Contributed by Joe Sarcone, MSPH
U.S. Department of Health and Human Services
The findings and conclusions in this paper are those of the author and do not represent the views of the U.S. Department of Health and Human Services.
According to the World Health Organization (2014) chronic diseases such as heart disease, cancer and diabetes are the leading cause of mortality in the world. Out of the 36 million people who died from chronic disease in 2008, nine million were under age 60 and 90 per cent of these premature deaths occurred in low and middle-income countries. While rates of some chronic disease have declined in Western populations chronic diseases are a growing cause of morbidity and mortality among vulnerable populations. The Centre for Aboriginal Health Research at the University of Victoria (2009) states that the aboriginal people of Canada experience higher rates of chronic disease in comparison to the population overall and that this is true of indigenous peoples around the world.
Although some types of cancer are less likely to occur in indigenous populations indigenous people are significantly more likely to have cancers that have a poor prognosis, usually diagnosed with cancer at a later stage, less likely to receive adequate treatment, and are more likely to die from cancers than other population groups (Australian Institute of Health and Welfare, 2013). For indigenous people cancer treatment is often only available at some distance from home and away from the support systems that surround them in their communities.
Consider this example from Alaska. According to the Alaska Native Epidemiology Center (2012) cancer is the leading cause of death among Alaska Native people more than heart disease, stroke, complications of diabetes, more than accidents and suicides. Prior to the mid 1900’s, cancer was considered a rare disease among Alaska Native people, but since that time cancer incidence has increased dramatically. Cancer incidence rates are high among Alaska Native people and many types of cancer exceed the rates of cancer in the US white population.
There are more than 300 former military sites scattered throughout rural Alaska (ACOE, 2012). Many of these contaminated sites are proximate to some 200 rural and remote Alaska Native villages. Alaska Native people practice customary and traditional use of the land for hunting, fishing and gathering or subsistence. Subsistence is a crucial social determinant of health.
Although the patterns of Alaska Native cancer incidence are largely explained by the higher prevalence of risk factors such as tobacco use (EpiCenter, 2012), many Alaska Native people believe that increased cancer incidence is the result of coincidental exposure to contaminants from former military sites. This is especially believed to be true for exposure to contaminants through ingestion of contaminated subsistence resources.
In most instances, human toxicology bears out a low level cancer risk associated with exposure to environmental contaminants despite what people may perceive as harm. However, the perception of harm in indigenous populations must be addressed. In indigenous communities human toxicology reaches right through community networks of obligation to deal directly with each individual living there. For example, what is the excess cancer risk to an individual of a certain age and weight, eating so many ounces of a food contaminated with a certain level of chemical over a lifetime? The outcome is a measure of the chance of morbidity or mortality for an exposed individual.
In traditional cultures the premature death of a hunter, linguist, story teller, artist or healer due to chronic disease such as cancer represents more than the loss to the culture of the individual. Instead it is the irreversible loss to the culture of traditional life. Here the adverse effect of a cancer on a human being is urgently supplanted by the cultural carcinogenicity of a suspected agent or behavior on a way of being. Within this context how do we address cancer health disparities across cultures with indigenous communities?
Human toxicology does not directly address concerns of irreversible cultural loss. Even as an indigenous population may assert that they are experiencing a high incidence of cancer due to exposure to an environmental contaminant, public health practitioners apply their best toxicology and epidemiology to an end that often times serves to diminish the role of environmental contaminants.
In Cancer clusters in the USA: What do the last twenty years of state and federal investigations tell us, Michael Goodman MD, MPH, Department of Epidemiology, Emory University, Rollins School of Public Health investigated 567 cancer studies. Of the studies investigated 72 were confirmed cancer clusters, 11 were clusters for which there was an established cause, and 3 identified cancer clusters that could be associated with environmental exposure (Goodman M., Naiman, Goodman D., and LaKind, 2012). Even so in indigenous populations the remaining perception of cancer linked to contaminant exposure resulting in cultural loss is devastating.
Lynda Earle (2013) of the National Collaborating Center for Aboriginal Health (NCCAH) at the University of Northern British Columba identifies culture as a determinant of health that is intricately tied to traditional foods. “Not only are traditional foods valued from cultural, spiritual and health perspectives, but the activities involved in their acquisition and distribution allow for the practice of cultural values such as sharing and cooperation. Among Alaska Native peoples, traditional food consumption is associated with other measures of culture such as speaking a Native language, using traditional medicine and participating in traditional events” (p.3).
The literature describing the health benefits of customary and traditional subsistence diets is extensive. Traditional diets tend to contribute to beneficial fat profiles important for cardiovascular health, tend to be lower in carbohydrates, including simple sugars, an important consideration in conditions such as obesity and diabetes, and are rich in micronutrients. These benefits as well as the physical activity associated with harvesting traditional foods are important components of primary prevention.
Traditional subsistence food insecurity can result from many factors including concern over contaminants in the foods. The Tribal Association for Solid Waste Management and Emergency Response (2004) found that 34% of tribes surveyed changed how much traditional foods they ate because of concerns about a contaminated site and 30% have had a subsistence activity stop all together because of concerns about contaminated sites. Earle (2013) observes that where there are issues of food insecurity traditional diets and associated physical activities have been replaced with patterns of consumption that increase the risk of developing chronic disease. The impact of the contaminants on the human being is overshadowed by the cultural carcinogenicity of the contaminants on a way of being.
Health Care and Public Health Provider Working Groups of representatives of the indigenous community and regional, state and federal partners can work together to address the cultural carcinogenic effect of contaminants by taking steps to 1) perform a health assessment of the contaminants of concern; 2) conduct a cancer study of the affected population; and, 3) offer cancer screening for early detection and treatment of cancer cases.
Public health assessments are conducted to determine whether people have been, or are currently being, exposed to hazardous substances released into the environment from a hazardous waste site or facility. The focus is to evaluate the community’s exposure to the contaminants that have been measured in the environment and to make a determination of health risk. Where there are harmful exposures appropriate recommendations are made to reduce or eliminate the exposures.
A cancer study of the community may include an evaluation over time of the observed number of cancer cases versus the expected number of cancer cases, a cancer case count review of the number and types of cancers, and an evaluation of cancer mortality. This information is useful in that it can provide people with more clarity about cancer and its causes. This cancer awareness together with screening and early detection increases the chance that a person diagnosed with cancer will survive the cancer.
Taken together health assessments, cancer studies and cancer screening/early detection address cultural carcinogens by providing people with information needed to make decisions that protect against chronic disease, maintain food security, promote good nutrition, and ensure cultural integrity. The extent to which cancer disease disparity in the indigenous population is alleviated by these actions remains to be measured.
Alaska Native Epidemiology Center (EpiCenter). (2012). Cancer in Alaska Native people: 40 year report, 1969-2008. Anchorage, Alaska: Alaska Native Tribal Health Consortium.
Australian Institute of Health and Welfare (AIHW). (2013). Cancer in Aboriginal and Torres Strait Islander Peoples of Australia: an Overview (Cancer series 78. Cat. no. CAN 75). Canberra, Australia: AIHW.
Centre for Aboriginal Health Research (CAHR), University of Victoria. (2009). The Crisis of Chronic Disease among Aboriginal Peoples: A challenge for public health, population health and social policy. Victoria BC, Canada: Reading.
Earle L. (2013), Traditional Aboriginal Diets and Health, University of Northern British Columbia, National Collaborating Center for Aboriginal Rights (NCCAR). Prince George BC, Canada: Earle.
Goodman, M. Naiman J.S., Goodman D., and LaKind J.S. (2012). Cancer clusters in the USA: What do the last twenty years of state and federal investigations tell us? Critical Reviews in Toxicology, 42(6), 474–490.
Tribal Association for Solid Waste Management and Emergency Response (2004). Tribal Hazardous Waste Site 2004 Report. Washington D.C.: Zender Environmental Science and Planning Services.
U.S. Army Corps of Engineers (ACOE). (2012). Formerly Used Defense Sites (FUDS) Inventory. Washington D.C.: U.S. Army Corps of Engineers. Headquarters
World Health Organization (WHO). (2014). Chronic diseases and health promotion. Geneva, Switzerland: http://www.who.int/chp/en/
Alaska Federation of Natives. (2016). Retrieved from http://www.nativefederation.org/annual-convention/quyana/