• Open Access

Authors' response


Correspondence to:
Ms Shaouli Shahid, Centre for International Health, Curtin University of Technology, GPO Box U1987, Perth, Western Australia. Fax: (08) 9266 2608; e-mail: s.shahid@curtin.edu.au

Worldwide, Indigenous peoples displaced as a result of colonisation share many features including ongoing marginalisation and poor health status. Cormack and others have questioned why we chose to compare four groups of Indigenous people with great diversity with respect to historical, political and cultural contexts. There are multiple reasons.

First, Australia, New Zealand, Canada and US all have a clear demarcated history of European arrival and colonisation that interfered with the Indigenous people who were the first recorded inhabitants or descendants of the land prior to European settlement. Second, all are wealthy, developed countries with an overall high standard of living and long life expectancy in the general population. Third, there are commonalities between the countries in terms of their democratic systems of government, the policy environment, and health care systems with their strong basis in biomedical science. Furthermore, others in Australia, including organisations such as Oxfam and the National Aboriginal Community Controlled Health Organisation, have drawn upon comparisons with these three other developed countries in terms of public health advocacy to do more to ‘Close the Gap’ in Indigenous Australians' life expectancy.1,2 The Tripartite Agreement was based upon the belief that Indigenous populations in Australia, New Zealand and Canada could learn and benefit from the experience of their Indigenous counterparts elsewhere.3,4

As our title and objectives indicate, we aimed to provide an overview of similarities and differences in cancer in these four Indigenous populations around Indigenous belief systems about cancer, and to position this through exploring the situation of cancer as an Indigenous health issue, looking for comparable data. The paper described substantial limitations in epidemiological data about Indigenous peoples' experience with cancer and difficulties that exist due to under-ascertainment of Indigenous identity. While there is epidemiological information from these countries, often it is for states or provinces where rates in Indigenous people are compared to that of the non-Indigenous population, with national Indigenous cancer data more limited. We referred to useful reviews of the epidemiology of cancer in Indigenous populations,5–7 and therefore did not cite many primary references.

Our generalisation about difficulties with data might not be so pertinent for New Zealand, which seems to be the point Cormack et al. are making. This reflects that NZ is a smaller country, with no states, that has only one Māori language. The references they have cited are descriptive epidemiological papers from NZ, primarily concerned with differences in rates of disease, by cancer and over time. While useful for describing discrepancies in incidence and outcomes, and for monitoring progress, such reports do not of themselves explain why such discrepancies in outcomes exist.

There are undoubtedly difficulties with the language used to describe the Indigenous experience in relation to cancer. Our words were influenced by the terms used in the literature we have accessed in developing this article, but we do not accept that “delayed presentation” is inherently victim blaming. Failure of logistical support and culturally safe service delivery do impede access to timely health care, and are the focus of much of our work.8–10 However, a review of barriers that Indigenous people face in accessing health care access was not our aim in this paper. Similarly, while the wider issues of inclusiveness and racism are not explored in detail in this paper, the Indigenous experience is framed in the context of colonisation. The importance of beliefs and the system-wide factors that underpin the disparities in outcomes between Indigenous and non-Indigenous Australians are topics taken up in further research.10

We do not claim (point four) that poorer Indigenous outcomes from cancer are only a result of different belief systems; what we have argued is that beliefs influence health behaviours and health care seeking. For example, Indigenous Australians as a group are not reaping the benefits that have occurred as a result of modern cancer interventions where cancer mortality rates in the Australian population overall have dropped by 12% between 1993 and 2003.11 Addressing this discrepancy is more likely to come from engagement with Indigenous people to better understand their beliefs and their barriers to accessing care than from ongoing investment in new chemotherapeutic drugs and high technology treatments, where most investment in cancer research goes. We agree that access to appropriate services underpins better outcomes. We were astounded at the dearth of published studies on Indigenous beliefs in relation to cancer from the four countries. Publication of qualitative studies is always selective in terms of the quotations drawn upon, and we reported only common beliefs across more than one of the Indigenous populations under consideration, as described in the methodology.

Finally, we are well-acquainted with the requirements upon researchers when undertaking research with Indigenous Australians,12 and a strong focus of our work has been on research that can make a difference, build the capacity of researchers (Indigenous and non-Indigenous) and strengthen partnerships between Indigenous and non-Indigenous people and organisations.