American Indian and Alaska Native Health Care
Andrea Arendt, RN, BSN
According to the November 1, 2000 population estimates of the US Census Bureau, there are approximately 2,448,000 American Indian and Alaska Natives (AI/AN) in the United States the majority of which reside in the western portion of the country. The term Alaska Native refers to a person with Athabascan, Tsimpsian, Tlingit, Haida, Eskimo, and/or Aleut descent. American Indian refers to people who are members of the approximately 554 federally-recognized American Indian tribes in the United States. The AI/AN population is growing at a rate of 2.7% per year. An estimated two thirds of AI/AN live off the reservation and about one half live in urban areas.1 The AI/AN represent a small but very diverse minority that presents many unique health issues and challenges.
Federal health care services for American Indians were first established in 1824 as part of the War Department. Federal policy towards Indians at that time was primarily aimed at military containment and Army physicians took measures to control the spread of infectious diseases among Indian tribes located near military posts.2 In 1849, military control of Indian affairs ended and the Bureau of Indian Affairs (BIA), which assumed responsibility for health care, was transferred to the Department of the Interior. Health care, as well as education and other federal services, are provided to members of federally recognized tribes. These services are ensured as a result of treaties signed between the tribes and Congress, giving the federal government the role of trustee.
In the late part of the nineteenth century, the policy of the federal government towards Indians was one of assimilation and Indian tribes were no longer viewed as separate nations. At the beginning of the 20th century, there was a move to create a more professionalized service. During the Hoover administration, the BIA was reorganized into five divisions: health, education, agricultural extension, forestry, and irrigation. Also, the organization was decentralized allowing for the flexibility demanded by the varying local conditions. Each division had a professional or technical director in Washington who had a direct relationship with the reservation superintendents. It was believed that improving services would lead to Indiansí assimilation with the general US population and government support could be withdrawn. In 1955, in an effort to dismantle the BIA, the Division of Indian Health (later renamed Indian Health Service), was formed within the Public Health Service.3 This transformation was supported by both politicians who wanted to eliminate sovereignty and those whose soul aim was to improve health services. Most tribal leaders were opposed to the transfer, fearing it would lead to assimilation, which they opposed.2
Today the Indian Health Service (IHS) provides health care for approximately 1.5 million AI/AN throughout itís twelve area offices. The annual appropriation is approximately $2.2 billion. IHS services are provided directly and through tribally contracted and operated health programs. Services are also purchased from private providers. Major health programs include the Diabetes Program, the Nutrition Program, the Mental Health Program, the Community Health Representative Program, the Dental Program, and the Accident and Injury Reduction Program, as well as several training programs.
Historically, there have been many conflicts between the IHS and the people it serves. The initial attitude was one of disregard for native attitudes and traditions. Politicians in Washington were in charge of policy making with little input from tribal leaders or the local health care providers. It has not been until more recent times that the idea of community leadership has been adopted and more AI/ANís have taken higher level positions in the organization. Despite a rough start, the IHS has done much to improve the health status of the AI/AN population. Since its inception, infant mortality dropped by 85%, maternal death rate dropped by 91%, mortality rate from tuberculosis decreased by 96%, deaths from diarrhea and dehydration decreased by 93%, and life expectancy has risen by 19%.4 The IHS can not claim sole responsibility for these improvements, but it has played a key role in increasing the health of AI/ANís.
Disparity between the health status of AI/ANís and the general US population has narrowed considerably. From 1972 to 1974 infant mortality rates were 25% higher and maternal mortality rates were 82% higher than the general US population. By the 1991 to 1993 time period, infant mortality had been reduced to only 4% higher. During this same time period maternal mortality had become 12% lower than the US average. In the same time span, mortality from diarrhea and dehydration went from 138% higher to 15% higher then the rest of the US. Although the gap has narrowed, AI/ANís still have considerably excessive mortality rates in many areas. The death rates from tuberculosis and unintentional injury during the same time periods have decreased but remain alarmingly high, going from 600% and 264% to 425% and 184%, respectively.2
The ten leading causes of death for AI/ANís are diseases of the heart, malignant neoplasms, unintentional injuries, diabetes mellitus, cerebrovascular disease, chronic liver disease and cirrhosis, chronic lower respiratory disease, influenza and pneumonia, suicide, and homicide.5 The examples of Type II diabetes mellitus and motor vehicle accidents will be used to address some of the health issues faced in the AI/AN population.
AI/ANís are disproportionately affected by Type II diabetes mellitus compared to the general US population. The age-adjusted prevalence rate in the AI/AN population is 10.9 per 100 persons compared with that of 3.9 per 100 persons in the non-Hispanic white population.6 Most disturbing is the increased prevalence in AI/AN children of Type II diabetes, a disease that has traditionally been thought of as a disease of adulthood. Complications associated with diabetes include blindness, renal disease, lower-extremity amputations, and cardiovascular disease as well as premature mortality. The largest risk factor for Type II diabetes is obesity due to high caloric intake. It is believed that AI/ANís are genetically geared to exist on a high-protein, low-fat diet and that they burn calories more slowly. As recently as sixty years ago, AI/ANís diet consisted of vegetables they gardened themselves and hunted meat. Their lifestyles demanded physical work. In more recent times, they have adopted a modern diet, one which is high in fat and calories, and a more sedentary lifestyle. The excess calories consumed by AI/ANís are stored as fat and predispose them to obesity. Additionally, the rapid rate of the change from their traditional way of life to a more modern one has been very damaging to AI/ANís health.
As mentioned previously, unintentional injury is the third leading cause of death in AI/ANís. This category includes deaths from motor vehicle accidents (MVAís), which account for 40% of all injury related deaths. Furthermore, deaths from MVAís in the AI/AN population occur at two-and -a half times more often than in the general population. One study investigating MVAís in rural and urban areas in the Pacific Northwest found several factors related to this increased mortality. One important factor is the large amount of AI/ANís who live in rural areas. Driving in rural areas is associated with higher vehicle speed and greater crash forces leading to a greater injury rate. AI/ANís were also found to have lower rate of restraint use and a higher rate of driving while intoxicated.7 These findings suggest that community education is an important key to prevention of MVA related deaths. A related issue is EMS response and transport time. Prolonged response and transport time is associated with higher mortality in traumas. EMS response and transport time may be prolonged in rural areas.
Another important issue related to the health care of AI/ANís is the lack of adequate health statistics and population specific research. This is especially true for AI/ANís living in urban areas, who are often overlooked by the IHS. Adequate data is essential for assessing community needs and planning appropriate health programs and services. In 1992, funded by a grant from the National Center for Health Statistics of the Centers for Disease Control and Prevention, the American Indian Health Care Association (AIHCA) published a report citing several factors related to the lack of quality data. These factors were racial misclassification on death certificates, lack of resources and special outreach efforts to collect data from difficult-to-reach populations, and poor utilization of existing data sets. Furthermore, they found that more research needs to be done to distinguish between race, ethnicity, and other socioeconomic variables. The report further indicated the importance of considering participation in community events, beliefs and spirituality, acculturation, and the seeking of traditional healers and cures in understanding the health status of the AI/AN population.
Use of traditional healers is still widespread in the AI/AN population. As mentioned previously, there are more than 500 tribes in the US. Each of these tribes have their individual sacred rituals and ceremonies, much of which are known only to members of the tribe. Medicine and religion are strongly linked in traditional native culture. It is believed that one must follow proscribed Ďlifewaysí in order to maintain optimal health (physical, mental, and spiritual). All things are believed to have life and spirit and are intricately related in the universe. Illness is perceived to be a disruption in the delicate balance between individual beings of the universe. The restoration or maintenance of health is achieved by correcting these imbalances. Traditional healers help in restoring balance. This may be achieved through simple ceremonies involving prayers or chants; herbal remedies including salves, ointments, and teas; or dances. Many AI/ANís practice both traditional and Western medicine.8 It is important for physicians and health care providers working in the AI/AN population to be aware of the vital role traditional medicine still plays in native culture. Collaboration between traditional healers and Western practitioners is an important step towards providing more holistic care. This may be especially true in areas of mental health.
In 1975, the Indian Self-determination and Educational Assistance Act (PL 93-638) was passed. It provided tribal governments a way to contract with the Secretaries of the Interior and of Health, Education, and Welfare to develop new services or assume control over services previously run by the federal government. A year later, the Indian Health Care Improvement Act (PL 94-437) was passed. The purpose of this law was to improve health care facilities, create new and needed services, and to attract more AI/ANís to the health care profession. These pieces of legislation allowed for increased community involvement and, along with the federal policy of Indian preference in hiring, allowed for AI/ANís to take positions of control in both the tribal and federal systems.3 The IHS is becoming less centralized and tribal governments are taking over control of health care services that were previously controlled by the federal government. Individual service units within area offices are becoming tribally run. There is some debate over the relinquishing of responsibility by the federal government, which goes beyond the scope of this paper. The important point is that the current system of health care for AI/ANís is in a state of reconstruction.
This paper is in no way an extensive list of issues confronted in the area of AI/AN heath. In understanding the health of a population, it is important to understand the structure of the system providing health care and the unique health characteristics of that population. History of the community along with the communityís individual attitudes and beliefs are other key components. Each tribe, though similar in some characteristics and experiences, have very different cultures. The maintaining of these individual identities is vital to them. As with any community, it is important to view the heath and health care of AI/ANís from a cultural perspective.
1. Duffie, MK. A pilot study to assess the health needs and statuses among a segment of the adult American Indian population of Los Angeles. Wicazo SA Review Spring 2001
2. Bergman AB, Grossman DC, Erdrich AM. A political history of the Indian Health Service. The Millbank Quarterly 1999;77:571-604.
3. Kunitz, SJ. Dances with Doctors. In:Cunningham A, Andrews B, editors. Western Medicine as Contested Knowledge. New York: Manchester University Press; 1997. p. 94-121.
4. Indian Health Service. Comprehensive health care program for American Indians and Alaska Natives. www.ihs.gov.
5. National Center for Health Statistics. National Vital Statistics Report 2001;Vol.49, No 11.
6. Centers for Disease Control and Prevention. Prevalence of Diagnosed Diabetes among American Indians/Alaskan Natives 1996. www.cdc.goc/epo/mmwr/preview/mmwrhtml/00055489.htm.
7. Grossman DC, Sugarman JR, Fox C, and Moran J. Motor-vehicle crash-injury risk factors among American Indians. Accid. Anal. and Prev. 1997;29,3: 313-319.
8. Avery C. Native American medicine: traditional healing. JAMA 1991; 265,17: 2271, 2273.
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