Bmj Usa: Editor's Choice

The first Americans

BMJ 2003; 327 doi: (Published 19 November 2003) Cite this as: BMJ 2003;327:E219
  1. Steven H Woolf, MD, MPH

    From BMJ USA 2003;May:234

    In an 1808 letter to Congress, Thomas Jefferson wrote, “With our Indian neighbors the public peace has been steadily maintained. Some instances of individual wrong have, as at other times, taken place, but in nowise implicating the will of the nation… And, generally, from a conviction that we consider them as part of ourselves, and cherish with sincerity their rights and interests, the attachment of the Indian tribes is gaining strength daily - is extending from the nearer to the more remote, and will amply requite us for the justice and friendship practised towards them” (

    Now, 200 years later, it can hardly be said that Native Americans have been the beneficiaries of overabundant “justice and friendship.” One need not recount their barbaric treatment in the 19th century and the vestiges that remain on today's reservations, but the social injustice that modern society affords the first Americans does weigh on the conscience. Large numbers suffer from poverty, poor housing, loss of culture, and sickness.

    The high disease rates and poor health care experienced by Native Americans are not unique but appear to be part of a global phenomenon among indigenous peoples, as the New Zealander Mason Durie writes in this issue (BMJ USA p 241). The public health histories of New Zealand's Maori, Australia's aborigines, Norway's Saami, native Hawaiians, and the First Nations of Canada bear striking resemblances to historical and modern patterns among Native Americans. A companion editorial by Charles Grim, director of the US Indian Health Service, paints a more positive picture, noting recent advances in the health care of Native Americans (BMJ USA p 242). For example, their life expectancy has increased by 7 years since 1973. Tribes are more engaged in self-management of health affairs.

    This is certainly good news, but there is still too much bad news. Rates of cigarette smoking, binge drinking, and illicit drug use remain higher among Native Americans than among whites. Fully 38% of Native Americans lack health insurance (the same is true for only 15% of whites). One out of every 5 Native American youths has not been to a doctor within the year. Infant, neonatal, and postneonatal mortality rates are 50% higher than those of whites. Among adults, 8% of whites - but 17% of Native Americans - rate their health as fair or poor. Having a chronic disease limits activity for 12% of whites but for 20% of Native Americans. Among women age 40 and older, more than 70% of whites but only 47% of Native Americans have had a recent mammogram.

    Society faces an ethical imperative to address the socioeconomic deprivation of Native Americans that lies at the heart of these disparities if, as Jefferson wrote, we “consider them as part of ourselves, and cherish with sincerity their rights and interests.” Otherwise, it can be said that inaction is, indeed, “implicating the will of the nation.”

    Articles cited in Editor's choice are below, beginning with their BMJ USA page number

    BMJ USA p 241 The health of indigenous peoples (Durie)

    BMJ USA p 242 The health of American Indians and Alaska natives (Grim)

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