Identity (within an indigenous context) refers to a large body of collective experiences. In its relation to culture, they are both constantly evolving; they are not fixed in time or location, but are constantly co-created and renegotiated within the context of broader society. For instance in relation to health, indigenous peoples define wellbeing far more broadly than physical health or absence of disease. The four elements of life—the physical, emotional, mental and spiritual—are represented in four directions of the medicine wheel, that are intricately woven together and interact to support a strong and healthy person.
An indigenous notion of healing process extends beyond the individual realm such that good health and healing require that an individual live in harmony with others, their community, and their spiritual side. All these factors interact to give a very different notion of health to what it means for their non-indigenous counterparts. As the definition of indigeneity is inherently social, and includes major elements of cultural identity, being isolated from aspects of this identity has negative impact on health of indigenous people.
However, in Nepal identities and cultures among indigenous communities are being interpreted through another society’s values and agendas. As late Harka Gurung said in his article Social exclusion and Maoist insurgency: "It was not the state but the donors who identified social exclusion, in addition to poverty as a factor of conflict."
Such identity deficits among indigenous populations are associated with negative health outcomes. Indigenous health inequalities not only arise from general socioeconomic factors but also in combination with culturally and historically specific factors particular to the peoples affected. The systemic devaluing of indigenous identity, indigenous knowledge, languages, and traditions; and the legacies of these and other policies of forced assimilation, disconnection from the land, lead to deterioration of overall wellbeing of indigenous peoples.
Language is crucial to identity, health and social relations. It is especially important as a link to spirituality, an essential component of indigenous health. However, the constitution of Nepal (1990), article 6.1 and 6.2 as stated by Late Harka Gurung embodies cultural discrimination, particularly with reference to language.
Moreover, the UNDP Human Development Index (HDI: health, education and income) between 2001 and 2006 saw a widening gap between the advantaged and disadvantaged regions, castes and ethnic groups. The inequality-adjusted HDI from the most recent Human Development Reports in 2010 and 2011 also report high inequalities within Nepal. Such disparities and discrimination by the state questions the validity of international ratifications such as the International Convention on the Elimination of All Forms of Racial Discriminations (ICERD), Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW), International Convention on Economic, Social and Cultural Rights, ILO 169, UN Declaration on the Rights of Indigenous People, etc.
Suppression of indigenous peoples and their rights can be seen as a fundamental health determinant. The wide variation in rates of addictive behaviors, sexual and gender-based violence and other indices of distress across indigenous and dalit communities suggests the importance of considering the nature of communities and the different ways that these groups have responded to the continuing stresses of suppression, bureaucratic surveillance and technocratic control.
The mediating mechanisms contributing to high levels of emotional stress, depression and anxiety are closely related to issues of individual identity and self-esteem, which in turn are strongly determined by collective processes in the community or larger political entities. Research has shown that addictive behavior has strong inverse proportional relation to socioeconomic status. Addictive behaviors provide the rewards that disadvantaged people are not otherwise getting as a result of their diminished social opportunities. Addictive behaviors also provide an escape from chronic stressors and are a form of self-medication. For many indigenous people, there are many layers of stressors such as racism, poverty, poor education, unemployment, family instability, and residential instability.
Many push-and-pull factors determine the patterns of rural-urban migration in indigenous peoples. The push factors that prompt individuals to move from their traditional communities include unemployment and the consequent poor social and economic conditions; low quality of life; scarcity of housing, health facilities and educational opportunities; and political pressures. Factors pulling people back to their communities include the failure to find employment or otherwise thrive in the city, the absence of affordable or acceptable housing, and the perception that rural communities are better places to live and raise children.
Emotional and spiritual connections to the land and culture are also major factors drawing people back to their origins. In view of these social difficulties and evident distress in the communities, social scientists speculate that culturally mediated ways of expressing depression might not be identified by standard surveys. These interactions between mental, emotional and spiritual stress and physical health are important for indigenous health. Interactions and co-morbidities between mental and physical health are also important. Mental health disorders are known to amplify the effects of physical disorders. In this connection, identity is a necessary prerequisite for mental health.
It has been found that identity deficit among indigenous people is associated with negative health outcomes.
Although the root causes of poor health (i.e. the social determinants) are important, the classic socioeconomic indicators of social determinants (for instance, income, education, employment, living conditions, social support and access to health services) are not the only factors determining health among indigenous peoples.
Social capital and resilience are also important relational notions that affect health. Social capital refers to sociability, social networks, and social support; mutual trust, reciprocity, and community and civic engagement. Resilience is what keeps people strong in the face of adversity and stress and has many indigenous facets: spiritual connections, cultural and historical continuity, and ties with family, community, and the land. Continuing transformations of identity may have catastrophic effects. Therefore, attempts to recover power and to maintain cultural traditions must contend with the political, economic, and cultural realities of consumer capitalism, and technocratic control.
Thus disadvantaged populations should be enabled to control their destinies, which is crucial to maintaining self-esteem and health: Autonomy is closely linked to self-esteem and respect. As low levels of autonomy and self-esteem are likely to lead to poor health, working in the area of indigenous health has political implications and often involves challenging government policy and community attitudes which have the potential to negatively impact people´s social, emotional, cultural and spiritual wellbeing. Based on these premises, I believe identity-based federalism (one which addresses important identity questions) would best serve the health needs of indigenous communities.
The author is a Phd student in Preventive Medicine and Epidemiology, University of Oslo
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