BMJ  2003;327:E220-E221 (4 October), doi:10.1136/bmjusa.03050002 (published 1 June 2003)

BMJ USA: Editorial

The health of American Indians and Alaska Natives

Health influence factors in common with other indigenous populations

From BMJ USA 2003;May:242

The health and welfare of the indigenous American Indian and Alaska Native people of the United States have improved significantly since passage of the Snyder Act in 1921, which authorized health services for them, and official establishment of the Indian Health Service (IHS) in 1955 as an agency of the US Department of Health and Human Services. Although the American Indian and Alaska Native populations of the United States number approximately 2.6 million, the provision of federal health services is available only to members of tribes that are federally recognized. Currently there are 562 federally recognized tribes in this country, with a total population of 1.6 million persons who are eligible for IHS services. Of the 50 states, 35 are considered "reservation" states because of the presence of Indian reservations — with 55.7 million acres of tribal land held in trust by the US government for the benefit of tribal governments and their members.¹

A significant factor in the improvement of health status for American Indians and Alaska Natives is the increasing involvement by American Indian tribes and Alaska Native villages in the delivery of health services to their communities. Durie indicates in his editorial (p 241) that political oppression and lack of self-governance among other indigenous populations, if allowed to continue, may have a devastating impact on health indicators. However, the US experience shows that is true only if the health indicators are for non-behavior related illness and disease.

In the last 50 years, there has been a dramatic decrease in the prevalence of many infectious diseases that were once the leading cause of morbidity and mortality among American Indians and Alaska Natives. This is due to increased medical care and to public health efforts undertaken in the late 1950s; such efforts included implementing massive vaccination programs and bringing safe water and sanitation facilities to reservation homes and communities. This was achieved at a time when federal government decisions were imposed on American Indians and Alaska Natives, and consultation did not have the support and presidential endorsement that it enjoys today. The paternalistic role of the federal government persisted until the mid-1970s.

In 1976 the Indian Self-Determination and Education Assistance Act (PL 93-638) was passed, allowing Indian tribes to contract with the IHS for services otherwise performed by the federal government. In 1994 the law was further amended to allow tribes to assume operational and administrative control over IHS programs; the federal funds to administer these programs were transferred to the tribes. Almost all of the 562 federally recognized tribes currently provide some level of health services to their members; approximately 52% percent of the IHS federal budget is transferred directly to tribes and to urban Indian health programs for this purpose.²

The Indian health model developed by the IHS and the participation of Indian people in decisions affecting their health have produced further significant health improvements: Indian life expectancy has increased by 7.1 years since 1973 (although it remains 6 years below that of the general US population), and while significant disparities still exist, the rates of death attributable to pregnancy and childbirth, tuberculosis, gastrointestinal disease, infancy, accidents, pneumonia, influenza, homicide, alcoholism, and suicide have declined.³ However, as the indigenous people of the United States adopt a more Western diet and sedentary lifestyle, we are beginning to see chronic diseases and lifestyle issues⁴ such as those cited by Durie (injury, alcohol and drug misuse, cancer, heart disease, kidney disease, obesity, suicide, and diabetes) as the dominant health factors throughout the life span of the Indian population.⁵

Health status is not determined just by the availability of health services or pharmaceuticals. As Durie indicates, it is the result of an interwoven tapestry of factors, such as socioeconomic status, education, community and spiritual wellness, cultural and family support systems, and employment opportunities, to name a few. To this end, we have begun to weave a network of support systems and partnerships among federal, tribal, and private foundations and academic centers, in order to address all of these factors, which contribute to the health and well-being of the people we serve.

As Durie points out, this transfer of autonomy to the tribes has further spurred the development of an indigenous health workforce (69% of the 15 000 employee IHS workforce is American Indian or Alaska Native; if medical professionals are excluded [:because there is not a large Indian applicant pool for these positions"], 88% of employees are American Indian or Alaska Native).⁶ Having a predominately indigenous workforce has facilitated the delivery of culturally sensitive and respectful services and the incorporation of traditional healing into the medical model of the IHS programs.

Like the indigenous populations of other countries, American Indians and Alaska Natives share a perspective on health and wellness that is also reflected in their cultures. The IHS has established a Traditional Medicine Initiative to foster formal relationships between local service units and traditional healers, so that cultural values and beliefs, as well as traditional healing practices, are respected and affirmed by the IHS as an integral component of the healing process.⁷ The correlation between health and beliefs has been shown in many studies⁸ and has a large influence over the behavior choices that can result in improved health.⁹

While the declaration of an international decade for the world's indigenous people has brought increased focus on the many issues they confront, much more needs to be accomplished before they will achieve parity in health and socioeconomic status, environmental safety, and political representation.

Indian Health Service, United States Department of Health and Human Services

---

Competing interests: None.

References

1. Orientation to the US Department of the Interior Bureau of Indian Affairs. Available at: http://www.doiu.nbc.gov/orientation/bia2.cfm. (accessed April 18, 2003).
2. The IHS Profile 2003. Rockville, Md: US Dept of Health and Human Services, Indian Health Service, 2003.
3. The IHS Quick Look. Rockville, Md: US Dept of Health and Human Services, Indian Health Service, 2003.
4. Walters KL. Substance use among American Indians and Alaska Natives: incorporating culture in an "indigenist" stress-coping paradigm. Public Health Rep 2002;177:S104-S117.
5. Grim CW. Emerging issues: planning a healthy future for American Indians and Alaska Natives. US Med 2003;39:36-37.
6. Indian Health Service. Year 2003 Profile. Available at: http://info.ihs.gov/Infrastructure/Infrastructure6.pdf. (accessed April 14, 2003).
7. Traditional Medicine Initiative. Rockville, Md: US Dept. of Health and Human Services, Indian Health Service, 2002.
8. Mental Health: Culture, Race, Ethnicity. In supplement to: Mental Health: A Report of the Surgeon General 1999. Rockville, Md: US Dept of Health and Human Services, 2001.
9. Consortium of Social Science Associations. Not What the Doctor Ordered — Challenges Individuals Face in Adhering to Medical Advice and Treatment. Congressional Briefing, Executive Summary. Washington, DC: Consortium of Social Science Associations, April 16, 1999.

CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    Technorati    What's this?