years for females³. Unsurprisingly then, when outcomes from specific diseases are considered, these are also indicative of inequalities. For example, Australia’s Health 2018 reports that coronary heart disease mortality is 2.1 times higher in Indigenous Australians, stroke 1.5 times, diabetes 4.0 times, and kidney disease 3.7 times². The most recent statistics for Māori report coronary heart disease mortality is over 2.1 times higher, stroke over 1.5 times, cancer 1.8 times, and COPD 2.9 times³. Again unsurprisingly when it comes to risk factors for poor health there are also inequalities: Indigenous Australians are 1.2 times as likely to be overweight or obese, and 1.6 times as likely to be obese², Māori are almost 1.3 times as likely to be overweight or obese, and 1.8 times as likely to be obese³.

These statistics are a reminder that although there have been improvements in the health of the indigenous peoples of Australia and New Zealand over time, significant inequity still exists.

A Lifestyle Medicine approach provides the best opportunity to understand and address the causes of these inequities. While there is certainly merit in identifying and removing barriers to access to our contemporary medical system for indigenous people, and in creating services specifically focussed on indigenous health, unfortunately this system does not perform particularly effectively to improve the overall health of our population, regardless of ethnic origins. While the tools of our current health system are effective at preventing and treating infectious disease, the five leading causes of death for Aboriginal and Torres Strait Islander people from 2008-2017 were all chronic diseases, with the exception of suicide⁴(and a strong argument could be made that suicide most often results from yet another chronic disease – depression). In New Zealand, apart from suicide and motor vehicle accidents for males, the five leading causes of death for Māori and non-Māori arealso all chronic diseases³.

Our contemporary medical system is ill-equipped to address the epidemic of chronic disease. Unlike infectious disease, which almost without exception is due to the acute actions of a single infectious agent, chronic disease is due to cumulative damage from a combination of agents or risk factors. This means a system in which the standard model of care focusses on a singular agent solution is unlikely to be effective. While this model can work very well for most infectious disease, where the temporary infectious agent is removed by treatment, it does not work well at all for the chronic disease scenario where exposures can be near constant and cumulative. The current system generally offers the option of taking a medication, with various short and long-term side effects, every day, for the rest of the patient’s life. This model certainly has its advantages if your priority is to providea perpetual source of income for doctors and drug companies, and undoubtably there are benefits from a public health perspective in the small numbers of events prevented. However, from a more practical perspective, this model does not work particularly well. Even highly motivated patients will often forget to take medications – those of us who work in clinical practice will recognise it is hard enough for patients to take antibiotics as directed, even for a period of a week or less. Indeed, research suggests that approximately half of patients do not take their medications as prescribed⁵. Relatively recently, both aspirin and statins, two ‘blockbuster’ and comparatively highly effective agents, have moved from being recommended by guidelines for primary prevention to secondary prevention only. Intriguingly too, recent research has found that demographic factors may also be associated with increased risk of harm from medications – the risk of haemorrhagic events for patients taking the blood thinner dabigatran etexilate is significantly increased for Māori and Pacific Peoples⁶.

It should be clear that medicine as it is currently practiced does not hold the key to dealing with the epidemic of chronic disease in Australia and New Zealand, and nor will it ameliorate health inequities. Perhaps the most important reason contemporary medicine is proving to be largely impotent against the oncoming tide of chronic disease is because the ‘social determinants’ or ‘distal determinants’ of health are the true drivers of these conditions. Both Australia’s Health 2018 and the recent Waitangi Tribunal Report on Stage One of the Health Services and Outcomes Kaupapa Inquiry⁷ emphasise the importance of the contribution of these determinants to the health status of the indigenous people of Australia and New Zealand respectively. Indeed Australia’s Health 2018 estimates that socioeconomic factors account for over a third of the health gap between Indigenous and non-Indigenous Australians. This is still an underestimate considering there is an approximate 10.8% overlap between socioeconomic factors and ’health risk factors’ (tobacco smoking, alcohol consumption, diet, insufficient activity, and overweight and obesity), along with a 46.8% ‘unexplained component’ in their model. Adding this to what is known and accepted from a Lifestyle Medicine paradigm, namely that distal determinants of health – the physical, political, economic, and socio-cultural environments – are the true drivers of health outcomes of populations through their influence on medial and proximal determinants⁸, then it becomes very clear that emphasis on improving access and increased spending on indigenous health with a focus on more proximal determinants will be misplaced.

Indigenous Australians in 2016 had an employment rate of just 45%, 57% lived in rental accommodation, and 47% between the ages of 20-24 had completed Year 12 or its equivalent². In 2013 Māori had an unemployment rate of 10.4%, 49.5% lived in rental accommodation, and 45.1% had attained school completion³. In the same year, nearly a quarter of Māori lived in the most deprived areas, compared with 6.8 percent of non-Māori³. Clearly what is needed first and foremost, if the gap is to be closed in health outcomes between indigenous and non-indigenous people in Australia and New Zealand, is real action on closing the socioeconomic gap. As health professionals we have an obligation to recognise this, and in so doing to recognise that our craft is not a panacea for the health inequalities experienced by indigenous people. We must advocate in the first instance not for additional resources to be allocated to medical treatment, but for these to be directed instead towards the direct alleviation of poverty and socioeconomic inequality in our society.

Nevertheless, where medicine is concerned, Lifestyle Medicine approaches have immense potential to empower indigenous peoples to improve health outcomes. Happily, Lifestyle Medicine also appears more compatible with indigenous models of health. Indeed, Aboriginal, Torres Strait Islander, and Māori peoples have recognised the importance of a holistic approach to health that we have come to categorise as ‘Lifestyle Medicine’ for generations, and have been shielded for the majority of their history from the pervasive influences of industrial-age thinking, germ theory, and the emphasis on individual endeavour and responsibility that characterise Western medicine. In Australia’s Health 2018, the following statement is made concerning the Indigenous Australian perspective on health: