33/57 Right to health and indigenous peoples with a focus on children and youth

GE.16-13843(E)



Human Rights Council Thirty-third session

Agenda item 5

Human rights bodies and mechanisms

Right to health and indigenous peoples with a focus on children and youth

Study by the Expert Mechanism on the Rights of Indigenous Peoples

Summary

In its resolution 30/4, the Human Rights Council requested the Expert Mechanism

on the Rights of Indigenous Peoples to prepare a study on the right to health and indigenous

peoples with a focus on children and youth and to present it to the Council at its thirty-third

session.

The present study consists of a critical analysis of the content of the right to health

vis-à-vis indigenous peoples and a review of the legal obligations of States and others in

terms of fulfilling that right.

Expert Mechanism advice No. 9 on the right to health and indigenous peoples is

contained in the annex.

Contents

Page

I. Introduction ...................................................................................................................................... 3

II. Right to health and indigenous peoples: legal and policy framework .............................................. 4

A. Normative framework on the right to health ............................................................................ 4

B. Other key instruments, policy processes and documents ......................................................... 5

III. Treaty rights, self-determination and health ..................................................................................... 6

IV. Indigenous peoples’ right to health: State obligations ...................................................................... 7

A. Availability, accessibility, acceptability and quality framework ............................................. 7

B. Respect, protect and fulfil framework ..................................................................................... 9

V. Indigenous children and youth and the right to health ..................................................................... 13

VI. Health rights of key indigenous groups ............................................................................................ 16

A. Women’s health ....................................................................................................................... 16

B. Health of indigenous persons with disabilities ........................................................................ 17

VII. Current challenges relating to indigenous peoples and the right to health ....................................... 18

A. Communicable and non-communicable diseases..................................................................... 18

B. Environmental health, climate change and displacement ........................................................ 19

Annex

Expert Mechanism advice No. 9 on the right to health and indigenous peoples .............................. 21

I. Introduction

1. In its resolution 30/4, the Human Rights Council requested the Expert Mechanism

on the Rights of Indigenous Peoples to conduct a study on the right to health and

indigenous peoples with a focus on children and youth and present it to the Council at its

thirty-third session.

2. The Expert Mechanism called for States, indigenous peoples, national human rights

institutions and other stakeholders to provide information for the study. The submissions

received have been made available on the Expert Mechanism website whenever permission

to do so has been granted. The study also benefited from presentations made at the Expert

Seminar on Indigenous Peoples and the Right to Health (Montreal, Canada, 21-22 February

2016) organized by the Office of the United Nations High Commissioner for Human Rights

and the Institute for the Study of International Development at McGill University. The

Expert Mechanism would like to thank the University of Auckland Faculty of Law for

providing research support. The Pan American Health Organization reviewed the study,

provided comments and contributed to the text.

3. Although this is the first study of the Expert Mechanism focusing on the right to

health, previous studies have addressed the links between access to justice and the health of

indigenous women and indigenous persons with disabilities (A/HRC/27/65), the health

implications for indigenous peoples of disaster risk reduction initiatives (A/HRC/27/66)

and the importance of indigenous cultures and languages for the health of indigenous

peoples (A/HRC/21/53).

4. Indigenous peoples’ conceptualization of health and well-being is generally broader

and more holistic than that of mainstream society, with health frequently viewed as both an

individual and a collective right, strongly determined by community, land and the natural

environment. The Permanent Forum on Indigenous Issues has noted that the right to health

“materializes through the well-being of an individual as well as the social, emotional,

spiritual and cultural well-being of the whole community” (see E/2013/43-E/C.19/2013/25,

para. 4). Indigenous concepts of health often incorporate spiritual, emotional, cultural and

social dimensions in addition to physical ones. Those concepts are inextricably linked with

the realization of other rights, including the rights to self-determination, development,

culture, land, language and the natural environment.

5. Indigenous peoples’ concept of health is frequently disregarded within non-

indigenous health systems, however, creating significant barriers to access (see

A/HRC/30/41, para. 31). In particular, a lack of understanding of social and cultural factors

deriving from the health-related knowledge, attitudes and practices of indigenous peoples

can have deleterious effects on indigenous well-being. Indigenous peoples worldwide

experience higher rates of health risks, poorer health and greater unmet needs in respect of

health care than their non-indigenous counterparts. Forced assimilation, political and

economic marginalization, discrimination and prejudice, poverty and other legacies of

colonialism have also led to a lack of control over individual and collective health.

6. A comprehensive analysis of the state of indigenous peoples’ health is beyond the

scope of the present study, which contains, instead, a critical analysis of the content of the

right to health vis-à-vis indigenous peoples and a review of the legal obligations of States

and others in terms of fulfilling that right.

II. Right to health and indigenous peoples: legal and policy framework

A. Normative framework on the right to health

7. The right to health of all peoples has long been recognized, for example in the

Universal Declaration of Human Rights, in particular its article 25, according to which

everyone has the right to a standard of living adequate for the health and well-being of

himself or herself and of his or her family, including food, clothing, housing and medical

care and necessary social services.

8. The United Nations Declaration on the Rights of Indigenous Peoples recognizes the

health rights of indigenous peoples and expands upon their varied dimensions and the

interplay with rights such as the right to self-determination. Article 21 recognizes the right

of indigenous peoples to the improvement of their economic and social conditions without

discrimination. Article 23 recognizes their right to determine and to develop priorities and

strategies for exercising the right to development and, in particular, to be actively involved

in developing and determining health programmes affecting them and to administer such

programmes through their own institutions where possible. Article 24 recognizes the right

of indigenous peoples to their traditional medicines, to maintain their health practices and

to access social and health services without discrimination; it affirms the equal right of

indigenous individuals to the enjoyment of the highest attainable standard of physical and

mental health. In addition, the Declaration recognizes the importance of upholding the

collective rights of indigenous peoples. Finally, article 29 (2) requires States to take

effective measures to ensure that no storage or disposal of hazardous materials shall take

place in the lands or territories of indigenous peoples without their free, prior and informed

consent.

9. Article 24 of the Declaration reflects the wording of article 12 of the International

Covenant on Economic, Social and Cultural Rights, a binding treaty enshrining the right of

all people to the highest attainable standard of mental and physical health. Article 12 sets

out an inclusive right, incorporating both health care and the social determinants of health,

and containing freedoms and entitlements: notably, the freedom to control one’s own health

and the entitlement to a system of health protection that provides equality of opportunity in

realizing the highest attainable standard of health. Non-discrimination and equal treatment

are among its key components; and, although many elements are subject to “progressive

realization” in view of resource constraints, obligations such as non-discrimination are of

immediate effect. While States have primary responsibility for realizing the right to health,

that responsibility is shared by all in society and individuals should have the opportunity to

participate in decision-making processes affecting the realization of their rights. States

should respect, protect and fulfil the right to health and ensure that health-care facilities,

goods and services are available, accessible, acceptable and of good quality (see

E/CN.4/2003/58, para. 34).

10. In its general comment No. 14 (2000) on the right to the highest attainable standard

of health, the Committee on Economic, Social and Cultural Rights further expands upon the

right to health vis-à-vis indigenous peoples, noting that they have the right to specific

measures to improve access to health services and care, which should be culturally

appropriate and take into account traditional practices and medicines, and that States should

provide resources for indigenous peoples to design, deliver and control services. The

Committee recognizes the collective dimension of health for indigenous peoples and

acknowledges the deleterious effect on health of the displacement from traditional

territories and environments that occurs as a consequence of development-related activities.

11. Article 25 of the International Labour Organization (ILO) Indigenous and Tribal

Peoples Convention, 1989 (No. 169), requires States to ensure that adequate health services

are made available to indigenous peoples and to provide resources to indigenous peoples to

allow them to design and deliver such services under their own control. It also requires

preference to be given to the training and employment of local community health workers.

The provision recognizes the importance of primary care and community-based health

services and of coordination with other social, economic and cultural measures.

Implementation of article 25 is supported by non-discrimination provisions (art. 3) and

provisions requiring States to consult with and ensure the effective participation of

indigenous peoples with the objective of achieving consent in relation to proposed

measures (art. 6).

12. Health-related rights are also recognized in other binding international instruments,

including the Convention on the Rights of the Child (art. 24), the Convention on the

Elimination of All Forms of Discrimination against Women (arts. 10-14), the Convention

on the Rights of Persons with Disabilities (art. 25) and the International Convention on the

Elimination of All Forms of Racial Discrimination (art. 5). Certain regional instruments

also uphold the right to health, including the African Charter on Human and Peoples’

Rights (art. 16), the African Charter on the Rights and Welfare of the Child (art. 14), the

Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in

Africa (art. 14) and the American Declaration on the Rights of Indigenous Peoples (art.

XVII). The Pan American Health Organization too has passed a number of resolutions

concerning the right to health of indigenous peoples. 1

13. Treaty bodies and special procedures, including the Special Rapporteur on the right

of everyone to the enjoyment of the highest attainable standard of physical and mental

health and the Special Rapporteur on the rights of indigenous peoples, have examined the

right to health from an indigenous perspective. Key findings of these mechanisms are

referred to throughout the present report.

B. Other key instruments, policy processes and documents

14. In 2014, the States participating in the high-level plenary meeting of the General

Assembly known as the World Conference on Indigenous Peoples committed themselves to

ensuring that indigenous individuals have equal access to the highest attainable standard of

physical and mental health and to intensifying efforts to reduce rates of HIV and AIDS,

malaria, tuberculosis and non-communicable diseases and to ensure access to sexual and

reproductive health. The importance of indigenous peoples’ health practices and their

traditional medicine and knowledge was also recognized.2

15. The Sustainable Development Goals, adopted in 2015, also touch on issues

concerning indigenous well-being.3 Goal 3 (to ensure healthy lives and promote well-being

for all at all ages) directs States to work towards achieving universal health coverage, which

will require States to extend services to indigenous peoples. The Goals on poverty, food

security, equitable and quality education, and gender equality are also relevant to

indigenous peoples’ well-being. Goals 13 (on climate change), 14 (on the protection of

ecosystems) and 15 (on sustainable development) are central to the realization of

indigenous peoples’ health rights, as they are closely interrelated with the rights to self-

determination and to the use of traditional lands, territories and resources. Goal 16

1 For example, see resolution CD47.R18.

2 General Assembly resolution 69/2.

3 General Assembly resolution 70/1.

(on access to justice and accountable and inclusive institutions) has clear implications for

indigenous peoples’ right to health, particularly in terms of redress. Finally, Goal 17 (which

includes a target on the availability of disaggregated data) calls for enhanced capacity-

building to increase data availability, which will assist States in identifying and remedying

health inequities.

16. The negotiations held at the twenty-first session of the Conference of the Parties to

the United Nations Framework Convention on Climate Change are also relevant, given the

disproportionate impact that climate change has on indigenous peoples. Those negotiations

culminated in the adoption of the Paris Agreement, in the preamble to which the parties to

the Convention recognized the rights of indigenous peoples, referring specifically to the

right to health. The parties also acknowledged that adaptation action should follow a

country-driven, participatory and fully transparent approach, based on and guided by the

knowledge of indigenous peoples, where appropriate (see decision 1/CP.21, annex). While

the importance of the effective participation of indigenous peoples had already been noted

(see decision 1/CP.16), the Paris Agreement went further by explicitly referring to human

rights, signalling that States recognized the links between climate-related obligations, the

right to health and indigenous peoples’ rights.

17. Finally, the Guiding Principles on Business and Human Rights are also highly

relevant to indigenous peoples, who disproportionately experience health rights

infringements through development-related activities carried out by non-State actors.

Although they are not parties to international human rights conventions, non-State actors

nevertheless have a responsibility to respect human rights, and adherence to the Guiding

Principles is necessary for indigenous peoples’ health rights to be fully realized.

III. Treaty rights, self-determination and health

18. The right to health is an indispensable element of indigenous peoples’ very existence

and a central component of their right to self-determination. The right to self-determination

is contained both in article 3 of the United Nations Declaration on the Rights of Indigenous

Peoples and article 1 of the International Covenant on Economic, Social and Cultural

Rights. All human rights are interdependent, including the rights to health and self-

determination. Indeed, full realization of health-related rights cannot be achieved without

self-determination, which is a non-derogable right the realization of which has associated

benefits in respect of health and other social and cultural rights. These can include an

improved diet, more frequent exercise and a renewed connection with traditional economic

bases.4

19. Some treaties between indigenous peoples and States provide mechanisms for the

realization of indigenous peoples’ rights to health and self-determination. These legal

agreements are thus highly relevant to a right-to-health analysis. Treaty No. 6, for example,

to which the British Crown and indigenous peoples in Canada became parties starting in the

1870s, included a “medicine chest clause” and a “famine and pestilence clause” that have

subsequently been interpreted as guarantees for the provision and delivery of health-care

services, medicines and supplies to indigenous peoples by the Crown.5 Treaties in other

countries provide for self-determination, which implicitly includes control over decisions

concerning the health and well-being of indigenous peoples, indirectly facilitating the

realization of the right to health. In New Zealand, the right to health of the Maori people is

effectively affirmed in the Treaty of Waitangi, which provides for the protection of self-

4 Submission by the New Zealand Human Rights Commission.

5 Submissions by the Maskwacis Cree and the Assembly of First Nations.

determination and cultural possessions (tangible and intangible), shared decision-making

and equal participation in society without discrimination.

20. The Special Rapporteur on the right to health has stated that the right to health raises

important issues of law, such as treaty rights to health.6 Article 37 of the United Nations

Declaration on the Rights of Indigenous Peoples confirms that indigenous peoples have the

right to the recognition, observance and enforcement of treaties. In line with article 43, the

survival, dignity and well-being of indigenous peoples are dependent on the rights

recognized in the Declaration, including the right to health, the right to self-determination

and treaty rights. Although the rights to self-determination and health are not contingent

upon the recognition of treaties, their formal inclusion in treaties provides a mechanism for

safeguarding those rights and strengthens the commitment of States to working with

indigenous peoples as equal partners in improving their living conditions. Accordingly,

States that have not yet adhered to such treaties should consider formally acknowledging

those rights in agreements with indigenous peoples.

21. The principle of free, prior and informed consent is another integral element of the

right to self-determination. It entitles indigenous peoples to effectively determine the

outcome of decision-making affecting them. It is both a process and a substantive

mechanism to ensure respect of indigenous peoples’ rights. Free, prior and informed

consent should be respected in decisions regarding health legislation, policy and

programmes affecting indigenous peoples, which are frequently taken without any

meaningful consultation. Health-care policymaking should adhere to both article 12 of the

International Covenant on Economic, Social and Cultural Rights (on the right to participate

in decision-making) and the United Nations Declaration on the Rights of Indigenous

Peoples, and reflect the principles outlined by the Expert Mechanism in its study on the

right to participate in decision-making (A/HRC/18/42).

IV. Indigenous peoples’ right to health: State obligations

22. Indigenous peoples worldwide share many challenges in realizing the highest

attainable standard of health. The challenges are examined in the present report using the

availability, accessibility, acceptability and quality framework, with State obligations

outlined using the respect, protect and fulfil framework. The availability, accessibility,

acceptability and quality framework extends beyond the infrastructure for delivering health

care to encompass the facilities, goods and services comprising the underlying determinants

of health care, such as safe drinking water and adequate food and sanitation.7

A. Availability, accessibility, acceptability and quality framework

Availability

23. Public health and health-care facilities, goods and services should be available in

sufficient quantity within a State, depending on its level of development. However,

availability is often constrained for indigenous peoples and communities. For example, in

certain areas in Africa where indigenous nomadic pastoralists and communities are located,

health infrastructure is non-existent.8 For facilities, goods and services to be available, they

6 Statement to the Third Committee of the General Assembly, 29 October 2004.

7 Committee on Economic, Social and Cultural Rights, general comment No. 14.

8 United Nations, Department of Economic and Social Affairs, State of the World’s Indigenous

Peoples: Indigenous Peoples’ Access to Health Services, second volume (New York, 2015).

must also be functional. Facilities located in areas inhabited by indigenous peoples are

frequently not operational owing to a lack of staff, medicines, supplies and other

consumables.

Accessibility

24. The four primary dimensions of accessibility are non-discrimination, physical

accessibility, economic accessibility and information accessibility. For indigenous peoples,

these four dimensions often intersect. Indigenous peoples are very likely to experience

discrimination when accessing health-care facilities, goods and services. Doctors, nurses

and other health-care professionals may refuse to treat indigenous peoples or indigenous

peoples undergoing treatment may encounter discriminatory beliefs, practices and

experiences, fuelling fear and distrust that further discourages use of health-care facilities.

That situation is amplified for indigenous persons with disabilities. Racism may even lead

to misdiagnosis and mistreatment for serious illnesses. Physical accessibility is an issue for

indigenous peoples, many of whom live in geographically isolated areas, often because of

displacement or the encroachment of non-indigenous peoples on their land.

25. Economic accessibility is another concern for indigenous peoples, who are

frequently among the most socioeconomically marginalized groups in society. This is

particularly true in countries without universal health care or with high out-of-pocket costs

for consumers. Information accessibility is also constrained for indigenous peoples: this can

be attributed to a number of factors, including health information being unavailable in

indigenous languages; higher rates of illiteracy among indigenous peoples with limited

educational opportunities; a lack of contact with health-care providers owing to

unavailability; and discriminatory or paternalistic attitudes among health-care providers.

Acceptability

26. The Committee on Economic, Social and Cultural Rights has acknowledged that the

right to take part in cultural life encompasses cultural appropriateness, which should be

taken into account in providing health-care services.9 Unfortunately, the health-care

facilities, goods and services available to indigenous peoples are often unacceptable in

nature. Interpersonal and structural racism frequently lead to system-wide policies and

practices that marginalize or exclude individuals and minimize access to facilities, goods

and services. One example of a basic failure to provide acceptable care is the non-provision

of services in indigenous languages (see CEDAW/C/FIN/CO/7), which constitutes

structural racism. Such failures can result in indigenous peoples internalizing stigma,

creating additional barriers to health care. Moreover, indigenous people are frequently

blamed for their illnesses and medical needs, either individually or as a group. Negative

attitudes and a lack of cultural sensitivity among health-care providers in some jurisdictions

also have an impact on indigenous peoples’ ability to seek health care.

Quality

27. Health-care facilities, goods and services should be scientifically, medically and

culturally appropriate, and of good quality. That requires skilled medical personnel,

scientifically approved and unexpired drugs and hospital equipment, safe drinking water

and adequate sanitation. Tension often exists between mainstream health-care services,

which are generally evidence-based and perceived to be of high quality, and the traditional

health-care practices of indigenous peoples, on which there is a paucity of evidence, often

9 See the Committee’s general comment No. 21 (2009) on the right of everyone to take part in cultural

life.

owing to a lack of research. That should not be viewed exclusively as a source of tension

between indigenous peoples and mainstream health-care providers. Indigenous

communities themselves often face challenges internally in seeking to balance traditional

and modern approaches to health and in addressing other social issues.10

B. Respect, protect and fulfil framework

Respect

28. Articles 2 (2) and 3 of the International Covenant on Economic, Social and Cultural

Rights and article 24 of the United Nations Declaration on the Rights of Indigenous Peoples

prohibit discrimination in access to health care and the underlying determinants of health.

States must refrain from denying or limiting indigenous peoples’ access to public health-

care facilities, goods and services. That immediate obligation is not subject to the principle

of progressive realization. States should also refrain from prohibiting or impeding

indigenous peoples’ use of traditional preventive care, healing practices and medicines.

29. Laws, policies and programmes concerning health should be reviewed (together with

indigenous peoples) and discriminatory elements removed or replaced. That obligation

extends to laws that are not de jure discriminatory but that have a disproportionate impact

on indigenous peoples. The obligation to respect extends to abstaining from enforcing

broader discriminatory laws or practices that can have detrimental health effects. For

example, laws and policies sanctioning practices such as the forced sterilization of

indigenous women and female genital mutilation should be removed.

30. The obligation to respect extends to the underlying determinants of health. States

should refrain from unlawfully polluting the air, the water and the soil, for example through

industrial waste from State-owned facilities or extractive industries. Such activities are too

frequently carried out on land inhabited by indigenous peoples and, along with the

agricultural use of pesticides, can represent a violation of indigenous peoples’ health-

related rights.11

31. Indigenous peoples must also be permitted to self-identify within States, which

would facilitate the collection of data disaggregated by health and other criteria, for the

provision of funding and assistance in realizing health-related rights. While certain

jurisdictions have banned the collection of data disaggregated by ethnicity for compelling

reasons, such laws should not be applied to prevent indigenous peoples from improving

their well-being.12

Protect

32. States often turn a blind eye to racism in health-care settings, even in the presence of

pervasive, persistent evidence that indigenous peoples are treated discriminatorily. States

should take measures to ensure equal access to treatment and health-care facilities within

their jurisdiction, as well as to protect indigenous peoples from discrimination perpetrated

by third-party health-care providers. States should consider implementing workforce

awareness-raising activities and campaigns challenging racist behaviour and stereotyping

and promoting more culturally sensitive approaches.

10 Submission by the Inuit Circumpolar Council.

11 See, e.g., Social and Economic Rights Action Centre and Center for Economic and Social Rights

v. Nigeria (2001).

12 Ian Anderson and others, “Indigenous and tribal peoples’ health (The Lancet–Lowitja Institute Global

Collaboration): a population study”, The Lancet, vol. 388, No. 10040 (20 April 2016).

33. States should protect indigenous communities from actions by private companies

and other third parties that deny indigenous peoples their sources of nutrition, medicinal

plants and livelihoods through increased pressure on land, environmental degradation or

displacement. Doing so necessarily includes respecting the principle of free, prior and

informed consent. States should prevent the appropriation and commodification of

indigenous knowledge, traditional medicines and practices by third parties. Article 31 of the

United Nations Declaration on the Rights of Indigenous Peoples confirms that indigenous

peoples have the right to maintain, control, protect and develop their cultural heritage,

traditional knowledge and traditional cultural expressions, as well as the manifestations of

their sciences, technologies and cultures, including human and genetic resources,

medicines, knowledge of the properties of fauna and flora, and sports and traditional games.

They also have the right to develop their intellectual property over such cultural heritage,

traditional knowledge and traditional cultural expressions.

34. Although indigenous peoples have the right to engage in traditional health-care

practices, States should take steps to work with indigenous communities towards the

eradication of harmful practices such as female genital mutilation.13 More research needs to

be carried out into traditional medicines, procedures and other interventions. However, such

research, and any potential commercialization, must take place in partnership with

indigenous peoples.

35. States should consider the wishes of indigenous communities living in voluntary

isolation or initial contact, in recognition of their greater vulnerability and need of

protection. States should develop preventive programmes to protect the health of those

groups, in particular by protecting their lands and territories from environmental damage

and by avoiding the transmission of diseases to which those groups lack immunity. States

must also create plans to provide access to mainstream and traditional medicine where it is

sought and develop an emergency plan to be implemented in the event of a threat of

imminent widespread mortality.14

36. Finally, States should ensure that adequate mechanisms exist for the provision of

redress and remedy in cases of infringements of the right to health, through mainstream or

indigenous juridical systems (A/HRC/27/65), which may have certain advantages in respect

of the resolution of complaints. In the Philippines, for example, complaints of violence

against women heard through the traditional justice system have reportedly been resolved

quickly, with high rates of acceptance by the parties.15

Fulfil

37. States should formulate and adopt national strategies to ensure that all individuals

have access, without discrimination, to the health facilities, goods and services necessary to

achieve the highest attainable standard of health. The creation of a national strategy should

be accompanied by implementation plans and right-to-health indicators for effective

monitoring, evaluation and accountability. States that are developing national action plans

for the implementation of the United Nations Declaration on the Rights of Indigenous

Peoples, as called for by the World Conference on Indigenous Peoples, should ensure that

13 Committee on the Rights of the Child, general comment No. 11.

14 OHCHR and the Spanish Agency for International Development Cooperation, “Directrices de

protección para los pueblos indígenas en aislamiento y en contacto inicial de la región amazónica,

el Gran Chaco y la Región Oriental de Paraguay” (Geneva, May 2012). Available from

http://www.amazonia-andina.org/sites/default/files/directrices-de-proteccion-para-los-pueblos-

indigenas-en-aislamiento-y-en-contacto-inicial_0.pdf.

15 Submission by the Asia Indigenous Women’s Network.

such plans include measures to fulfil indigenous peoples’ right to health. As indigenous

peoples have the right to specific measures to improve their access to health services and

care, the immediate obligation to create a national health plan requires States to make

provision for indigenous peoples’ needs in a “mainstream” plan, as in Guatemala,16 or a

separate indigenous health plan, like the Maori Health Strategy, He Korowai Oranga, in

New Zealand.17 In addition, States should ratify and incorporate into national law relevant

international instruments containing health rights, such as the Declaration, the ILO

Indigenous and Tribal Peoples Convention, 1989 (No. 169), and the International Covenant

on Economic, Social and Cultural Rights.

Facilitate

38. In accordance with the right to self-determination, States should provide sufficient

resources to indigenous communities to create and operate their own health-care initiatives.

Care provided by indigenous community-controlled organizations is often of a higher

quality than that provided by mainstream services, significantly improving the availability

and accessibility of health care. Indigenous organizations can create a virtuous cycle in

respect of health and employment, serving as prominent employers of indigenous peoples

and helping to combat poverty within indigenous communities. In Australia, the Aboriginal

community-controlled health-care sector employs nearly 4,000 people and services over 60

per cent of Aboriginal people outside major metropolitan centres, with superior

performance to mainstream services noted on key indicators.18 In Colombia, 80 per cent of

the professional staff of Pueblo Bello indigenous hospital in Valledupar are of indigenous

origin — a significant achievement in intercultural practice.19

39. States should also facilitate access to health-care services through improved birth

registration processes, where appropriate. Article 7 of the Convention on the Rights of the

Child gives every child the right to be registered immediately after birth. Yet, many

registration systems remain inadequate in relation to indigenous births. A lack of

registration and identification documents directly impedes access to health-care facilities,

goods and services where identification is a prerequisite for obtaining care

(CRC/C/CRI/CO/4) and prevents the collection of disaggregated data, which is vital in

monitoring disparities in health-care status between different ethnic groups. Registration

can be facilitated through targeted registration campaigns, as in Brazil,20 or use of

indigenous registrars or a specific minorities registration section within State institutions, as

in Panama, Peru and Thailand; alternatively, traditional birth attendants can improve birth

registration rates, as has occurred in Ghana and Malaysia.21 Birth registration should not,

however, be a precondition for accessing health-care services.

16 Submission by Guatemala.

17 See www.health.govt.nz/our-work/populations/maori-health/he-korowai-oranga.

18 Kathryn Panaretto and others, “Aboriginal community controlled health services: leading the way in

primary care”, Medical Journal of Australia, vol. 200, No. 11 (16 June 2014).

19 Anna R. Coates and others, “Indigenous child health in Brazil: the evaluation of impacts as a human

rights issue”, Health and Human Rights Journal, vol. 18, No. 1 (16 May 2016).

20 Ibid.

21 United Nations Children’s Fund, “Birth registration: right from the start”, Innocenti Digest series

No. 9 (March 2002).

Provide

40. Although certain indigenous peoples have stated that communities should take

ownership over responses to emerging crises and rely less on external support,22 this does

not absolve States of their obligations to provide financial and other support. States incur a

special obligation to provide (for those who do not have means) the necessary health

insurance and health-care facilities, a specific right under the International Covenant on

Economic, Social and Cultural Rights.23 Even in times of severe resource constraints,

individuals and groups in situations of vulnerability should be protected by the adoption of

relatively low-cost, targeted programmes (E/1991/23-E/C.12/1990/8). States can adopt

measures, temporarily or permanently, to remedy structural discrimination: these can

include programmes or the provision of funding or other resources to achieve the highest

attainable standard of health.

41. States should also provide certain resources while indigenous peoples establish their

own services and workforce cadre. For example, in the absence of sufficient medical

professionals able to speak indigenous languages, States should provide interpretation

services facilitating effective communication in health-care settings, as is done in Norway,

where a 24-hour-a-day Sami interpretation service has been established in collaboration

with indigenous peoples.24 Affordable versions of such programmes could be implemented

by other States, given the rapidly increasing prevalence of mobile telephone coverage

worldwide. Training and incorporating traditional indigenous practitioners into health-care

systems could also address immediate shortages of medical staff in remote indigenous

territories.

Promote

42. States should ensure that health-care research agendas sufficiently recognize and

involve indigenous peoples. Failure to collect health data disaggregated by ethnicity, self-

identified indigenous status or cultural identity can conceal deep inequities. Disaggregated

data should be collected, in a consensual manner, to identify barriers to the enjoyment of

the right to health and for inclusive policymaking. Such data should address issues such as

gender, socioeconomic status and disability, as data focused purely on indigenous status

does not fully capture the composite rights of indigenous peoples who are marginalized

owing to other aspects of their identity.25

43. For health-care facilities, goods and services to be acceptable to indigenous peoples,

they must be culturally appropriate. This requires communicating in a respectful and

inclusive way, empowering patients in decision-making and building relationships so that

patients and providers work together to ensure maximum effectiveness of care.26 To achieve

this, three steps are necessary: changes should be made to mainstream health-care facilities,

goods and services; more indigenous individuals should be trained as health-care providers;

and indigenous-specific services should be created.

44. To improve mainstream services, States should ensure that curricula of medical and

health-care training programmes render graduating professionals culturally competent.

Programmes should include education on colonial history and its legacies (where relevant),

indigenous culture (including traditional approaches to medicine), stereotyping and racism,

22 Submission by the Inuit Circumpolar Council.

23 Committee on Economic, Social and Cultural Rights, general comment No. 14.

24 Submission by Norway.

25 Doreen Demas, presentation to the Expert Seminar on Indigenous Peoples and the Right to Health.

26 National Aboriginal Health Organization, Cultural Competency and Safety: A Guide for Health Care

Administrators, Providers and Educators (Ottawa, 2008).

and health-care disparities and social inequities. Information on effective communication

with indigenous peoples should also be included. Specific programmes can also be created

addressing indigenous health, such as the University of Northern British Columbia

Aboriginal child and youth mental health certificate (for students who want to practice in

remote indigenous communities) and the Native American Child Health initiative created

by the American Academy of Pediatrics (dedicated to indigenous health care).

45. States should facilitate the entry of indigenous professionals in health care, as

indigenous peoples are currently underrepresented. Facilitation of workforce entry can take

many forms: for instance, through training quotas, earmarked funding or scholarships,

and/or travel allowances. Indigenous peoples can receive professional training to bridge the

divide between mainstream facilities, goods and services, and indigenous communities.

Such training should be conducted sensitively and without prejudice to indigenous

medicinal and health-related knowledge and practice.

46. States should also promote health through the provision of culturally appropriate

information concerning healthy lifestyles and nutrition, disease and illnesses (including

mental illness), harmful traditional practices, and the availability of services. Information

should be provided in the patient’s language and information mechanisms that incorporate

non-verbal communication patterns, as well as cultural beliefs and practices, should be

developed. In some indigenous communities, certain issues, such as HIV/AIDS and sexual

and reproductive health, remain taboo: State cooperation with indigenous organizations is

vital in implementing culturally appropriate awareness-raising campaigns among these

communities.

47. The spiritual and biomedical benefits of traditional health-care practices and

traditional medicines can promote and enhance indigenous health and bring unwell people

into contact with health-care systems, facilitating access to care. Rather than stigmatizing

and suppressing such practices and medicines, States should consider incorporating them

into their health planning and promotion activities.

48. Indigenous peoples should be supported in making informed choices about their

health by providing them with information and by taking State measures designed to

facilitate healthy choices, including physical activity. States should promote healthy and

traditional diets among indigenous people through the protection of indigenous peoples’

traditional agricultural practices, education campaigns and, where necessary, direct

provision of or economic subsidies for healthy foods, particularly in rural or remote areas

where processed or packaged foods are frequently more easily available and affordable to

indigenous peoples.

V. Indigenous children and youth and the right to health

49. Alongside the International Covenant on Economic, Social and Cultural Rights and

the United Nations Declaration on the Rights of Indigenous Peoples, article 24 of the

Convention on the Rights of the Child requires States to take appropriate measures to

ensure the realization of the highest attainable standard of health for children. In its general

comment No. 11 (2009) on indigenous children and their rights under the Convention, the

Committee on the Rights of the Child noted that indigenous children frequently suffer

poorer health than non-indigenous children owing to inferior or inaccessible health

services, and that positive measures may be required to eliminate conditions causing

discrimination and ensure the equal enjoyment of Convention rights. The Committee urged

States to consider implementing special measures to ensure that indigenous children are not

discriminated against and can maintain their cultural identity, and noted that States parties

have a positive duty to ensure that indigenous children have equal access to health services

and to combat malnutrition as well as infant, child and maternal mortality. In its general

comment No. 15 (2013) on the right of the child to the highest attainable standard of health,

the Committee interpreted the right to health of all children as including the right to grow

and develop to their full potential and live in conditions that enable them to attain the

highest standard of health through the implementation of programmes that address the

underlying determinants of health.

50. Unfortunately, alarming gaps in child health indicators persist between indigenous

and non-indigenous populations globally. Infant mortality rates remain significantly higher

among indigenous groups than among their mainstream counterparts.27 Indigenous women

and children can be vulnerable to violence, malnutrition, malnourishment, anaemia and

malaria.28 Some of these discrepancies are attributable to inequalities in social determinants

of health. Disproportionately large numbers of indigenous children live in poverty (general

comment No. 11) and in remote areas with limited access to health care, quality education,

justice and participation opportunities (see E/C.19/2005/2, annex III).

51. Indigenous peoples continue to experience intergenerational trauma owing to the

removal of children from families and residential schooling. The health impacts of such

practices are profound and include mental illness, physical and sexual abuse, self-harm and

suicide, and drug or alcohol addiction. A correlation has been demonstrated between the

intergenerational effects of those events and suicide29 and sexual abuse during childhood.30

52. Indigenous children and youth are particularly vulnerable to human rights violations,

because of their age and the intersectional nature of the discrimination experienced by

indigenous peoples. Children and youth have not historically been recognized as holders of

rights; that is especially the case for indigenous children, who are frequently deprived of

fundamental rights concerning their families, communities and identity. The combined

effect of intergenerational trauma and lack of progress towards the realization of indigenous

human rights has resulted in many indigenous children experiencing a multitude of early

and traumatic life experiences, placing them at risk of ill health, mental illness, suicide and

contact with the criminal justice system.31

53. Indigenous youth frequently find themselves caught between their indigenous

languages, customs and values and those of the wider community. They often migrate from

their traditional communities to urban areas to seek out increased employment and

educational opportunities, incurring increased health risks. Indigenous youth not only

experience higher rates of unemployment than their non-indigenous counterparts: they are

also vulnerable to depression, substance abuse and other risky health outcomes that occur in

the absence of strong social support and in the presence of discrimination.

54. In addition to difficulties experienced by indigenous peoples in accessing

appropriate and good-quality health services, indigenous children and youth face three key

issues compounding their social and economic disadvantage, relating to education, family

and community integrity, and mental health.

27 Ian Anderson and others (see footnote 12).

28 Submission by the Indigenous Women’s Network, India.

29 Zahra Rehman, presentation to the Expert Seminar on Indigenous Peoples and the Right to Health.

30 Gregory Corosky, presentation to the Expert Seminar on Indigenous Peoples and the Right to Health.

31 Hannah McGlade, Our Greatest Challenge: Aboriginal Children and Human Rights (Canberra,

Aboriginal Studies Press, 2013).

Education

55. Education is a key underlying determinant of health for indigenous peoples.

Illiteracy rates are frequently high (CERD/C/EDU/CO/20-22) and indigenous children are

significantly less likely than non-indigenous children to attend school, which undermines

health through decreased health literacy and loss of the numerous, indirect benefits of

higher educational attainment. Lower educational attainment is “inextricably tied” to

homelessness and the overrepresentation of indigenous peoples in the prison system.32

Decreased participation in formal education is frequently the result of a combination of a

lack of availability, accessibility, acceptability and quality. Even where services are

accessed, boys and girls record different completion rates: for instance, 89 per cent of

indigenous girls in Peru aged 12-16 drop out of school (see A/HRC/29/40/Add.2, para. 68).

56. States should do more to provide redress for these health rights violations. Investing

in indigenous children’s early development through education and providing support to

families (e.g. around parenting) are highly effective means of reducing health inequalities.

States should cooperate to ensure the adoption of effective interventions: for instance,

nurse-family partnerships have been adapted for use in indigenous communities following

evidence of effectiveness in the United States of America.33 At the primary and secondary

levels, educational facilities should be made available and accessible by States, including

through radio broadcasts and long-distance education programmes or through the

establishment of mobile schools for nomadic indigenous peoples (general comment

No. 11).

Family and community integrity

57. The importance of healthy communities and families to indigenous children cannot

be underestimated. Such support networks provide physical, mental and social health

benefits, help to break entrenched cycles of intergenerational disadvantage and build

resilience and capability. The Committee on the Rights of the Child has noted, in its general

comment No. 11, that maintaining the best interests of the child and the integrity of

indigenous families should be primary considerations in the development of health and

other programmes. Unfortunately, indigenous children are still removed from their homes

at a significantly higher rate than their non-indigenous counterparts, which can cause

significant childhood trauma. Moreover, indigenous children are vulnerable to abuse while

in the care of the State. States should prevent and provide redress for any action that

deprives indigenous peoples, including children, of their ethnic identities, such as

placement of indigenous children in alternative care.

Mental health

58. The high prevalence of mental illness and suicide among indigenous peoples is

alarming, particularly among indigenous youth. There are various protective factors and

preventive strategies for suicide, including strong cultural affiliations (A/HRC/21/53). One

systematic review found that school-based suicide prevention strategies reduced depression

and feelings of hopelessness and that “gatekeeper” training (teaching specific community

groups how to identify and support individuals at high risk of suicide) increased the

32 Submission by Brenda Gunn, University of Manitoba, Canada.

33 Submission by Australia.

knowledge and ability to assist those at risk of suicide. Other strategies effective in non-

indigenous communities, such as suicide-risk screening, could also be considered.34

59. Information on best practices for the prevention of mental illness and suicide should

be shared between communities. Research in the circumpolar region has demonstrated the

value of community-based and culturally guided interventions and evaluations, which could

be utilized elsewhere.35 Regional coordinating projects, such as the Rising Sun project

facilitated by the Arctic Council, assist in sharing data and comparing interventions.36

Finally, promising new initiatives such as the “health scouts” programme in the Philippines,

where children lead resilience training, should be explored.37

VI. Health rights of key indigenous groups

A. Women’s health

60. Indigenous women experience a broad, multifaceted and complex spectrum of

mutually reinforcing human rights abuses (A/HRC/30/41); these frequently include health

rights violations that extend beyond denial of access to medical services.

61. Firstly, indigenous women face many barriers to the realization of their sexual and

reproductive health and rights. A lack of available, accessible and acceptable health-care

services, as well as limited access to good-quality care, contributes to disproportionately

high rates of maternal mortality, teenage pregnancy and sexually transmitted infections and

to low rates of utilization of contraceptives, as indigenous women are often excluded from

reproductive health services. High rates of teenage pregnancy can also be attributed to

certain structural causes such as a lack of education for girls and forced marriage.

62. Secondly, indigenous women persistently experience high rates of maternal ill-

health. Globally, maternal mortality rates are consistently higher among indigenous women

than among non-indigenous women.38 Indigenous women are frequently at risk of

undernourishment, anaemia and other nutritional deficiencies, illnesses such as gestational

diabetes and frequently have little or no access to basic antenatal, intra-partum and

postnatal care.39

63. Finally, indigenous women and girls continue to experience violence at higher rates

than the general population. In accordance with article 22 (2) of the United Nations

Declaration on the Rights of Indigenous Peoples, States should take measures to ensure that

indigenous women enjoy full protection against all forms of violence and discrimination.

Nevertheless, indigenous women are disproportionately represented among victims of rape,

assault and other forms of violence. Many forms of violence against indigenous women

have a strong intergenerational element and stem from marginalization and legacies of

34 Anton Clifford, Christopher Doran and Komla Tsey, “A systematic review of suicide prevention

interventions targeting indigenous peoples in Australia, United States, Canada and New Zealand”,

BMC Public Health, vol. 13 (2013).

35 Jennifer Redvers and others, “A scoping review of indigenous suicide prevention in circumpolar

regions”, International Journal of Circumpolar Health, vol. 74 (2015).

36 Submission by the Inuit Circumpolar Council.

37 Penelope Domogo, presentation to the Expert Seminar on Indigenous Peoples and the Right to Health.

38 Ibid.

39 Michael Gracey and Malcolm King, “Indigenous health part 1: determinants and disease patterns”,

The Lancet, vol. 374, No. 9683 (July 2009).

colonization that permit or enable abuse.40 The health-related impacts of violence against

women include injuries, sexually transmitted infections, gynaecological problems, mental

illness and substance dependence. Violence against women also affects children exposed to

such violence, who experience higher rates of morbidity and mortality.41

64. These challenges can be overcome in partnership with indigenous peoples. For

example, community maternity wards, maternal houses and waiting homes have reduced

perinatal risk in Guatemala and Peru.42 Involvement and further training of traditional

midwives in modern health-care delivery approaches may reduce maternal morbidity and

mortality, while also improving service acceptability. States should consider opportunities

for South-South cooperation concerning sexual and reproductive health, in particular in

relation to intercultural standards (E/2013/43-E/C.19/2013/25).

65. In many indigenous communities, birth rates remain significantly higher compared

with the national average, partly reflecting the value indigenous communities place on

motherhood and childbearing. These views can occasionally clash with prevailing beliefs in

mainstream medicine regarding, for instance, birth practices and contraception. The

perceived conflict between the rights of indigenous peoples and the rights of women,

however, is often illusory. The elimination of customary law or practices that violate

women’s rights, such as forced marriage and domestic violence, has long been sought by

many indigenous peoples. Other practices that are traditional or preferred by indigenous

peoples should not be prohibited by States; instead, dialogue on pregnancy spacing,

contraceptive use and parenting should be conducted in a culturally sensitive manner.

66. States must do more to address gender-based violence. Indigenous women and girls

frequently have no effective legal remedies for such acts. In certain jurisdictions, violence

perpetrated against women by State officials such as police officers and military or

paramilitary forces occurs. In such cases, women experience a two-fold rights violation:

firstly, through the experience of violence and, secondly, through the lack of redress from

the very mechanism that has perpetrated the violence. States must take steps to prevent such

violence and ensure that acceptable mechanisms to provide redress for such violations are

available and accessible to all women.

B. Health of indigenous persons with disabilities

67. Indigenous persons experience higher rates of disability globally compared to the

general population. Barriers such as multiple forms of discrimination, poverty, systemic

and physical barriers and violence contribute to the lack of full enjoyment of their human

rights. The Convention on the Rights of Persons with Disabilities recognizes the right to

health (art. 25) and the difficult conditions faced by persons with disabilities who are

subject to multiple or aggravated forms of discrimination, including indigenous persons

with disabilities (preamble).

68. Indigenous children with disabilities face physical, systemic and attitudinal barriers

that impede the realization of their rights to education, accessible services and disability-

related rehabilitation programmes. Too often, indigenous children with disabilities face

40 Ellen Gabriel, presentation to the Expert Seminar on Indigenous Peoples and the Right to Health.

41 World Health Organization, “Violence against women: intimate partner and sexual violence against

women”, factsheet No. 239 (January 2016). Available from:

www.who.int/mediacentre/factsheets/fs239/en/.

42 United Nations Population Fund and the Spanish Agency for International Development Cooperation,

“Promoting equality, recognizing diversity: case stories in intercultural sexual and reproductive health

among indigenous peoples” (Panama, August, 2010).

discrimination, abuse and bullying from their peers, caregivers and members of their

communities. Indigenous status, intellectual disability and imprisonment frequently co-

occur.43

69. Indigenous persons with disabilities may also experience delays in recognition of

their condition owing to racism or discrimination, or even an over-diagnosis of their

intellectual disability owing to cultural bias in testing.44 Moreover, “institutionalized

ableism” can obscure undiagnosed illnesses among people living with disabilities, where

medical abnormalities are attributed to disability rather than to a separate pathology.45 The

potential for this to occur in indigenous people is significant given frequent issues with

language and other communication barriers and given health professionals’ lack of

education. Training and education curricula should include content regarding the needs of

indigenous persons with disabilities, so as to raise the awareness of practitioners.

70. Indigenous persons living with a disability in remote areas are often required to

periodically reconfirm their disability through central medical organizations to remain

eligible for disability pensions, creating hardship. States and other actors should recognize

and address the multiple burdens of discrimination suffered by indigenous persons with

disabilities.

VII. Current challenges relating to indigenous peoples and the right to health

A. Communicable and non-communicable diseases

71. Indigenous peoples experience disproportionately high levels of infectious diseases

such as HIV/AIDS, malaria and tuberculosis, with the risk of becoming infected with HIV

increasing among those migrating to urban areas. States should recognize the higher risk

profile of indigenous peoples in relation to these diseases and the multiple burden of

discrimination indigenous peoples suffer upon contracting such illnesses. In addition,

indigenous peoples disproportionately suffer from “neglected” tropical diseases such as

trachoma, helminth infections, yaws, leprosy and strongyloidiasis.46 Widespread or mass

consensual treatment for these conditions should be considered by States, where effective

medications exist. It is also important that State funding for indigenous health activities is

not predicated on wellness, particularly in communities already experiencing disadvantage.

In the Russian Federation, an increasing incidence of tuberculosis in indigenous

communities has been used as a criterion for the non-approval of or reduction in federal

subsidies.47

43 Matthew Frize, Dianna Kenny and C.J. Lennings, “The relationship between intellectual disability,

indigenous status and risk of reoffending in juvenile offenders on community orders”, Journal of

Intellectual Disability Research, vol. 52, No. 6 (June 2008).

44 Ibid.

45 Submission by the First Peoples Disability Network.

46 Peter Hotez, “Aboriginal populations and their neglected tropical diseases”, PLoS Neglected Tropical

Diseases, vol. 8, No. 1 (January 2014).

47 Russian Federation, federal government act No. 217 of 10 March 2009 on approval of the terms of

distribution of subsidies from the federal budget to the budgets of subjects of the Russian Federation

to support the economic and social development of the indigenous peoples of the North, Siberia and

the Far East of the Russian Federation.

72. There has also been an enormous rise in the incidence of non-communicable

diseases among indigenous peoples, who experience disproportionately high rates of

cardiovascular illness and diabetes. Such high rates are linked to the migration of

indigenous peoples from rural to urban areas, whose lifestyles rapidly change to incorporate

modern diets high in calories, fat and salt.48 For example, in the Philippines, development

and changes in agricultural practices and dietary preferences have contributed to soaring

rates of diabetes, renal disease, cardiovascular disease, hypertension and cancer.49

Moreover, global data reveal high rates of alcohol and tobacco use among indigenous

peoples, in particular men.

73. States should take specific steps to combat the extraordinary burden of these

illnesses among indigenous peoples. Affordable access to key medications, such as insulin

and anti-hypertensives, should be ensured, as their high out-of-pocket costs can lead to a

rapid, yet preventable, deterioration in health. Telemedicine or mobile health initiatives to

monitor indigenous peoples with chronic illness living in remote areas should also be

considered. The value of exercise and sport should not be underestimated, both in terms of

non-communicable disease prevention and indirect health benefits, such as increased social

inclusion and self-esteem. Among indigenous Australian youth there is a positive

relationship between self-reported participation in sport and health outcomes, including

mental health; involvement in sport has even been shown to deter juvenile delinquency. 50

It

is very encouraging that traditional games and sports events such as the World Indigenous

Games held in 2015 are being supported and promoted by States, given their role in

prevention of illness and wellness promotion.

74. Good occupational health for indigenous persons is also crucial. For example, some

indigenous peoples suffer from silicosis as a consequence of poor occupational hygiene in

stone processing factories, a traditional livelihood in some indigenous territories of the

Russian Federation. States should protect the health of indigenous peoples working in both

traditional and mainstream industries.51

B. Environmental health, climate change and displacement

75. Poor environmental health has long been a concern of indigenous peoples. The

Committee on the Rights of the Child has highlighted the importance of environmental

health to children and recognized climate change as a particularly urgent threat to

indigenous children’s health and lifestyles, noting that States should put children’s health

concerns at the centre of their climate change adaptation and mitigation strategies (general

comment No. 15).

Those who are already vulnerable, including indigenous peoples,

experience the worst effects of climate change (A/HRC/31/52). For example, climate

change is contributing significantly to food insecurity among the Inuit peoples of the

Canadian Arctic, whose hunting and fishing practices have been threatened by significant

reductions in their icy hunting grounds.52 Replacement of traditional food sources with

mainstream dietary elements is costly in such locations, and carries its own health risks.

48 Michael Gracey and Malcolm King (see footnote 39).

49 Penelope Domogo, presentation to the Expert Seminar on Indigenous Peoples and the Right to Health.

50 Submission by Cultural Survival.

51 Outcome document of the expert seminar entitled “Finno-Ugric peoples and sustainable development:

health of indigenous peoples”, held in Petrozavodsk, Russian Federation, on 25 and 26 May 2016.

52 Sheila Watt-Cloutier, presentation to the Expert Seminar on Indigenous Peoples and the Right to

Health.

76. The development-related activities of States or third parties, such as multinational

corporations, may also compromise indigenous peoples’ underlying determinants of health,

such as food, safe drinking water and sanitation. This can occur through the displacement

of indigenous peoples from traditional lands or from land or water contamination, which in

turn results in infringements of the right to health and other rights, including the right to

life.53 Contamination can also occur through the use of pesticides that are banned in certain

States but that are nevertheless exported and used elsewhere.54 It is an ironic outcome of

development and globalization that indigenous peoples are consistently among those most

vulnerable to food insecurity, malnutrition and chronic diseases, given their wealth of

traditional knowledge regarding sustainable, healthy living in rural ecosystems. This

vulnerability is a living reality for many indigenous peoples; diabetes and cardiovascular

diseases have been causally linked to the impact of colonization and dispossession of lands,

territories and resources.55

77. Efforts should be made to promote cooperation between indigenous peoples and

businesses and to minimize the negative impact of development, as examples from the

Russian Federation illustrate.56 Identifying indigenous peoples’ rights to land, forests and

marine and other natural resources is also vital to indigenous peoples’ livelihoods and well-

being. The importance of maintaining a connection with the land is also recognized in

regional legal instruments.57 Where indigenous peoples are empowered to care for and

maintain their land, another virtuous cycle is created: natural resources are used more

sustainably, employment prospects are created and the overall health of communities

improves. Indigenous peoples should retain decision-making control over these resources to

ensure sufficient food and nutritional security, especially where communities are dependent

on marine and terrestrial resources for survival (E/2005/43-E/C.19/2005/9).

53 See e.g. Xákmok Kásek Indigenous Community v. Paraguay, Inter-American Court of Human Rights,

24 August 2010.

54 Submission of the International Indian Treaty Council.

55 Royal Commission on Aboriginal Peoples, Report of the Royal Commission on Aboriginal Peoples:

Volume 3 — Gathering Strength (Ottawa, Canada Communication Group, 1996).

56 United Nations Development Programme, Russian Union of Industrialists and Entrepreneurs and

Global Compact Network Russia “United Nations Global Compact Network Russia: corporate social

responsibility practices”.

57 See the African Union Convention for the Protection and Assistance of Internally Displaced Persons

in Africa, art. 4 (5).

Annex

Expert Mechanism advice No. 9 on the right to health and indigenous peoples

A. General advice

1. The right to health of indigenous peoples is enshrined in multiple international and

national instruments, and forms an important part of human rights law. That right is

interrelated with various key rights accrued by indigenous peoples, including the rights to

self-determination; development; culture; land, territories and resources; language; and the

natural environment.

2. Indigenous concepts of health are broad and holistic, incorporating spiritual,

environmental, cultural and social dimensions in addition to physical health. Forced cultural

assimilation; land dispossessions and the use of indigenous land for the extractive industry;

political and economic marginalization; poverty; and other legacies of colonialism have led

to a lack of control over individual and collective health and undermined the realization of

indigenous peoples’ health rights.

3. Health statistics the world over illustrate indigenous peoples’ disadvantaged position

in terms of access to quality health care and their vulnerability to numerous health

problems, including communicable and non-communicable diseases. Indigenous women,

youth, children and persons with disabilities face particular challenges, including higher

maternal mortality and suicide rates, and face multifaceted forms of discrimination.

B. Advice for States

4. States should recognize and enhance the protection of the right to health of

indigenous peoples by ratifying and incorporating into their domestic law the Indigenous

and Tribal Peoples Convention, 1989 (No. 169), of the International Labour Organization,

the International Covenant on Economic, Social and Cultural Rights and other key human

rights treaties, and by taking concrete measures to implement the United Nations

Declaration on the Rights of Indigenous Peoples.

5. States should recognize the inherent right of indigenous peoples to determine their

own futures, including in terms of exercising control over their own health. States should

consider entering into treaties with indigenous peoples, explicitly safeguarding rights to

self-determination and health, and implement relevant treaty commitments where they

already exist.

6. Health is an indispensable component of indigenous peoples’ very existence,

survival and entitlement to live in dignity and determine their own futures. States should

therefore seek the free, prior and informed consent of indigenous peoples before

implementing laws, policies or programmes affecting their health or health rights.

7. States should implement national plans for indigenous peoples’ health with the full

participation of indigenous peoples and with their free, prior and informed consent, or

create or amend existing national health plans to incorporate specific programmes and

policies for indigenous peoples. States should also incorporate the right to health into

national action plans for the implementation of the United Nations Declaration on the

Rights of Indigenous Peoples.

8. States should ensure that indigenous peoples are given full access to publicly run

health-care facilities, goods and services, as well as to facilities, goods and services relating

to underlying determinants of health, such as safe and potable water and adequate food and

sanitation. The introduction and implementation of comprehensive anti-discrimination laws

and the collection and use of disaggregated data are vital for achieving this objective.

9. Laws and policies that permit or sanction violence against indigenous peoples, even

if only implicitly, should be repealed by States, and steps should be taken to address

violence perpetrated by State representatives (such as armed forces) and third parties.

Violence in health-care settings, such as forced sterilization and female genital mutilation,

as well as discrimination against lesbian, gay, bisexual and transgender indigenous persons,

should be explicitly prohibited.

10. States should not endanger the environmental health of indigenous peoples,

including through air pollution or water and soil contamination by State-owned facilities or

other activities. States should take steps to protect indigenous peoples from environmental

damage caused by third parties (such as private companies) by minimizing, through

legislative and practical measures, the impact that extractive industries in particular have on

the physical and mental health of indigenous peoples.

11. Indigenous peoples should be permitted to identify as distinct groups within States

and States should take positive measures to ensure the collection of disaggregated data on

indigenous peoples. States should facilitate access to health-care services through improved

birth registration processes and by removing birth registration as a precondition for

accessing health-care services.

12. States should take steps to support the preservation of indigenous cultures and

protect indigenous peoples from the appropriation and commodification of their knowledge,

their traditional medicines and other traditional practices by third parties. Indigenous

peoples should be allowed to practice traditional medicine and enjoy its benefits but

harmful practices that infringe on other rights, such as female genital mutilation, should be

eradicated, in partnership with indigenous peoples.

13. States should provide sufficient resources to indigenous peoples to facilitate the

creation and operation of their own health-care initiatives or, in the absence of indigenous-

controlled services, provide programmes and interventions directly to indigenous peoples,

including through the implementation of special measures necessary for indigenous peoples

to fully realize their health rights.

14. States should secure access to quality health-care services, including preventive

care, for nomadic and remote indigenous peoples, indigenous peoples in conflict-affected

areas and indigenous persons in detention, including through mobile clinics, telemedicine

and information and communications technologies.

15. States should ensure that interpretation services are available to indigenous patients,

to ensure adequate communication in health-care settings. Recognizing the role of

languages in the healing process, States should also promote the use of indigenous

languages in health-care settings.

16. States should take steps to train indigenous health-care workers and accredit

indigenous health practitioners and integrate them into health-care systems. States should

also improve health-care training curricula to train health-care workers to deliver culturally

appropriate services, and create programmes and services to raise the awareness of

practitioners regarding the treatment and management of indigenous persons.

17. Culturally appropriate health promotion tools and information should be devised and

disseminated by indigenous peoples in partnership with States, to prevent both

communicable and non-communicable diseases. Sufficient resources should be allocated

for healthy lifestyle information programmes to be devised and States should design

specific strategies for the prevention of communicable and non-communicable diseases in

partnership with indigenous peoples and with their free, prior and informed consent.

18. States should implement legislation, policies and programmes that support

indigenous peoples in making informed choices about their health and that include

initiatives to improve indigenous peoples’ choices regarding the underlying determinants of

health, such as healthful food and physical activity.

19. Educational initiatives for indigenous peoples should be prioritized by States, given

the strong direct and indirect links between health and educational attainment. States should

ensure that every indigenous child has access to primary and secondary education and that

all indigenous peoples can access health-related educational resources.

20. The high rate of removal of indigenous children from their families and

communities worldwide and the far-reaching health effects of intergenerational trauma

attributable to such removal and placement in residential schools and other facilities should

be further investigated by States. Steps should be taken to preserve the integrity of

indigenous families in accordance with the rights of the child and to ensure that affected

indigenous persons receive the preventive and curative health-care services they require for

addressing sequelae such as mental illness.

21. States, in cooperation with indigenous peoples, must take immediate steps to reduce

the high rate of indigenous suicide worldwide, in particular among children and youth.

Proven preventive measures should be implemented in high-risk communities and

sufficient resources should be allotted to achieve genuine improvements in mental health

among indigenous peoples.

22. States should provide resources and materials to deliver culturally appropriate health

care to women, especially in respect of maternal health and sexual and reproductive health

and rights.

23. States should ensure that women are protected from violence by enforcing criminal

laws and making use of indigenous juridical mechanisms. States should also offer support

services and resources for women who experience violence, including monetary resources

where necessary.

24. States should take steps to combat discrimination against indigenous persons with

disabilities by implementing legislation, policies and programmes and creating mechanisms

to protect these people from having their rights abused by third parties. States should also

implement culturally appropriate services (diagnostic and otherwise), taking into account

indigenous needs in identifying and managing disability.

25. States should promote the exercise of indigenous traditional games and sport, for

example through the World Indigenous Games.

26. States need to legally recognize and protect the right of indigenous peoples to their

lands, territories and resources through appropriate laws and policies, given their intrinsic

connection with the rights to health and to food.

27. States should make concrete plans to implement the provisions of the Paris

Agreement, to mitigate the harmful effects of climate change and to tailor their health-

sector planning to prepare for the health-related impacts of climate change, which

disproportionately affect indigenous peoples.

28. States should ensure that adequate mechanisms are in place to provide redress and

remedy for health rights infringements, including treaty rights, either through mainstream

or indigenous juridical systems. Indigenous juridical systems may have certain advantages

in terms of the resolution of complaints linked to health rights violations.

C. Advice for indigenous peoples

29. Indigenous peoples should strengthen advocacy efforts for the recognition of

indigenous health rights and rights to self-determination, with the aim of creating equitably

funded indigenous community-controlled health-care facilities, goods and services that are

available, accessible, acceptable and of good quality.

30. Indigenous peoples should continue to advocate for proportionate representation and

genuine participation in policy decisions regarding health care and push States to ensure

that their free, prior and informed consent is obtained before implementing laws, policies

and projects affecting indigenous peoples.

31. Indigenous peoples can take measures to protect and promote traditional medicine

and associated practices, including advocating for State recognition to receive full

protection under the Nagoya Protocol on Access to Genetic Resources and the Fair and Equitable Sharing of Benefits Arising from Their Utilization to the Convention on

Biological Diversity, and for traditional healing and medical practices to be included in

mainstream health-care services.

32. Indigenous peoples should ensure that steps are taken within communities to protect

children and youth from practices with negative health impacts, including alcohol and drug

misuse, and work with States to address these issues.

D. Advice for international organizations

33. While acknowledging the work done in this area by the Pan American Health

Organization, the Expert Mechanism suggests that the World Health Organization consider

appointing a global focal point on indigenous peoples’ health issues to better address the

pressing concerns that are raised worldwide in respect of the realization of indigenous

health rights.

34. The United Nations, its agencies and other international organizations should

emphasize the importance of providing mental health services to indigenous peoples and

take steps to address suicide among indigenous people, in particular indigenous children

and youth. The World Health Organization should also coordinate further research into

youth suicide. The above-mentioned organizations should share information and support

indigenous communities in tackling this issue.

35. The United Nations Population Fund should take into consideration the rights of

indigenous peoples, in particular women and young people, in their planning, given the

disproportionate burden of morbidity and mortality suffered by indigenous women and the

gaps in the realization of their sexual and reproductive health rights.

36. The World Health Organization, the World Bank and other international

organizations should conduct research into and disseminate information on best practices

regarding community-controlled health care, to promote its adoption.

37. Together with States, multilateral agencies and other entities should also invest more

resources in research and development for novel, affordable treatments for neglected

tropical diseases that are disproportionately experienced by indigenous peoples.

38. The World Health Organization and other United Nations agencies should work with

indigenous peoples to develop policy guidelines for incorporation of indigenous traditional

knowledge into national health-care systems, including through the recognition of best

practices.