American Indians and Alaska Natives die at higher rates than other Americans from tuberculosis (500% higher), alcoholism (514% higher), diabetes (177% higher), unintentional injuries (140% higher), homicide (92% higher) and suicide (82% higher). Those statistics, supplied by the U.S. Indian Health Service [IHS], are troubling. But they’re not new, and, given the shameful history of health care for America’s first residents, they’re certainly not surprising.
When European explorers first encountered the native tribes of America, they brought along many things the Indians had never seen before—including smallpox, trachoma, measles, influenza, cholera, typhoid and venereal diseases. As a result, Indian populations experienced continuing waves of devastating epidemics, and the health of America’s first residents began a downward spiral.
For a while in early U.S. history, the policy of maintaining a separate Indian Country was generally accepted. But by the 1840s, to make way for westward expansion, that notion gave way to the idea of creating reservations.
“Government policy became aimed at ‘civilizing’ the tribes by destroying native culture and replacing it with the values and practices of white America,” wrote Robert Trennert, in White Man’s Medicine: Government Doctors and the Navajo, 1868-1955.
The effect was further deterioration of Indian health. In the confined, alien environment of the reservation, old methods of nutrition and sanitation disappeared. Traditional means of food production, such as the buffalo hunt, vanished, because Indians were expected to adopt farming. But reservation agriculture seldom produced enough food, leaving the residents vulnerable to starvation and disease.
A national disgrace
Under these circumstances, the government had no choice but to introduce some form of basic health care. Responsibility fell to the U.S. Office of Indian Affairs [OIA]. Originally a part of the War Department, it moved in 1849 to the newly created Department of the Interior.
Meanwhile, Indians continued to acquire white-men’s diseases. Well-meaning military units and missionaries often added to the natives’ health problems, wrote Trennert.
“They gave them bacon, coffee and unfamiliar types of beans. The Indians didn’t know how to prepare these foods, so many died from stomach disorders.
By the late 1800s, while health care for other Americans was benefiting from many advancements, reservation Indians still had no hospitals or facilities for treating acute illnesses, accidents or contagious diseases. “These services ought to be furnished them in the name of humanity,” then-Indian Commissioner Thomas J. Morgan wrote. “I have been powerless to remedy a great evil, which in my view amounts to a national disgrace.”
In 1873, the humanitarian advocacy of Morgan and a number of missionaries paid off. The Office of Indian Affairs established a division to supervise health efforts on reservations and began a field-nurse program. The first federal Indian hospital was built in the 1880s in Oklahoma.
A slow and painful period of catching up
But both Indian health services and health status took many years to catch up to contemporary standards. In the 1920s, an Indian facility in New Mexico lacked the money to buy a sterilizer, so its staff made do with a pressure cooker owned by the doctor’s wife. As recently as 1953, the incidence of tuberculosis among Indians was five times that of the general population.
One hero in this otherwise dismal saga was John Collier, who served as commissioner of Indian Affairs in the 1930s. Collier’s reformist program created unprecedented research and prevention programs, and construction of more hospitals, with the total reaching 93 by 1935.
A major turning point came in 1955, when the U.S. Public Health Service took over responsibility for Indian health. In the 1950s, there was pressure to eliminate the Bureau of Indian Affairs completely. The move to the U.S. Public Health Service essentially saved health care for the community.
Today, the Indian Health Service [IHS] is the primary source of health care for approximately 1.9 million American Indian and Alaska Native people. Along with tribal authorities, it operates more than 500 healthcare facilities of varying sizes and has more than 15,000 employees, 70 percent of whom are Native Americans and Alaska Natives.
Progress, but still a long way to go
Under the IHS, health status among the nation’s more than 566 Indian tribes, bands and villages has increased significantly. Since 1973, infant mortality has decreased by 54 percent, maternal mortality by 65 percent and tuberculosis mortality by 74 percent.
In 1997, IHS opened the Alaska Native Medical Center in Anchorage—but only after a 30-year political battle to get it funded. The center offers contemporary care in a setting sensitive to native traditions. It includes an igloo-like meditation room, and its windows can be unlocked for special ceremonies—to let the spirit escape after a death, for example.
Still, health status among America’s natives is not on a par with the general U.S. population. According to HIS statistics:
- Diseases of the heart, malignant neoplasm, unintentional injuries, diabetes mellitus, and cerebro-vascular disease are the five leading causes of American Indian and Alaska Native deaths (2004-2006).
- American Indians and Alaska Natives born today have a life expectancy that is 5.2 years less than the U.S. all races population (72.6 years to 77.8 years, respectively; 2003-2005 rates)
Funding for Indian Health Services is a continuing problem. IHS says that the federal government spends more per-capita on health care for prisoners than for Native Americans who get their care from the Indian Health Service. President Obama’s Indian Health Service (IHS) budget request for Fiscal Year (FY) 2012 totaled $4.624 billion. This figure represented a 14.1% increase over the FY 2010 appropriated level and 4.9% increase over the President’s budget request for FY 2011. But Congress’ obsession with budget-cutting could change that picture, and IHS could lose 2 percent of its budget if Congress implements across-the-board cuts.
The future of health care for Native Americans is also entangled in the future of the Affordable Care Act. The healthcare reform act includes a range of Indian-specific provisions, and tribal organizations are concerned that, if the Supreme Court strikes down the law, critical, Indian-specific services would disappear. According to the National Indian Health Board, a lobbying group, the reforms include:
… enhanced authorities to recruit/retain health care professionals to overcome high vacancy rates, comprehensive behavioral health initiatives, and…authority to operate modern methods of health care delivery such as long-term care and home- and community-based care, among others.
It would be nice to be able to say that America has, at long last, made peace with its native population. But given the gap between health services offered to Native Americans and Alaska Natives and that available to the general population, and the continuing disparities in health status, there’s clearly still a lot of work to be done.
[The historical narrative included in this post has been adapted, with permission of the American Hospital Association, from an original article written by Gloria Bilchik and published in 100 Faces of Healthcare.]