Today is “Indigenous Peoples’ Day”.

It’s currently reckoned that we share our precious world with around 370 million human beings who are ethnologically designated as being ‘indigenous’. That's a lot of people – a number that’s a good 10% more than the population of the United States (which contains its own indigenous population of course), or a little over twice the population of Russia. Unfortunately the sort of bio-social support these diverse minorities deserve is astonishingly deficient, with one of the most significant deficiencies relating to their access to decent health care. What we know about their general health profiles, however, is enough to unequivocally state that these millions of indigenous peoples suffer much higher TB burdens than their non-indigenous counterparts. Thankfully the Stop TB Partnership has recently published an impressive (and truly shocking) document illustrating exactly this.

Here’s what the document had to say about these peoples by way of preamble:

These populations are among the world’s most marginalized, and … are also among the world’s poorest. This extreme poverty stems from multiple factors, including lack of access to education, forced displacement, loss of lands and resources, armed conflict, and the degradation of indigenous socio-political structures. Poverty and marginalization have served to establish a substantial gap in the achievement of multiple rights, including the right to health. http://www.stoptb.org/assets/documents/resources/publications/acsm/6_27-UNOPS-KPB-Indigenous-Web.pdf

Of course poverty and gaps in health care mean higher levels of TB in any population, but there were some truly astonishing degrees of differences identified by Stop TB. What first shocked us were the names of some of the countries where much of the data that confirmed these shocking higher TB burdens came from. Some data came from India of course (where a third of the world’s TB is now believed to be festering and where indigenous poverty is truly appalling with indigenous people somehow surviving below a poverty line that is officially defined as being as little as US$0.30 a day. (This poverty line is calculated from an official rural one of c. 500 Rupees a month per person [‘Expert Group on Methodology for Estimation of Poverty’. Available from: http://planningcommission.gov.in/eg_poverty.htm]). But other data came from some of the richest countries on our planet – from Australia, Canada, New Zealand and the United States.

So the first question we feel obliged to ask on Indigenous Peoples’ Day is this:

Why, when targets have been set for driving TB into the ground for nearly a quarter of a century, is there still such abject neglect of indigenous populations in four of the richest countries? Surely – if progress has ever been seriously intended to be seen anywhere – we should have seen it here in these wealthy countries, so why can't we see some evidence of this now?

Immediately below we list a few of these estimated differences. We offer them in alphabetical order simply because (given that the baseline comparative rates of national TB disease are so variable) it seems misleading to do otherwise:

Brazil (Amazon tribes) – TB that is at least 20 times higher than rates of TB in the general population.

Canada (Inuit) – 156 times higher (yes, you read that right: one hundred and fifty-six times higher).

Equador (Chine) – 41 times higher.

India (forest peoples) – 17 times higher.

 New Zealand (Maori) – 14 times higher.

Paraguay (Aches peoples) – 75 times higher.

U.S.A. (native Hawaiians and Pacific islanders) – 23 times higher.

None of these comparative rates are insignificant, in fact not one of them is even remotely reasonable given that TB is in most cases a curable disease. Surely a rate that might be only twice as high as the rest of the population would still deserve identifying today. Stop TB rightly states that these numbers confirm something awful - amounting to the systematic neglect indigenous peoples have experienced globally in terms of their health. They also list its cause as being down to systematic racism and discrimination, lack of registration/citizenship, and the inability to access health insurance or receive key primary care services.

So, today on Indigenous Peoples’ Day we call on the UN and on all the health ministries of the world to do something about this.

But we also ask a challenging question of ourselves, which is this:

What can we ourselves do about it?

Well, here is our immediate (but far from final) answer to help honour this day:-

Article 24 of the UN Declaration on the Rights of Indigenous Peoples stipulates the right of indigenous peoples to “traditional medicines and their health practices, including the conservation of their vital medicinal plants, animals and minerals” . Of course, this right is primarily intended to protect such peoples’ own indigenous traditional resources, but given our own current experiences we can’t avoid wondering – might this Article also apply to a traditional resource from another culture entirely that has little need of it now?

 In other words, how might moxa (as it was traditionally used in Japan for the treatment of tuberculosis) fit into this complex multi-ethnic picture?

Given that we know how low-tech and adaptable small-cone moxa is as a therapy, we wonder whether it might fit in quite helpfully.

 Of course there are some very serious issues to consider here (ones that are quite independent of the key issue of efficacy). If we assume for a minute that moxa might be of help, we wonder exactly how a transplantation of a traditional therapy from one culture (that is now highly developed) into any completely different one might be most appropriately facilitated. Indeed, we also wonder how could it be done in ways which avoid justifiable suspicions or reluctance on behalf of populations who have experienced discrimination, scientific experimentation, forced sterilization and grossly unequal distribution of power in the delivery of health services? (And - let’s not pussy foot around this - also in too many instances full-blown genocide as well).  In effect, how might moxa be most usefully re-indigenised into a new culture?

But might the act of idigenising moxa in any case do these peoples a fundamental disservice by somehow implying that they deserve what might be judged by some to be a second class intervention when in fact what they really deserve is the same as the rest of us? These are certainly thorny questions to consider, but with the results of the Ugandan RCT under our belt and ongoing promising research in DPRK (two massively different countries culturally) we now feel bold enough to consider them in a public domain.

We thank Stop TB for its document because, apart from properly identifying something awful, it also clarifies things for us: specifically it homes in on the role of traditional healers in these communities and states categorically that  they must play a key part in any effective future response to these intra-national lethal ethnologically-distinct epidemics. The Partnership sees a part of any solution as involving a collaboration between traditional healers and national TB programmes [that] should be encouraged in order to boost diagnosis and treatment among indigenous populations. In other words the involvement of traditional healers is seen to be vital. There have previously been understandable concerns expressed amongst the biomedical status quo that such an inclusive policy would risk derailing any effectively managed TB program because it might blur medical paradigms (with the obvious risk of TB of stoking drug-resistance in the process if this isn’t done well) but Stop TB has an answer to this:

Additional evidence has shown that indigenous peoples can successfully balance traditional interventions and formal TB treatment[1]; furthermore, supportive TB treatment delivered by traditional healers can positively influence both treatment outcomes and other aspects of the treatment experience.[2][3]

 Please note the word ‘supportive’, because we have only ever identified the potential of moxa for TB as being an adjunctive treatment for TB (i.e. for use alongside existing drugs as an immuno-modulatory agent that might help recovery). In fact the only instance in which we believe it should be considered at all for use without approved drugs would be in the case of programmatically incurable disease.

So how might moxa be introduced as a supportive tool? Well our first answer is not from ‘the top down’, and Stop TB is clear about this as well:

Considering the reliance on traditional medicine and the effectiveness of collaborating with traditional healers to address TB in some settings, the involvement of indigenous communities in the design and implementation of TB interventions cannot be undermined.

We’d go further than this and say that the importance of the involvement of indigenous communities in the design and implementation of TB interventions in their own settings cannot be underestimated.

But there are also complex practical realities to consider here, and they're ones which surely give us further food for thought. Many indigenous peoples are largely nomadic. In Ethiopia, for instance, as many as 12 million Afar people are pastoralists who range from grazing sites to grazing sites following their animals making it a huge challenge for them to be supported by any TB program. In Namibia the San people embark on long hunting expeditions that interrupt  their TB treatment, something that’s been identified as causing community MDR-TB. To complicate this, both of these peoples are now living on the front line of Climate Change - experiencing new environmental stresses in already extreme conditions which are having direct negative effect on both  their community and individual resiliences against infectious disease.

 There are of course no simple answers to this, and we don’t want to pretend that there might be, but we do feel that it is time for us as a charity to more actively explore these sorts of issues. Stop TB, for instance, insist that community input needs to be be key to developing solutions for addressing issues of early diagnosis, medication adherence and other common issues in the successful treatment of TB. Otherwise, as the document very soberly observes such solutions risk being unsuccessful. One thing we know for sure is that any options should also closely note Stop TB’s own conclusion that it can only be  indigenous-run and indigenous-staffed care, or at minimum care informed by the indigenous communities themselves, [that can] overcome the current disparities in TB diagnosis and treatment.

 We close this blog by inviting engagement or comment from anyone anywhere. We would love to hear from you.

Thank you for reading and in the meantime we wish you a Happy Indigenous Peoples’ Day!

 

[1] Gianella C, Ugarte-Gil C, Caro G, Aylas R, Castro C, Lema C. TB in vulnerable populations: the case of an indigenous community in the Peruvian Amazon. Health and Human Rights Journal. 2016;18(1) (https://www. hhrjournal.org/2016/06/tuberculosis-in-vulnerable-populations-the-case-of-an-indigenous-community-in-the-peruvian-amazon/

[2] Colvin M, Gumede L, Grimwade K, Maher D, Wilkinson D. Contribution of traditional healers to a rural tuberculosis control programme in Hlabisa, South Africa. Int J Tuberc Lung Dis. 2003;7(9 Suppl 1):S86–91.

[3] Madamombe I. Traditional healers boost primary health care: reaching patients missed by modern medicine. Africa Renewal Online. January 2006 (http://www. un.org/africarenewal/magazine/january-2006/traditional-healers-boost-primary-health-care, accessed 3 March 2017).