The cultural and historical heritage of Indigenous societies around the world is incredibly rich and diverse and is connected by common threads, including holistic notions of health that are grounded in spiritual values of interconnectedness with other living beings and nature. However, the ability of these societies to live and thrive in environments that are conducive to good health is severely challenged by another shared legacy — one of colonialism, historical trauma and structural racism.

Indigenous peoples are burdened by deep health inequities, including a substantial disparity in life expectancy, which can be up to 20 years lower than that of non-Indigenous populations1. Non-communicable diseases, including chronic kidney disease (CKD)2, are key contributors to this premature mortality, and interventions to improve Indigenous health will only succeed if the factors that drive the high prevalence and poor outcomes of these chronic conditions are addressed.

CKD among Indigenous people is most often accompanied by comorbidities such as diabetes or hypertension, which not only represent important CKD risk factors but also contribute to adverse outcomes2. CKD hospitalizations and mortality are also disproportionately high among Indigenous people, as is the incidence of kidney failure, which reflects a higher risk of accelerated CKD progression2. The effect of this heightened disease burden is exacerbated by inequities in access to healthcare, including kidney transplantation, with lower rates of transplantation and longer waiting times reported for Indigenous people compared with their non-Indigenous counterparts3.

Several factors contribute to these kidney health inequities, including social exclusion, financial disadvantage, and remote or rural living with environmental destruction, factors that are all linked to a legacy of colonialism and discrimination. A systemic mistrust of non-Indigenous health services has subsequently ensued. Lack of cultural competency in non-Indigenous healthcare settings further compromises cultural safety and, consequently, patient outcomes. The limited availability of healthcare services within Indigenous communities creates another access barrier for patients, as they are required to leave the safety of their communities and cultural roots to access specialist care.

Given the multitude of factors that underlie Indigenous kidney health disparities, multipronged interventions that are adapted to local circumstances and address individual, microsystem, exosystem and macrosystem factors3 are required to improve patient outcomes. Political will is key to enact change at the macrosystem level — historical disempowerment and minoritization, and their long-lasting effect on local cultures and values2,3, can only be addressed through direct acknowledgment of the harm done and active implementation of policies aimed at redressing current inequities. At the exosystem and microsystem levels, interventions are needed to ensure that Indigenous communities can live in a healthful environment that also promotes healthy lifestyle choices (including access to affordable, nutritious and culturally appropriate food), provides safe spaces for community gathering and physical activity, and where basic rights such as access to clean and safe water are guaranteed. Moreover, effective, culturally safe telehealth and community-based healthcare, including community house dialysis programmes, can mitigate some of the barriers associated with remote dwelling and social exclusion2.

Indigenous representation and self-determination are key at all levels of intervention, and ‘two-eyed seeing’ — in which Indigenous and non-Indigenous knowledge and views are both respected and integrated4 — represents a guiding principle for meaningful change. Indigenous-led health education and disease screening initiatives that are aligned with local Indigenous traditions and values, as well as being strength-based and empowering, are crucial to improving kidney health literacy, enabling effective personal health management and reducing disease incidence2,3. The same principles apply to research initiatives and should be at the core of healthcare policy development.

“multilevel interventions that …enhance Indigenous representation and self-determination are urgently needed”

Global health disparities among Indigenous populations are stark and multilevel interventions that not only dismantle the systemic structures that perpetuate the harms of colonialism but also enhance Indigenous representation and self-determination are urgently needed. Such policies would enable and empower Indigenous communities to develop and preserve healthful environments, which — combined with access to supportive healthcare and health education that respects Indigenous traditions and values — could begin to improve Indigenous health outcomes around the world.