By Sherry Salway Black (Click here to view the entire P&R issue)
The health disparities of Indigenous Peoples in the United States are numerous and pressing, and offer a significant policy challenge to the next Congress and Presidential Administration. Both must be committed to honoring the long-standing treaty obligations that the United States has to provide adequate health care services to Indigenous tribal nations. The United States has a legal responsibility to provide health care to Indigenous Peoples. In fulfilling this obligation it must ensure that there is sufficient funding for tribal and Indian Health Service programs, staffing, technology, research and facility construction, modernizing and maintenance.
Who are Indigenous Peoples?
In the contiguous 48 United States and Alaska, many Indigenous Peoples are mistakenly called Indians, American Indians or Native Americans. They are not Indians or American Indians, because they are not from India. They are not Native Americans, because Indigenous Peoples did not refer to these lands as America until Europeans arrived and imposed this name. Indian, American Indian and Native American are colonized and inaccurate labels that subjugate the identities of Indigenous Peoples. While many Indigenous Peoples still prefer to use these former labels. a growing number want to be identified according to their own tribal nation or affiliation.
Indigenous Peoples are diverse populations who reside on ancestral lands, share an ancestry with the original inhabitants of these lands, have distinct cultures and languages, and regard themselves as different from those who have colonized and now control their lands and lives. As of July 1, 2007, the U.S. Census Bureau estimated the population of Indigenous Peoples, including those of more than one race, to be 4.5 million, or 1.5 percent of the total U.S. population. Of this group, 2.9 million identified themselves only as American Indian or Alaska Native. There are more than 560 federally-recognized Indigenous tribes in the United States. Approximately half of the Indigenous population resides on or near federal Indian reservations, while the remaining half reside in urban areas.
Not much is known about the health circumstances of urban natives. One major study completed by the Urban Indian Health Commission in 2005 reported that cardiovascular diseases, diabetes and depression afflict urban Indigenous Peoples in disproportionate numbers.
The Legal Basis for Indigenous Health Care
From 1778 to 1871, the Indigenous nations, of what is now referred to as the United States of America, negotiated and signed nearly 400 treaties with this nation. During this century of treaty-making, the U.S. government agreed to provide, among other things, health services to Indian tribes in exchange for billions of acres of land, natural resources, friendship and peace. In a confirmation of the treaty process, the legal basis to provide health care was accepted by the U.S. and first articulated in The Snyder Act of 1921. This legislation enabled the U.S. Congress to authorize the Bureau of Indian Affairs (BIA) to expend such moneys as Congress may from time to time appropriatefor the relief of distress and conservation of health.â€ In 1955, health services for Indigenous Peoples were transferred from the BIA to the Indian Health Service (IHS). which became part of the Public Health Service (PHS). The Indian Health Service is now a program within the U.S. Department of Health and Human Services that is responsible for providing health services to Indigenous Peoples who are members of federally-recognized tribes in the United States.
The Indian Health Care Improvement Act, P.L. 94-437, (IHCIA) was first enacted in 1976 as the next legal provision of health care services to Indigenous Peoples to address long-standing health care disparities. The major aims of this legislation were to increase the number of health professionals serving Indigenous communities; allow services to urban populations; remedy health facility problems; and to ensure access to other federal health care such as Medicaid and Medicare. The IHCIA has been reauthorized five times, adding a number of amendments each time. In the original findings of this legislation, the U.S. Congress agreed that:
- Federal health services to maintain and improve the health of the Indians are consonant with and required by the Federal government/s historical and unique legal relationship with, and resulting responsibility to, the American Indian people,..
- A major national goal of the United States is to provide the quantity and quality of health services which will permit the health status of Indians to be raised to the highest possible level and to encourage the maximum participation of Indians in the planning and management of those services,…
- The unmet health needs of the American Indian people are severe and the health status of Indians is far below that of the general population of the United States.
Some progress has been made in upgrading the health of Indigenous Peoples that can be attributed to the actions of U.S. federal government. However, much remains to be done. Despite the compelling and binding language in the IHCIA, the U.S. has rarely lived up to its promises to provide sufficient, proper and necessary health care to Indigenous communities. Once the U.S. got all the lands and resources it needed from Indigenous Peoples, it has maintained a steady path of insufficient, marginally effective assistance in raising the health status of Indigenous Peoples to the highest possible level. This negligence, self-serving behavior and dishonesty are transparent and have taken an enormous toll on the health of our peoples.
The health of Indigenous Peoples seriously lags behind the rest of the U.S. population in several critical areas. This is especially true for those who reside on or near Indian reservations and depend on the U.S. federal government to provide health services to them through the Indian Health Service. Indeed, for many of us who grew up on our reservations, we have had an up-close view of the struggles, hardships and suffering that have gripped lives of our friends, relatives and members of our tribes due to insufficient health services. While many have been able to overcome challenging health circumstances, many have experienced more than their share of difficulties in achieving and maintaining a sufficient level of health. While health statistics show that various groups of Indigenous Peoples carry an enormous burden of illness, statistics rarely give true insights into the pain, hopelessness and distress that is felt and shared by those who live in this reality.
For many years, I witnessed the sorrow of death and the despair of disability within my own tribal community. Many needlessly succumbed to numerous preventable diseases such as diabetes, alcoholism, suicide, homicide, depression, obesity, substance abuse, hypertension, heart disease and cancer, to name a few. Because of the significant loss of life among my tribe, I’ve learned to appreciate the Years of Potential Life Lost (YPLL) statistical measure that is used to calculate the total number of years lost in a community from premature death from a certain cause. While this computation yields important data, I believe that the subsequent stress and grief that lingers among our communities, due to high morbidity and mortality, is a major contributor to the continuing poor health of Indigenous Peoples.
When I was the health director for my tribe more than 20 years ago, we faced many daunting challenges. Chronic illnesses and behavioral disorders were widespread and, in many instances, deadly. Shortages in funding to deliver health services were common and often compromised the care of many of our most vulnerable citizens. The lack of competent medical personnel, substandard health care facilities, traveling long distances to reach medical services under difficult conditions, and the absence of advanced, life-saving technologies also produced a daily hardship for our reservation communities. While some studies report that progress has been made to reduce or eliminate gaps in Indigenous Peoples health, many communities and individuals continue to be confronted by many of the challenges we faced more than two decades ago.
At present, there are numerous and appalling health disparities among Indigenous Peoples that require immediate attention and resolution. A press release sent out on September 8, 2003 by the U.S. Department of Health and Human Services titled, Eliminating Health Disparities in the American Indian and Alaska Native Community, underscores this reality. The statement reported that death rates, due to a number of specific illnesses and disorders, were significantly higher for Indigenous Peoples than for other Americans:â€‰
- Alcoholism 770% higher
- Tuberculosis 750% higher
- Diabetes 420% higher
- Accidents 280% higher
- Homicide 210% higher
- Suicide 190% higher
In 1994, when I completed the writing of my Ph.D. dissertation, The Use of Health Services by American Indians on Federal Indian Lands, I referred to several of these same mortality health statistics to show the poor health of Indigenous Peoples. The data that I reported came from 1987 statistics that were collected by the Indian Health Service:
- Tuberculosis 400% higher
- Alcoholism 322% higher
- Diabetes 139% higher
- Accidents 139% higher
- Homicide 64% higher
- Suicide 28% higher
In 2002, the National Center for Health Statistics reported that Indigenous Peoples have higher mortality rates than whites in all age categories up to age 64. The largest gap is in the 25-44 years age category: There are 227.4 deaths among Indigenous People per 100,000, versus 141.7 for whites a 62% higher rate of death. However, in certain geographical areas, life expectancy for Indigenous men is dismal. In an investigation of mortality disparities by race and counties in the United States covering the period 1982 -2001, Christopher J.L. Murray found that the lowest life expectancy for men in the United States was in South Dakota counties that had large populations of Indigenous Peoples. Those living in these areas can expect to live 66.6 years, well short of the 79 years for low-income rural white people in the Northern Plains. Focusing only on Indigenous men in these counties, life expectancy plummets to 58 years.
There are lapses and severely inadequate levels of funding to pay for the health needs of Indigenous Peoples. For instance, a 2003 study by the U.S. Commission on Civil Rights, titled A Quiet Crisis, found that the unmet health care needs of Native Americans remain among the most severe of any group in the United States. Despite their need for health care and although there are designated health services, the monetary value of Native American care is significantly less than the average health expenditure for all Americans. The federal government’s rate of spending on health care for Native Americans is 50% less than for prisoners or Medicaid recipients, and 60% less than is spent annually on health care for the average American. IHS real spending per Native American, after adjusting for inflation and population growth, has fallen over time, despite funding increases.
There are very troubling epidemics of substance abuse and dependence among Indigenous Peoples. On September 8, 2003, the U.S. Department of Health and Human Services issued a press release that identified a number of disparities within the Indigenous population:
- Rates of substance dependence and abuse among persons age 12 and older is highest among American Indians and Alaska Natives (14.1%).
- Rates of illicit drug use (10.1%), alcohol (44.7%).
- Binge alcohol use (27.9%) is among the highest in the nation.
Death due to alcohol abuse among Indigenous Peoples is overwhelming. Examining death certificates from 2001 to 2005, the Centers for Disease Control and Prevention released a report on August 28, 2008 that found the rate of alcohol-related deaths among Indigenous Peoples was close to four times higher than that of the overall U.S. population. During this period, 11.7% of deaths, or 1,514 deaths, were alcohol-related, compared with 3.3% for the U.S. as a whole. The findings showed that 68% of the deaths were men and 66%were younger than 50 years old, and 7% were less than 20 years old.
The fact that two-thirds of the deaths involve people younger than age 50 is very troubling. Many in this group represent the next generation of elders that will not be lending their knowledge, presence and experience to those younger age groups who might have depended on them for learning their tribal language, culture and critical aspects of traditional leadership. The fact that such a large number are men means that many children will grow up without fathers, uncles, brothers and grandfathers who, in most tribal communities, serve as important supports and mentors.
For every 100,000 American Indian deaths, 55 involved excessive alcohol use. In the general population, excessive alcohol consumption figured in 27 of every 100,000 deaths. The leading causes cited in alcohol-related deaths among Native Americans:
- Motor vehicle crashes: 27.5%.
- Liver disease: 25.2%.
- Alcohol dependence: 6.8%.
- Homicide: 6.6%.
- Liver cirrhosis: 6.2%.
- Suicide: 5.2%.
Among different age groups and tribal communities, there exist widespread epidemics of depression, anxiety and other mood disorders. Psychologists refer to depression as a whole body illness. It causes intense emotional pain, helplessness, hopelessness, loss of sleep and interest in life. It is strongly associated with suicide, thoughts of death, and chronic fatigue, sadness and negative emotions. In a 2005 report titled, Invisible Tribes: Urban Indians and their Health in a Changing World, it was reported that depression afflicts Indigenous Peoples in disproportionate numbers. About 30% of this population suffers with depression. Those most affected live in cities. In a national study titled, Prevalence of depression among U.S. adults with diabetes: findings from the 2006 behavioral risk factor surveillance system, which examined depression and diabetes, Indigenous Peoples were identified as the ethnic group having the highest prevalence rates of depression (27.8%).
Of course, diabetes presents a major problem for many communities. On a personal level, I know the disease quite well. Of my 11 brothers and 4 sisters in my family, only 5 of us are not burdened by this illness. My father died from diabetes-related complications, and my mother has lived with it for nearly 40 years. Numerous studies show that Indigenous Peoples have the highest prevalence of type 2 diabetes in the world. The incidence of type 2 diabetes is rising faster among Indigenous children and young adults than in any other ethnic population, 2.6 times the national average. In a report titled, The Diabetes Epidemic Among American Indians and Alaska Natives, the National Diabetes Education Program, National Institutes of Health, U.S. Department of Health and Human Services, reports that about 16.5% of American Indians and Alaska Natives age 20 years and older who are served by the Indian Health Service have diagnosed diabetes.
What is the Future of Indigenous Health?
On March 12, 2008, a U.S. House of Representative subcommittee held a hearing on President Bushâ€™s proposed 2009 Indian Health Service budget, which presented a $21 million decrease from the 2008 budget. The chairman of the committee, Rep. Norm Dicks (D-WA), met with 30 tribal representatives who expressed concern over the budget proposal. Chairman Dicks quoted the Governor of the Pueblo of Acoma, Chandler Sanchez, stating that, The Indian Health Service is dying a slow death from a 1,000 budget cuts. During the hearing, IHS Acting Director Robert McSwain acknowledged that the Bush cuts would severely restrict the agency’s ability to meet the needs of many of its patients and would result in:
- 218,000 fewer outpatient visits
- 9,000 fewer patients receiving services from diabetes programs
- 12,465 fewer patients receiving dental services
- 1,500 fewer patients receiving mammogram screenings
- 3,000 fewer patients receiving cancer screenings
Despite numerous health disparities faced by Indigenous Peoples and a legal responsibility agreed to by the United States to meet the health care needs of these groups, the funding that has been provided to the Indian Health Service has never been adequate. Services are fragmented and mediocre; medical personnel are in short supply; facilities are outdated; technology and research are limited; and the patients who use this system have substantial needs, often beyond the capacity of the health care system. Long ago, Indigenous nations exchanged their lands, freedom and resources for federal promises of providing for the health of the people. However, the United States has insufficiently delivered on its promise. As a result, the health of Indigenous Peoples has suffered, especially when compared to the rest of America. As the November election shuttles out the failed policies of the Bush Administration, let’s demand that the next Congress and occupant of the White House will honor the obligations that this nation has to the health of Indigenous Peoples.
I do not use the terms Indian, American Indian or Native American to describe the Aboriginal Peoples of the United States. I only use them when I am directly quoting another source I am citing. For reasons of clarity, accuracy and consistency with United Nations definitions, I prefer to use the term Indigenous Peoples.