Compliance, culture, and the health of Indigenous people

From the medical literature of the 70's to recent research, compliance has been named as an issue in the management of chronic disease, particularly in Indigenous contexts. Compliance can also be thought of as a universal problem that has different names in different contexts. In this paper compliance is described as a measure, with a numerator and a denominator, and progress towards better compliance is discussed in terms of manipulation of each element. The numerator is adherence, which has proven resistant to significant improvement, and the denominator is the advice and treatment, based on Western scientific medicine. Reduced to its most elemental terms, compliance compares the beliefs of patients with those of Western medicine. Proposed solutions to improve compliance have included moving to 'concordance' by reaching shared understanding of treatment goals, or forgetting compliance altogether and concentrating on institutional and organisational change to better align services with expectations of the population of interest. Indigenous Australian health care has been particularly beset with treatment failure as a result of 'poor compliance'. This paper suggests that compliance per se is not the problem. Rather, the extent to which it is apparent is a measure of dissonance between the belief systems. This gap between the culture of Western medicine and Indigenous culture should not be narrowed by the extinction of Indigenous belief, but by the development of a shared knowledge which includes Indigenous health beliefs and practices.