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Healing through language: Positive physical health effects of indigenous language use

Healing through language: Positive physical health effects of indigenous language use F1000Research 2016, 5:852 Last updated: 19 JUL 2019 REVIEW Healing through language: Positive physical health effects of indigenous language use [version 1; peer review: 2 approved with reservations] 1-4 5 66 D. H. Whalen , Margaret Moss , Daryl Baldwin Endangered Language Fund, New Haven, CT, USA Speech-Language-Hearing Sciences, Graduate Center, City University of New York, New York, NY, USA Haskins Laboratories, New Haven, CT, USA Linguistics, Yale University, New Haven, CT, USA School of Nursing, University of Buffalo, Buffalo, NY, USA The Myaamia Center, Miami University, Oxford, OH, USA First published: 09 May 2016, 5:852 ( Open Peer Review v1 https://doi.org/10.12688/f1000research.8656.1) Latest published: 09 May 2016, 5:852 ( Reviewer Status     https://doi.org/10.12688/f1000research.8656.1) Abstract   Invited Reviewers This article summarizes existing work that indicates language maintenance 1 2 and revitalization efforts result in health-related benefits for Native Americans and other indigenous populations. Although forced loss of version 1 ancestral language has been a feature of life in most indigenous published report report communities since the first contact with Europeans, the pace of loss has 09 May 2016 accelerated in the past 50 years. Among the many hardships such communities face, an especially troubling one is lowered health status. Richard T Oster, University of Alberta, There are indications, however, that language maintenance and Edmonton, Canada revitalization efforts have positive effects on physical and communal health among indigenous populations. The types of language programs currently Terryann Coralie Clark, University of Auckland, in place are outlined along with a variety of studies that will measure health Auckland, New Zealand improvement outcomes correlated with language revitalization efforts. Such evidence justifies increased support for language revitalization in order to Any reports and responses or comments on the improve health. article can be found at the end of the article. Keywords indigenous health , language , Native American , revitalization , community Corresponding author: D. H. Whalen ([email protected]) Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2016 Whalen DH et al. This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite this article: Whalen DH, Moss M and Baldwin D. Healing through language: Positive physical health effects of indigenous language use [version 1; peer review: 2 approved with reservations] F1000Research 2016, 5:852 ( https://doi.org/10.12688/f1000research.8656.1) First published: 09 May 2016, 5:852 (https://doi.org/10.12688/f1000research.8656.1)  Page 1 of 10 F1000Research 2016, 5:852 Last updated: 19 JUL 2019 have a higher rate of disability than any other single group at 15%, Introduction almost 25% higher than for whites. While some of this is due to Indigenous communities have some of the worst health outcomes rural poverty, disparities are profound even within urban areas (as within their larger societies (Gracey & King, 2009). This is true reported for Canada) (Firestone et al., 2014). across the world, for example, in Australia and New Zealand (Anderson et al., 2006), Latin America (Pan American Health Organization, 2001), Canada (Frohlich et al., 2006), and the United Current, low socio-economic status clearly is a major factor for States (U.S. Commission on Civil Rights, 2004). Although many poor health outcomes in NAs, but NA health today also results from factors, such as location, poverty, and access to health facilities, historical trauma and its inter-generational continuation. Federal contribute to this disparity, there is a growing recognition that Indian Policies from 200 years of removal, reservations, relocation/ historical trauma plays a role as well (Duran et al., 1998; Sotero, assimilation, termination, and language eradication have resulted 2006). The present survey examines published studies that address in loss of identity, shame, guilt, unresolved grief and depression one salient means of recovering from historical trauma, namely, (Brave Heart & DeBruyn, 1998; Oster et al., 2014), key features of maintenance and revitalization of indigenous language. These historical trauma. In today’s Native America, extreme poverty, poor studies consistently find that there are physical health advantages health, and high homicide and suicide rates are tragic outcomes to be gained from such efforts. of this historical trauma (Brave Heart & DeBruyn, 1998; Sotero, 2006). The ways in which languages emerge, evolve, and fall dormant have been increasingly discussed by linguists, biologists and cogni- Indigenous language loss and language use tive scientists in the last two decades (Hale et al., 1992; Wang & The loss of languages worldwide has been substantial over the Minett, 2005). However, health scientists have not largely embraced past 200 years. Many linguists estimate that half to 90% of the this discussion as relevant. Although native language is sometimes world’s languages will be moribund by the end of this century mentioned in “health literacy” (e.g. Berkman et al., 2011), health (Grenoble & Whaley, 1998; Hale et al., 1992; Whalen & Simons, related outcomes as a result of language maintenance and revitali- 2012). Even so, there was little concentrated effort to retain and zation efforts have not received much attention. Here, we explore revitalize language among NA communities until recently, aided by the limited existing literature on health outcomes of indigenous lan- the passage of the Native American Languages Act of 1990. Despite guage use and outline promising research avenues for the future. subsequent progress, NA languages are still rapidly losing speakers and the knowledge residing in their languages. Language is a uniquely efc fi ient means of maintaining and passing on crucial cultural knowledge and thus promotes cultural diversity Language and culture are intertwined, and neither completely (McCarty & Zepeda, 2010). Although languages have come and determines the other (McCarty & Zepeda, 2010), but language use gone throughout history, indigenous languages in a variety of post- is a substantial indicator of cultural coherence. Many NA com- colonial situations have been oppressed through official policies and munities are engaged in the revival of language and culture (see social pressures (Dussias, 1999; Oster et al., 2014). These forced examples Table 1), and raising the health of the community is often language shifts caused the loss of social and behavioral knowledge an explicit goal. For example, Stephanie Fielding (Mohegan Tribe, and understanding that was created over millennia, ultimately con- Council of Elders), states, “The Mohegan language program is tributing to disastrous, endemic health deficits ( Gracey & King, more than a cultural effort, it is aimed at bringing our community 2009; Hallett et al., 2007; King et al., 2009). together to improve its cohesion and health” (personal communica- tion, 20 April 2016). There are indications that such efforts can be successful (e.g., Hinton, 2001:225), but the next section will survey Emerging evidence (see “Existing studies” section below) ties indi- published studies that more directly assess the effects of language vidual and/or communal health to efforts that promote ancestral maintenance (i.e., for first language (L1) speakers) and language language and cultural fluency in a community-driven educational revitalization (i.e., for second language (L2) learners). environment. Some of the literature addresses indigenous groups affected by the four settler states of the United States (US), Canada, New Zealand and Australia. The similarities in colonialism, history Existing studies and outcomes for the original peoples outweigh the inevitable dif- Native health, from their own perspective, includes four domains: ferences in specific situations. Further, the political boundaries spiritual, mental, emotional and physical; a disruption in any part, between Canada and the US do not reflect original use and are often is a loss in ‘health’ (Moss, 2015). More often there are several unrecognized by the first peoples. Here, indigenous people of North domains affected, so each must be considered in this discussion. America (hereafter, called Native Americans or (NA)) will be an exemplar as we explore the ability to use one’s ancestral language Spiritual life has always been key for American Indians. Intergen- as a knowledge-seeking catalyst to optimize health. erational trauma or historical trauma has been termed as a ‘spiritual injury’, or ‘soul wound’. A large driver of this trauma was the taking away of language (Duran et al., 1998). Prayers and ‘medicine men’ Health status have utilized indigenous languages traditionally (Moss, 2000). In Native Americans suffer some of the poorest health statuses and many cases it is the spirit that is being healed. health outcomes of any other racial group in the US (Indian Health Service, 2014). This includes shorter lifespans, higher death rates While the present survey focuses on the physical effects, men- from a wide variety of causes, and more limited access to health tal and emotional factors certainly play a role in suicide. services. According to the 2010 American Community Survey, NA Page 2 of 10 F1000Research 2016, 5:852 Last updated: 19 JUL 2019 Table 1. Types of language learning environments and programs for Native American (NA) languages. L1/L2 indicates whether the language is a first language (L1) or learned later in life (L2) for the target population. Ratings of “poor” are often due to small numbers available. Type of Environment/ Examples L1/L2 Feasibility Feasibility Program for Use in for Use in Retrospective Prospective Research Research Learning from L1 parents Previously: About 200 US NA languages; L1 Good Poor currently: about 30; www.ethnologue.org Regular gatherings of L1 Zuni (Moss, 2000); Wisconsin “keckīwak L1 Moderate Good speakers elders” meetings Master/Apprentice Cf. Hinton (2001) L1 + L2 Poor Poor School instruction, Cf. Cantoni (1996) L2 Moderate Good classroom Immersion schools Hawaiian (Wilson, 2012); Alutiiq L2 + L1 Good Good (www.alutiiqlanguage.org) Learning from L2 parents Myaamia (www.myaamiacenter.org); L2 + L1 Poor Moderate Wampanoag (www.wlrp.org) Hallett et al. (2007) found the youth suicide rate for indigenous by the National Institutes of Health, in a Hawaiian language bands in British Columbia in which 50% of the community is con- immersion school. The Nāwahī program in Hawaii has a 100% th versationally fluent (L1) to be 1/6 that of less fluent bands. The graduation rate (Wilson, 2012), compared to 70% for standard language factor was predictive even when other correlated cultural schools (Kamehameha Schools, 2009). factors were subtracted from the analysis. Why focus on language? On the physical side, another study found that the percentage of Language transmission is a particularly effective means of rein- smokers in US Southwestern tribes, where indigenous languages forcing culture and has the benefit of integrating most cultural and are widely spoken, was only 14 percent as compared to 50 per- communal activities. Language is also an extremely efficient means cent among Northern Plains tribes, where language use is sparse of establishing membership or inclusion in a community. Studies (Nez Henderson et al., 2005). A survey study in California (Hodge that might disentangle language and culture are possible, but the & Nandy, 2011:797) found that those who could speak their ances- approach argued for here takes it as a given that language is the tral language were more frequently classified in a (within-study most efficient means of transmitting, maintaining, and even reviv - defined) “good” wellness group (82.4%) than were those who could ing culture. not speak it (70.1%). A survey of residents of the Hopi reservation found that language use was positively correlated with “practicing There are different kinds of environments and programs for lan- Hopi behaviors to keep healthy” (Coe et al., 2004:405). A recent guage learning and use (Table 1). Evaluation can be a challenge, study found that Canadian First Nations groups with greater cul- whether the study is retrospective or prospective, due to large dif- tural retention, as indexed by language use, had significantly lower ferences in specifics and small numbers in many cases. Census data rates of diabetes after factoring out socioeconomic factors (Oster can, with limitations, add to the results. Prospective studies could et al., 2014). All of these studies combined L1 and L2 speakers. compare such health measures as absentee rates from school or changes in the Youth Risk Behavior Surveillance System (YRBSS; In Australia, speaking an Aboriginal and/or Torres Strait Islander Centers for Disease Control and Prevention, 2004). While indirect, language was found to reduce several health risk factors such as these measures can be obtained for all children, allowing larger excessive alcohol consumption (8% vs. 18% for English monolin- cohorts than would be possible if only eventual negative outcomes guals), illicit drug use (16% vs. 26%), and violence victimization were measured. (25% vs. 37%) (Australian Institute of Aboriginal and Torres Strait Islander Studies (AIATSIS), 2005:3). Those who spoke their The main recommendation suggested by these studies, then, is heritage language were also found to have half the rate of “poor that language programs prospectively include assessment of health health” as those who had switched to English (Trewin & Madden, outcomes along with the core of the program (see also Marmion 2005:95). Alcohol, violence and drug use (especially methampheta- et al., 2014:46). In this way, samples across the wide variety of mines) are problematic in NA populations at rates exceeding the programs can be compared, with the expectation that those with the general US population (IHS, 2014:191). most positive health outcomes can be replicated in other programs. Comparisons, both in effectiveness and cost, to standard health One result based exclusively on L2 learners examined high programs are also needed, given that language programs are school graduation rates, which are taken as a health indicator typically less expensive than many other types of programs. Page 3 of 10 F1000Research 2016, 5:852 Last updated: 19 JUL 2019 Speaking an indigenous language in and of itself may not be Conclusion solely responsible for improved health status; rather, community Language programs in NA communities hold the promise of validation of the indigenous knowledge system, community-driven improving the mental and physical health of those who participate tribal education, comprehending indigenous medicine, and youth in them. All generations seem able to take advantage of this pos- empowerment through language and culture identity formation all sibility. Data exist on palliative effects of use of a Native language play significant roles in the ability of a minority language to thrive and/or cultural practices on smoking (Nez Henderson et al., 2005), and for the community to experience healthy outcomes from the suicide rates (Hallett et al., 2007) and alcohol (Torres Stone et al., collective effort. 2006; Whitbeck et al., 2004) and substance abuse (First Peoples’ Heritage Language and Culture Council, 2012:213), but many more issues are likely to be evident as more data are collected. A return to native spirituality has been shown to improve treatment results (Berry et al., 2012; Gone & Calf Looking, 2015), an effect Author contributions that could be expected to increase with inclusion of the ancestral All authors reviewed the literature and provided input to and language. As Tulloch et al. (2013) point out, the many informal reviewed all drafts of the manuscript. programs that have appeared recently are not well studied and may require novel methodologies. Competing interests No competing interests were disclosed. The Endangered Language Fund has launched a program called Healing Through Language to facilitate the support and assessment Grant information of language programs throughout Native America (www.healing- The author(s) declared that no grants were involved in supporting throughlanguage.org). Communities throughout the US and else- this work. where have started language programs with a wide range of models. Because this one type of program can, apparently, lead to positive Acknowledgements outcomes in so many areas, we would expect to find a substan - Helpful comments were provided by Monica Macaulay, Alice Taff, tial return in health benefits on investment in language programs in Susan Penfield and Linda Mayes. Native America. 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Terryann Coralie Clark  Department of Nursing, U. Auckland/MPH, Ph.D., Auckland, New Zealand Thank you for the opportunity to review this review. I think this article is of significant importance for indigenous peoples and links ancestral  wisdom with some evidence. I do think that the article is weak in some areas: Abstract I think the abstract could stronger. It is unclear what you conclude and what evidence you have. e.g. Evidence suggests that language maintenance can be associated with improved health, social and education outcomes for American Indians an indigenous populations. This is evidenced by ... Introduction The links between language and well-being need to be stronger. Need more evidence that language is associated with well-being. What is the theories about how language and cultural maintenance, cultural connection improve outcomes? Think your paper would be stronger if it maintained its international literature focus - there is more evidence if you use Australia, NZ and other indigenous people. Need to state what the purpose of the paper is. What you intend to review. Health status This section could be stronger. There is a lot of evidence about poor health among indigenous peoples. What is health from an indigenous perspective? Indigenous language and loss Talking about 'language loss' suggests that it was somehow accidental. Language was a purposeful way to colonise indigenous peoples.   Existing studies (Evidence to support language revitalisation?) Not sure about this heading - what is meant by existing studies? Watch causation language - these are associations e.g. "speaking an indigenous language was found to reduce several health risks (p.3) " - should read speaking and indigenous language was associated with reduced risk. Page 6 of 10 F1000Research 2016, 5:852 Last updated: 19 JUL 2019 Why focus on language? Think this section should come earlier - what is the theory that language is a powerful protective factor? The table provided is unrelated to the content and doesn't add much. Unsure what this is for - link to purpose statement at the beginning. e.g. The purpose of this review is to review the literature about the importance of language to indigenous well-being and identify the programmes and data available that might be evaluated? Need more on this as it is not clear from your review. Conclusions Should be more focused. Overall - I think this is useful information for indigenous peoples but it requires a significant restructure and rewrite to make it cohesive. Competing Interests: No competing interests were disclosed. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Reviewer Report 07 June 2016 https://doi.org/10.5256/f1000research.9315.r14162 © 2016 Oster R. This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Richard T Oster  Department of Medicine, U. Alberta/Ph.D., Edmonton, AB, Canada This is a timely and important article. Indigenous peoples continue to voice the importance of culture and language revitalization for their well-being. As a result, more and more research is being conducted linking language and health in Indigenous populations. A review or summary of that work is needed, hence the current article. I commend the authors for undertaking this vital task. Generally, the article is well written and informative. However, I found that some sections were not thoroughly explored and the authors would do well by deepening their literature review and expanding on their ideas. My comments are as follows: 1.  I suggest the authors capitalize the term “Indigenous” throughout the article. 2.  Abstract, third sentence: it is not clear what the authors mean by “communities” here. Also, Page 7 of 10 F1000Research 2016, 5:852 Last updated: 19 JUL 2019 2.  Abstract, third sentence: it is not clear what the authors mean by “communities” here. Also, compared to what population is their “lowered health status”? 3.  Abstract: it would be useful to add a sentence on how language revitalization is thought to improve health. 4.  Introduction: the authors state that this current article is a survey. This is a bit confusing. The authors should be clear on what type of article this is. It is not a quantitative survey, systematic review, meta-analysis, review, or literature search. As the article is now, an “opinion piece” seems more appropriate. However, I’m hoping that the authors can expand on many of their ideas and explore the known literature further. In which case, the article may be appropriately termed a “review”. 5.  Introduction, paragraph 3, last sentence: I’m not sure that the references cited support the claim being made that language shifts have caused the health deficits we see today among Indigenous populations. Perhaps the authors can rework this sentence. 6.  Health status: this is one of the sections that seems lacking in its scope. Perhaps the authors can expand and describe some of the major health disparities among Indigenous populations. Some epidemiological data would be helpful to the reader to understand the scope of the disparities. 7.  Indigenous language loss and language use: it would be helpful to the reader if the authors provided examples of some of the Indigenous languages. What are some of the major Indigenous languages worldwide? How many are there? How many have been lost? It would also be helpful if the authors provided some data on how much Indigenous languages are being spoken today around the world and in North America. 8.  Existing studies and why focus on language sections: These sections in particular need to be expanded upon. Are the authors able to conduct a formal literature search? Perhaps with keywords? Also, the authors may want to explore and include other literature that has explored the relationship between language/culture and emotional/mental health. The extensive writings of Laurence Kirmayer come to mind as a good place to start. What is explicitly missing from this article is the how piece... How does language revitalization lead to better health? Is it due to enhanced sense of identity (as Chandler and Lalonde argue)? Enhanced spiritual health? Enhanced sense of community/belonging? The provision of strong role models that teach the language? Protection from early life traumas? There is also an entire field of neurological research that has looked at how learning multiple languages can impact the brain and health. The authors would do well to explore these different areas and give the reader an idea on the how. Even looking into some of the qualitative research with Indigenous peoples suffering from some of the major health problems that Indigenous populations face (e.g. diabetes) would be beneficial as often language/culture is brought up as a key determinant of health in these studies. Moreover, has there been research that has shown not shown a relationship between language and health? Lastly, second paragraph, last sentence: Has there been work done that specifically examined language loss and sense of spiritual well-being? 9.  I was pleased that the authors recommend that future studies aimed at language revitalization include assessments of health outcomes. Perhaps the authors could expand on what these health assessments may look like? What should be measured and how? 10.  Conclusion: It would make more sense perhaps to include and expand upon the Berry 2012, Gone Page 8 of 10 F1000Research 2016, 5:852 Last updated: 19 JUL 2019 10.  Conclusion: It would make more sense perhaps to include and expand upon the Berry 2012, Gone 2015, and Tullouch 2013 references in the “existing studies” or “why focus on language” sections. 11.  Last paragraph of conclusion: the ideas presented in this paragraph seem to come out of nowhere as they have not been discussed earlier in the article. Again, the authors would do well to really spend some time reading and then summarizing in the “existing studies” or “why focus on language” sections the known literature on how and why language revitalization may lead to improved health. These sections are the place (as opposed to the conclusion) to introduce and describe in-depth the other contributors related to speaking an Indigenous language that may be responsible for improved health status. Competing Interests: No competing interests were disclosed. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Comments on this article Version 1 Reader Comment 10 May 2016 Nick Thieberger, University of Melbourne, Australia Some additional references that may be useful: Bialystok, E., Craik, F. & G. Luk, G. 2012. Bilingualism: consequences for mind and brain. Trends in Cognitive Sciences 16(4): 240-250. Biddle, N. and H. Swee. 2012. ‘The Relationship Between Wellbeing and Indigenous Land, Language and Culture in Australia’. Australian Geographer 43: 215–232.  Waldram, James B. 2009. The persistence of traditional medicine in urban areas: the case of Canada's Indians. Am Indian Alsk Native Ment Health Res.  1990 4(1):9-29. Competing Interests: No competing interests were disclosed. 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Healing through language: Positive physical health effects of indigenous language use

Whalen, D. H.; Moss, Margaret; Baldwin, Daryl
F1000Research – May 9, 2016
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F1000Research 2016, 5:852 Last updated: 19 JUL 2019 REVIEW Healing through language: Positive physical health effects of indigenous language use [version 1; peer review: 2 approved with reservations] 1-4 5 66 D. H. Whalen , Margaret Moss , Daryl Baldwin Endangered Language Fund, New Haven, CT, USA Speech-Language-Hearing Sciences, Graduate Center, City University of New York, New York, NY, USA Haskins Laboratories, New Haven, CT, USA Linguistics, Yale University, New Haven, CT, USA School of Nursing, University of Buffalo, Buffalo, NY, USA The Myaamia Center, Miami University, Oxford, OH, USA First published: 09 May 2016, 5:852 ( Open Peer Review v1 https://doi.org/10.12688/f1000research.8656.1) Latest published: 09 May 2016, 5:852 ( Reviewer Status     https://doi.org/10.12688/f1000research.8656.1) Abstract   Invited Reviewers This article summarizes existing work that indicates language maintenance 1 2 and revitalization efforts result in health-related benefits for Native Americans and other indigenous populations. Although forced loss of version 1 ancestral language has been a feature of life in most indigenous published report report communities since the first contact with Europeans, the pace of loss has 09 May 2016 accelerated in the past 50 years. Among the many hardships such communities face, an especially troubling one is lowered health status. Richard T Oster, University of Alberta, There are indications, however, that language maintenance and Edmonton, Canada revitalization efforts have positive effects on physical and communal health among indigenous populations. The types of language programs currently Terryann Coralie Clark, University of Auckland, in place are outlined along with a variety of studies that will measure health Auckland, New Zealand improvement outcomes correlated with language revitalization efforts. Such evidence justifies increased support for language revitalization in order to Any reports and responses or comments on the improve health. article can be found at the end of the article. Keywords indigenous health , language , Native American , revitalization , community Corresponding author: D. H. Whalen ([email protected]) Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2016 Whalen DH et al. This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite this article: Whalen DH, Moss M and Baldwin D. Healing through language: Positive physical health effects of indigenous language use [version 1; peer review: 2 approved with reservations] F1000Research 2016, 5:852 ( https://doi.org/10.12688/f1000research.8656.1) First published: 09 May 2016, 5:852 (https://doi.org/10.12688/f1000research.8656.1)  Page 1 of 10 F1000Research 2016, 5:852 Last updated: 19 JUL 2019 have a higher rate of disability than any other single group at 15%, Introduction almost 25% higher than for whites. While some of this is due to Indigenous communities have some of the worst health outcomes rural poverty, disparities are profound even within urban areas (as within their larger societies (Gracey & King, 2009). This is true reported for Canada) (Firestone et al., 2014). across the world, for example, in Australia and New Zealand (Anderson et al., 2006), Latin America (Pan American Health Organization, 2001), Canada (Frohlich et al., 2006), and the United Current, low socio-economic status clearly is a major factor for States (U.S. Commission on Civil Rights, 2004). Although many poor health outcomes in NAs, but NA health today also results from factors, such as location, poverty, and access to health facilities, historical trauma and its inter-generational continuation. Federal contribute to this disparity, there is a growing recognition that Indian Policies from 200 years of removal, reservations, relocation/ historical trauma plays a role as well (Duran et al., 1998; Sotero, assimilation, termination, and language eradication have resulted 2006). The present survey examines published studies that address in loss of identity, shame, guilt, unresolved grief and depression one salient means of recovering from historical trauma, namely, (Brave Heart & DeBruyn, 1998; Oster et al., 2014), key features of maintenance and revitalization of indigenous language. These historical trauma. In today’s Native America, extreme poverty, poor studies consistently find that there are physical health advantages health, and high homicide and suicide rates are tragic outcomes to be gained from such efforts. of this historical trauma (Brave Heart & DeBruyn, 1998; Sotero, 2006). The ways in which languages emerge, evolve, and fall dormant have been increasingly discussed by linguists, biologists and cogni- Indigenous language loss and language use tive scientists in the last two decades (Hale et al., 1992; Wang & The loss of languages worldwide has been substantial over the Minett, 2005). However, health scientists have not largely embraced past 200 years. Many linguists estimate that half to 90% of the this discussion as relevant. Although native language is sometimes world’s languages will be moribund by the end of this century mentioned in “health literacy” (e.g. Berkman et al., 2011), health (Grenoble & Whaley, 1998; Hale et al., 1992; Whalen & Simons, related outcomes as a result of language maintenance and revitali- 2012). Even so, there was little concentrated effort to retain and zation efforts have not received much attention. Here, we explore revitalize language among NA communities until recently, aided by the limited existing literature on health outcomes of indigenous lan- the passage of the Native American Languages Act of 1990. Despite guage use and outline promising research avenues for the future. subsequent progress, NA languages are still rapidly losing speakers and the knowledge residing in their languages. Language is a uniquely efc fi ient means of maintaining and passing on crucial cultural knowledge and thus promotes cultural diversity Language and culture are intertwined, and neither completely (McCarty & Zepeda, 2010). Although languages have come and determines the other (McCarty & Zepeda, 2010), but language use gone throughout history, indigenous languages in a variety of post- is a substantial indicator of cultural coherence. Many NA com- colonial situations have been oppressed through official policies and munities are engaged in the revival of language and culture (see social pressures (Dussias, 1999; Oster et al., 2014). These forced examples Table 1), and raising the health of the community is often language shifts caused the loss of social and behavioral knowledge an explicit goal. For example, Stephanie Fielding (Mohegan Tribe, and understanding that was created over millennia, ultimately con- Council of Elders), states, “The Mohegan language program is tributing to disastrous, endemic health deficits ( Gracey & King, more than a cultural effort, it is aimed at bringing our community 2009; Hallett et al., 2007; King et al., 2009). together to improve its cohesion and health” (personal communica- tion, 20 April 2016). There are indications that such efforts can be successful (e.g., Hinton, 2001:225), but the next section will survey Emerging evidence (see “Existing studies” section below) ties indi- published studies that more directly assess the effects of language vidual and/or communal health to efforts that promote ancestral maintenance (i.e., for first language (L1) speakers) and language language and cultural fluency in a community-driven educational revitalization (i.e., for second language (L2) learners). environment. Some of the literature addresses indigenous groups affected by the four settler states of the United States (US), Canada, New Zealand and Australia. The similarities in colonialism, history Existing studies and outcomes for the original peoples outweigh the inevitable dif- Native health, from their own perspective, includes four domains: ferences in specific situations. Further, the political boundaries spiritual, mental, emotional and physical; a disruption in any part, between Canada and the US do not reflect original use and are often is a loss in ‘health’ (Moss, 2015). More often there are several unrecognized by the first peoples. Here, indigenous people of North domains affected, so each must be considered in this discussion. America (hereafter, called Native Americans or (NA)) will be an exemplar as we explore the ability to use one’s ancestral language Spiritual life has always been key for American Indians. Intergen- as a knowledge-seeking catalyst to optimize health. erational trauma or historical trauma has been termed as a ‘spiritual injury’, or ‘soul wound’. A large driver of this trauma was the taking away of language (Duran et al., 1998). Prayers and ‘medicine men’ Health status have utilized indigenous languages traditionally (Moss, 2000). In Native Americans suffer some of the poorest health statuses and many cases it is the spirit that is being healed. health outcomes of any other racial group in the US (Indian Health Service, 2014). This includes shorter lifespans, higher death rates While the present survey focuses on the physical effects, men- from a wide variety of causes, and more limited access to health tal and emotional factors certainly play a role in suicide. services. According to the 2010 American Community Survey, NA Page 2 of 10 F1000Research 2016, 5:852 Last updated: 19 JUL 2019 Table 1. Types of language learning environments and programs for Native American (NA) languages. L1/L2 indicates whether the language is a first language (L1) or learned later in life (L2) for the target population. Ratings of “poor” are often due to small numbers available. Type of Environment/ Examples L1/L2 Feasibility Feasibility Program for Use in for Use in Retrospective Prospective Research Research Learning from L1 parents Previously: About 200 US NA languages; L1 Good Poor currently: about 30; www.ethnologue.org Regular gatherings of L1 Zuni (Moss, 2000); Wisconsin “keckīwak L1 Moderate Good speakers elders” meetings Master/Apprentice Cf. Hinton (2001) L1 + L2 Poor Poor School instruction, Cf. Cantoni (1996) L2 Moderate Good classroom Immersion schools Hawaiian (Wilson, 2012); Alutiiq L2 + L1 Good Good (www.alutiiqlanguage.org) Learning from L2 parents Myaamia (www.myaamiacenter.org); L2 + L1 Poor Moderate Wampanoag (www.wlrp.org) Hallett et al. (2007) found the youth suicide rate for indigenous by the National Institutes of Health, in a Hawaiian language bands in British Columbia in which 50% of the community is con- immersion school. The Nāwahī program in Hawaii has a 100% th versationally fluent (L1) to be 1/6 that of less fluent bands. The graduation rate (Wilson, 2012), compared to 70% for standard language factor was predictive even when other correlated cultural schools (Kamehameha Schools, 2009). factors were subtracted from the analysis. Why focus on language? On the physical side, another study found that the percentage of Language transmission is a particularly effective means of rein- smokers in US Southwestern tribes, where indigenous languages forcing culture and has the benefit of integrating most cultural and are widely spoken, was only 14 percent as compared to 50 per- communal activities. Language is also an extremely efficient means cent among Northern Plains tribes, where language use is sparse of establishing membership or inclusion in a community. Studies (Nez Henderson et al., 2005). A survey study in California (Hodge that might disentangle language and culture are possible, but the & Nandy, 2011:797) found that those who could speak their ances- approach argued for here takes it as a given that language is the tral language were more frequently classified in a (within-study most efficient means of transmitting, maintaining, and even reviv - defined) “good” wellness group (82.4%) than were those who could ing culture. not speak it (70.1%). A survey of residents of the Hopi reservation found that language use was positively correlated with “practicing There are different kinds of environments and programs for lan- Hopi behaviors to keep healthy” (Coe et al., 2004:405). A recent guage learning and use (Table 1). Evaluation can be a challenge, study found that Canadian First Nations groups with greater cul- whether the study is retrospective or prospective, due to large dif- tural retention, as indexed by language use, had significantly lower ferences in specifics and small numbers in many cases. Census data rates of diabetes after factoring out socioeconomic factors (Oster can, with limitations, add to the results. Prospective studies could et al., 2014). All of these studies combined L1 and L2 speakers. compare such health measures as absentee rates from school or changes in the Youth Risk Behavior Surveillance System (YRBSS; In Australia, speaking an Aboriginal and/or Torres Strait Islander Centers for Disease Control and Prevention, 2004). While indirect, language was found to reduce several health risk factors such as these measures can be obtained for all children, allowing larger excessive alcohol consumption (8% vs. 18% for English monolin- cohorts than would be possible if only eventual negative outcomes guals), illicit drug use (16% vs. 26%), and violence victimization were measured. (25% vs. 37%) (Australian Institute of Aboriginal and Torres Strait Islander Studies (AIATSIS), 2005:3). Those who spoke their The main recommendation suggested by these studies, then, is heritage language were also found to have half the rate of “poor that language programs prospectively include assessment of health health” as those who had switched to English (Trewin & Madden, outcomes along with the core of the program (see also Marmion 2005:95). Alcohol, violence and drug use (especially methampheta- et al., 2014:46). In this way, samples across the wide variety of mines) are problematic in NA populations at rates exceeding the programs can be compared, with the expectation that those with the general US population (IHS, 2014:191). most positive health outcomes can be replicated in other programs. Comparisons, both in effectiveness and cost, to standard health One result based exclusively on L2 learners examined high programs are also needed, given that language programs are school graduation rates, which are taken as a health indicator typically less expensive than many other types of programs. Page 3 of 10 F1000Research 2016, 5:852 Last updated: 19 JUL 2019 Speaking an indigenous language in and of itself may not be Conclusion solely responsible for improved health status; rather, community Language programs in NA communities hold the promise of validation of the indigenous knowledge system, community-driven improving the mental and physical health of those who participate tribal education, comprehending indigenous medicine, and youth in them. All generations seem able to take advantage of this pos- empowerment through language and culture identity formation all sibility. Data exist on palliative effects of use of a Native language play significant roles in the ability of a minority language to thrive and/or cultural practices on smoking (Nez Henderson et al., 2005), and for the community to experience healthy outcomes from the suicide rates (Hallett et al., 2007) and alcohol (Torres Stone et al., collective effort. 2006; Whitbeck et al., 2004) and substance abuse (First Peoples’ Heritage Language and Culture Council, 2012:213), but many more issues are likely to be evident as more data are collected. A return to native spirituality has been shown to improve treatment results (Berry et al., 2012; Gone & Calf Looking, 2015), an effect Author contributions that could be expected to increase with inclusion of the ancestral All authors reviewed the literature and provided input to and language. As Tulloch et al. (2013) point out, the many informal reviewed all drafts of the manuscript. programs that have appeared recently are not well studied and may require novel methodologies. Competing interests No competing interests were disclosed. The Endangered Language Fund has launched a program called Healing Through Language to facilitate the support and assessment Grant information of language programs throughout Native America (www.healing- The author(s) declared that no grants were involved in supporting throughlanguage.org). Communities throughout the US and else- this work. where have started language programs with a wide range of models. Because this one type of program can, apparently, lead to positive Acknowledgements outcomes in so many areas, we would expect to find a substan - Helpful comments were provided by Monica Macaulay, Alice Taff, tial return in health benefits on investment in language programs in Susan Penfield and Linda Mayes. Native America. 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Terryann Coralie Clark  Department of Nursing, U. Auckland/MPH, Ph.D., Auckland, New Zealand Thank you for the opportunity to review this review. I think this article is of significant importance for indigenous peoples and links ancestral  wisdom with some evidence. I do think that the article is weak in some areas: Abstract I think the abstract could stronger. It is unclear what you conclude and what evidence you have. e.g. Evidence suggests that language maintenance can be associated with improved health, social and education outcomes for American Indians an indigenous populations. This is evidenced by ... Introduction The links between language and well-being need to be stronger. Need more evidence that language is associated with well-being. What is the theories about how language and cultural maintenance, cultural connection improve outcomes? Think your paper would be stronger if it maintained its international literature focus - there is more evidence if you use Australia, NZ and other indigenous people. Need to state what the purpose of the paper is. What you intend to review. Health status This section could be stronger. There is a lot of evidence about poor health among indigenous peoples. What is health from an indigenous perspective? Indigenous language and loss Talking about 'language loss' suggests that it was somehow accidental. Language was a purposeful way to colonise indigenous peoples.   Existing studies (Evidence to support language revitalisation?) Not sure about this heading - what is meant by existing studies? Watch causation language - these are associations e.g. "speaking an indigenous language was found to reduce several health risks (p.3) " - should read speaking and indigenous language was associated with reduced risk. Page 6 of 10 F1000Research 2016, 5:852 Last updated: 19 JUL 2019 Why focus on language? Think this section should come earlier - what is the theory that language is a powerful protective factor? The table provided is unrelated to the content and doesn't add much. Unsure what this is for - link to purpose statement at the beginning. e.g. The purpose of this review is to review the literature about the importance of language to indigenous well-being and identify the programmes and data available that might be evaluated? Need more on this as it is not clear from your review. Conclusions Should be more focused. Overall - I think this is useful information for indigenous peoples but it requires a significant restructure and rewrite to make it cohesive. Competing Interests: No competing interests were disclosed. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Reviewer Report 07 June 2016 https://doi.org/10.5256/f1000research.9315.r14162 © 2016 Oster R. This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Richard T Oster  Department of Medicine, U. Alberta/Ph.D., Edmonton, AB, Canada This is a timely and important article. Indigenous peoples continue to voice the importance of culture and language revitalization for their well-being. As a result, more and more research is being conducted linking language and health in Indigenous populations. A review or summary of that work is needed, hence the current article. I commend the authors for undertaking this vital task. Generally, the article is well written and informative. However, I found that some sections were not thoroughly explored and the authors would do well by deepening their literature review and expanding on their ideas. My comments are as follows: 1.  I suggest the authors capitalize the term “Indigenous” throughout the article. 2.  Abstract, third sentence: it is not clear what the authors mean by “communities” here. Also, Page 7 of 10 F1000Research 2016, 5:852 Last updated: 19 JUL 2019 2.  Abstract, third sentence: it is not clear what the authors mean by “communities” here. Also, compared to what population is their “lowered health status”? 3.  Abstract: it would be useful to add a sentence on how language revitalization is thought to improve health. 4.  Introduction: the authors state that this current article is a survey. This is a bit confusing. The authors should be clear on what type of article this is. It is not a quantitative survey, systematic review, meta-analysis, review, or literature search. As the article is now, an “opinion piece” seems more appropriate. However, I’m hoping that the authors can expand on many of their ideas and explore the known literature further. In which case, the article may be appropriately termed a “review”. 5.  Introduction, paragraph 3, last sentence: I’m not sure that the references cited support the claim being made that language shifts have caused the health deficits we see today among Indigenous populations. Perhaps the authors can rework this sentence. 6.  Health status: this is one of the sections that seems lacking in its scope. Perhaps the authors can expand and describe some of the major health disparities among Indigenous populations. Some epidemiological data would be helpful to the reader to understand the scope of the disparities. 7.  Indigenous language loss and language use: it would be helpful to the reader if the authors provided examples of some of the Indigenous languages. What are some of the major Indigenous languages worldwide? How many are there? How many have been lost? It would also be helpful if the authors provided some data on how much Indigenous languages are being spoken today around the world and in North America. 8.  Existing studies and why focus on language sections: These sections in particular need to be expanded upon. Are the authors able to conduct a formal literature search? Perhaps with keywords? Also, the authors may want to explore and include other literature that has explored the relationship between language/culture and emotional/mental health. The extensive writings of Laurence Kirmayer come to mind as a good place to start. What is explicitly missing from this article is the how piece... How does language revitalization lead to better health? Is it due to enhanced sense of identity (as Chandler and Lalonde argue)? Enhanced spiritual health? Enhanced sense of community/belonging? The provision of strong role models that teach the language? Protection from early life traumas? There is also an entire field of neurological research that has looked at how learning multiple languages can impact the brain and health. The authors would do well to explore these different areas and give the reader an idea on the how. Even looking into some of the qualitative research with Indigenous peoples suffering from some of the major health problems that Indigenous populations face (e.g. diabetes) would be beneficial as often language/culture is brought up as a key determinant of health in these studies. Moreover, has there been research that has shown not shown a relationship between language and health? Lastly, second paragraph, last sentence: Has there been work done that specifically examined language loss and sense of spiritual well-being? 9.  I was pleased that the authors recommend that future studies aimed at language revitalization include assessments of health outcomes. Perhaps the authors could expand on what these health assessments may look like? What should be measured and how? 10.  Conclusion: It would make more sense perhaps to include and expand upon the Berry 2012, Gone Page 8 of 10 F1000Research 2016, 5:852 Last updated: 19 JUL 2019 10.  Conclusion: It would make more sense perhaps to include and expand upon the Berry 2012, Gone 2015, and Tullouch 2013 references in the “existing studies” or “why focus on language” sections. 11.  Last paragraph of conclusion: the ideas presented in this paragraph seem to come out of nowhere as they have not been discussed earlier in the article. Again, the authors would do well to really spend some time reading and then summarizing in the “existing studies” or “why focus on language” sections the known literature on how and why language revitalization may lead to improved health. These sections are the place (as opposed to the conclusion) to introduce and describe in-depth the other contributors related to speaking an Indigenous language that may be responsible for improved health status. Competing Interests: No competing interests were disclosed. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Comments on this article Version 1 Reader Comment 10 May 2016 Nick Thieberger, University of Melbourne, Australia Some additional references that may be useful: Bialystok, E., Craik, F. & G. Luk, G. 2012. Bilingualism: consequences for mind and brain. Trends in Cognitive Sciences 16(4): 240-250. Biddle, N. and H. Swee. 2012. ‘The Relationship Between Wellbeing and Indigenous Land, Language and Culture in Australia’. Australian Geographer 43: 215–232.  Waldram, James B. 2009. The persistence of traditional medicine in urban areas: the case of Canada's Indians. Am Indian Alsk Native Ment Health Res.  1990 4(1):9-29. Competing Interests: No competing interests were disclosed. The benefits of publishing with F1000Research: Your article is published within days, with no editorial bias You can publish traditional articles, null/negative results, case reports, data notes and more The peer review process is transparent and collaborative Page 9 of 10 F1000Research 2016, 5:852 Last updated: 19 JUL 2019 Your article is indexed in PubMed after passing peer review Dedicated customer support at every stage For pre-submission enquiries, contact [email protected]  Page 10 of 10

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