Why Achieving Health Equity for Indigenous Peoples Requires Indigenizing the Social Determinants of Health

Indigenous peoples in the United States experience significant health disparities. American Indians and Alaska Natives (AI/ANs) have the highest prevalence of type 2 diabetes of any population group in the country¹; higher incidence rates of liver, stomach, kidney, lung, colorectal, and breast cancers than other populations²; and the highest age-adjusted suicide rates of any population group.³ The life expectancy of AI/ANs is seven years less than that of the US general population,⁴ declining from 72 years in 2019 to 65 years in 2021.⁴ Although the COVID-19 pandemic led to a dramatic drop in life expectancy among AI/ANs, COVID-19 alone does not account for this disparity.⁵ During the two decades before COVID-19, the life expectancy of AI/ANs remained stagnant while continuing to rise in all other population groups.⁵ Similar trends have been observed in Canada, New Zealand, and Australia, where gaps in health outcomes between Indigenous and non-Indigenous people are stagnating and, in some cases, even worsening.⁶

The social determinants of health (SDOH)—the social conditions in which people are born, grow, live, and age—are widely recognized as the primary influences of health. The World Health Organization and others expand on these determinants to include structural determinants such as governance, macroeconomic policies, social policies, culture, and societal values.

In this issue of AJPH, Oré et al. (p. 726) assert that the pervasive nature of AI/AN health disparities highlights limitations of the current framing of the SDOH for Indigenous peoples. The authors describe interconnected social contexts and conditions beyond the mainstream SDOH that shape the health and well-being of Indigenous peoples. They propose four important constructs to guide an Indigenous SDOH framework: sovereignty and governance, language and identity, land and kinship, and Indigenous knowledge, worldviews, and practices. They argue that incorporating these constructs into an SDOH framework is necessary to eliminate Indigenous health disparities and provides a lens to recognize the unique histories, strengths, and challenges faced by Indigenous communities. The authors emphasize the importance of co-creating SDOH frameworks alongside Indigenous communities using a collaborative approach to ensure that Indigenous knowledge systems and lived experiences are centered, positioning this work as a critical contribution to decolonizing public health and eliminating disparities.

We agree with this important reframing and extend the authors’ perspective to include two additional points. First, structural racism and settler colonialism are interrelated, ongoing, and enduring forces that undermine the health of Indigenous peoples and other racial groups and must be included in SDOH frameworks to more effectively address health disparities.⁷ Second, an Indigenous SDOH model such as that proposed by Oré et al. offers lessons not just for Indigenous health but also for reimagining health systems for all peoples.

The current SDOH framework fails to include many of the integral factors causing health disparities, perhaps most important structural racism. Yearby⁸ argues that structural racism, the way systems are structured to advantage the majority and disadvantage racial and ethnic minorities, is the root cause of racial health disparities. Yearby outlines several ways in which US law structures the employment system in a racially discriminatory way, resulting in racial health disparities.⁸ For Indigenous populations, who globally experience the greatest disparities in health, settler colonialism is identified as the most important determinant of health and further elucidates racism’s impact on health.⁷ Even modern racialization is seen as an extension of settler colonialism and serves to solidify colonial powers.⁷

All of the determinants of health for Indigenous peoples—social and structural—interact with and are affected by settler colonialism as it manifests in both historical and contemporary ways. For example, Indigenous erasure, the process whereby settler societies disregard and eliminate the presence of AI/AN peoples, cultures, knowledges, and sovereignty, is evidenced in the ongoing exclusion of AI/ANs from national health data sets and the narrative that all AI/ANs have long vanished.⁹ Efforts to eliminate tribal sovereignty,¹⁰ assimilate AI/AN culture,¹¹ and pollute and exploit AI/AN lands^12–14 are continuous and persistent. Because structural racism and settler colonialism are intertwined—one cannot exist without the other—these powerful forces continue to threaten and undermine the health of Indigenous people as well as the health of the planet. Explicitly naming these forces in SDOH frameworks alone is not sufficient, but it will allow the opportunity to further understand health disparities from Indigenous perspectives and develop interventions that can more effectively eliminate Indigenous health disparities.

Oré et al. propose constructs of sovereignty, identity, kinship, and intergenerational knowledge that are rooted in Indigenous experiences, worldviews, and intergenerational wisdom. However, these constructs hold resonance for more than just Indigenous peoples. Indigenous frameworks and conceptualizations of health often emphasize the interconnectedness of physical, spiritual, emotional, and relational health as inseparable components of well-being. This holistic approach to health recognizes the complexity of human health and offers an approach rooted in health as a collective value and responsibility, addressing gaps in Western health systems that often compartmentalize care and neglect relational and environmental dimensions of health.

As noted by Ore at al., for Indigenous peoples the physical world is inseparable from human experience. Extending this perspective beyond Indigenous peoples, it becomes clear that all people are inextricably linked to their environments through the food they eat, the water they drink, and the air they breathe. Indigenous peoples, as the original stewards of Turtle Island (now North America), hold invaluable knowledge about how to live in reciprocity with land and waterways to promote holistic health, not only for humans but for all of our relations. Indigenous teachings and worldviews remind us that health, rather than being an individual endeavor, is a collective responsibility that requires reciprocity with ourselves, one another, and the natural world. By applying values from these Indigenous-centered frameworks, public health systems can move toward more comprehensive and relational strategies to improve the health of all people.

The constructs proposed by Oré et al. and other Indigenous-centered frameworks are crucial not only for their potential to eliminate health disparities in Indigenous communities but also because they offer perspectives to guide the field of public health to be a more inclusive, effective, and socially just discipline that serves the holistic health needs of all people. Indigenous health frameworks are not just for Indigenous peoples; they are powerful blueprints for building holistic and sustainable health systems that benefit all people.

To translate Indigenous-centered frameworks into meaningful change, the public health community must take deliberate, collaborative, and sustained actions. Policymakers, researchers, and public health practitioners have an opportunity—and a responsibility—to create environments where Indigenous health frameworks can thrive. Long-term investments in Indigenous-led health initiatives, including research, education, and program development, are essential for creating systems that align with Indigenous values and knowledge. Public health systems should seek to learn from and integrate Indigenous knowledge and practices while ensuring that these collaborations are equitable and rooted in mutual respect. Educational initiatives that elevate Indigenous perspectives in public health curricula, such as the Indigenous SDOH training developed by Oré et al., can help train the next generation of practitioners to approach public health work with cultural humility and relational accountability.

Finally, public health must embrace its role in addressing the structural inequities, including settler colonialism, that perpetuate health disparities. By centering Indigenous health frameworks, we can reimagine public health systems that honor the interconnectedness of people, communities, and the natural world and the transformative power in these connections. The time for action is now, and the path forward is clear: build with, listen to, and amplify Indigenous voices so that good health becomes a shared reality for all.