Post-Contact Medicine and Modes of Curing

Tribes affected: Pantribal

Significance: Meeting the health care needs of contemporary American Indians, especially those living on reservations, is largely the responsibility of the Indian Health Service

By the middle of the nineteenth century, the American Indian population had been decimated by three centuries of contact with Europeans and European Americans. Among the primary factors in this vast depopulation was the devastation caused by infectious European diseases (such as smallpox), against which Indians did not have immunity. Moreover, by the mid- to late nineteenth century, nearly all the native population of the United States had been consigned to reservations. These reservations, found today in thirty-two states, are located primarily in Alaska, Arizona, Minnesota, Montana, New Mexico, South Dakota, Utah, Washington, and Wisconsin.

In various treaties with the federal government, Indians were historically guaranteed health care services. Until the late nineteenth century, such care was under the jurisdiction of the Department of War and was provided by military doctors stationed on or near reservations. Some health care was also provided by religious and social groups. It was not until 1921 that the federal government, in the Snyder Act, officially mandated that health services be provided to American Indians.

By the middle of the twentieth century, Indian health care had come under the jurisdiction of the Indian Health Service of the U.S. Public Health Service. Central issues such as the rural location of many American Indians, the widespread existence of Indian poverty, and the high incidence of certain health problems among Indians—especially accidental death, diabetes, depression, and many alcohol-related diseases—have complicated the problem of providing adequate health care to Indians.

Early Indian Health Care

In many cases, nineteenth century peace treaties between the federal government and the Indian tribes who agreed to live on reservations included some sort of health care provisions. Initially, the radically underfunded programs aimed at meeting these needs were of two types. First, health funds were combined with funds aimed at general education and were administered by either religious or philanthropic organizations that operated with widely varying degrees of success. Second, the Department of War used the most appropriate—or convenient—personnel at military posts close to the individual reservations to carry out Indian medical care and training in health-related areas such as sanitation. The quality of the health care Indians received varied greatly and depended on the attitudes of the personnel who were involved in it.

Development of the Indian Health Service

In the middle of the nineteenth century, the U.S. Department of the Interior was created. At this time civilians took over Indian health care entirely as this charge passed into the hands of the Bureau of Indian Affairs (BIA). While initially inefficient at providing health care, the Bureau of Indian Affairs (BIA) began to organize a medical care division in the middle of the 1870’s. This division grew slowly; by the 1920’s its main efforts were in the treatment of trachoma, tuberculosis, and the other contagious diseases that were endemic among reservation populations. Indians were given the right of American citizenship in 1924. Regrettably, however, the next thirty years saw relatively little overall improvement of their health, despite the efforts of the health care practitioners who worked among them.

In 1955 the Public Health Service took over Indian health care via the Division of Indian Health, which is now called the Indian Health Service. This change was mandated by Public Law 83-568 (the Transfer Act), which stated that “all the functions, responsibilities, authorities, and duties . . . relating to the maintenance and operation of . . . health facilities for Indians, and conservation of Indian health . . . shall be administered by the Surgeon General of the Public Health Service.” Three factors enabled the Indian Health Service to operate more efficiently than had previous agencies concerned with American Indian health.

First and foremost of these was the widespread use of antibiotics such as penicillin, which could cure many diseases very quickly and gave Indians more faith in the efficacy of white medicine. Second, federal legislation made it possible for physicians and other health professionals to serve in the Public Health Service Officer Corps instead of performing active military service. This brought a great many more qualified individuals into the Indian Health Service. Third, many of the Indians who had served in the U.S. armed forces during World War II had returned to their reservations. Now familiar with life and medical care off reservations, they became an essential cadre of advocates for the Indian Health Service; they also soon represented many members of its staff.

Another valuable aspect of the Indian Health Service is its efficient hierarchical organization and governance at all of its levels from the national office to its management areas to its service units (often a whole tribe). The hierarchy leads to swifter action and to better communication than was possible under other systems. One problem associated with the Indian Health Service is the lack of choice of individual physicians; reservation inhabitants must accept the care of a reservation’s appointed doctors or must purchase their own health care.

Health Service Weaknesses and Solutions

Most weaknesses of the Indian Health Service arise from its relatively inadequate funding, the transience and undersupply of its biomedical staff, and the fact that it is smaller than might be desired (fifty-one hospitals and about 425 outpatient clinics and health centers). These factors are aggravated by the lack of many essential, high-technology medical services at its component hospitals, health centers, and clinics. Nevertheless, these facilities are usually very well run within their limitations, such as the facts that the population being served lives mostly on reservations that are located in isolated rural areas and that transportation difficulties arise when patients must be moved to distant, private-sector health providers for services that are otherwise unavailable to them.

The problems of Indian Health Service health care delivery, as well as some of the solutions, are exemplified by the Navajo reservation, with a population of more than 200,000. This reservation, on which live the members of the largest American Indian tribe, is located on an area about the size of West Virginia and sprawls over parts of Arizona, New Mexico, and Utah. The reservation’s Indian Health Service component is divided into eight of the 137 service units found in the United States. It contains hospitals with a total of about five hundred beds as well as numerous clinics and other health centers.

Problems of overcrowding and the already mentioned lack of high-technology health services necessitate the expensive transfer of many Navajo Indian patients to private-sector facilities. A partial solution to this logistics problem is the use of a relatively economical ambulance service operated by the Navajo tribe. Other problems include the high incidence of heart disease, alcohol-related deaths (from cirrhosis of the liver, for example), homicide, suicide, and diabetes that consume much of the resource base of the Navajo reservation service units. Present solutions include using both Medicare and Medicaid revenue obtained for qualifying Indians. In the long run, increased budgets for the Indian Health Service and additional hospital facilities will be required.

Another severe problem is the high turnover and shortage of nurses and other essential health care professionals. Permanent nursing positions in the Indian Health Service, for example, are reported to be only 75 to 80 percent filled. It has been noted by upper-level Indian Health Service administrators that increasing staff salaries will only partly solve the problem. Rather, the problem is viewed as being largely attributable to both geographic and professional isolation. Complicating the issue still more are the existing decreases and the expected ending of some federal programs that pay all of the educational costs of physicians and nurses in return for a term of practice in the underserved regions of the United States, including Indian reservations. This is particularly problematic because a large percentage of the Indian Health Service professional staff comes from this source (the National Health Service Corps, NHSC). Even in the best of times, however, only 5 to 10 percent of NHSC physicians have remained in the Indian Health Service for even one year beyond the time required by their scholarship program obligations. A positive change is the increased number of Indians entering and projected to enter the system as professional staff.

Identifying Indians to Be Served

Estimates of the percentage of Native Americans who are being treated by the Indian Health Service vary from 60 to about 80 percent, depending upon the source of the estimate of the total U.S. Indian population. One basis for counting the Indian population is self-assessment of being an Indian via the U.S. Census. Another approach is based on the percentage of Indian blood possessed by a person. The Indian Health Service itself is not concerned with quantifying the amount of Indian blood in the people it serves. Rather, service at one of its facilities depends on being recognized as an Indian by a contemporary Indian tribe. Requirements for this recognition vary from tribe to tribe, but they often consist of being of one-fourth Indian blood. Indian Health Service facilities are not limited to reservation-based Indians, although most facilities are located on or near reservations. One reason that the service provides care for both reservation and nonreservation Indians is that many tribes count individuals as members regardless of their formal place of residence.

Special Health Needs

The American Indian population has traditionally exhibited a significantly greater incidence of infant mortality as well as adult deaths from a number of diseases than seen in the general U.S. population. These problems have been attributed to Indian families’ generally lower incomes as well as to their poorer nutrition and living conditions. Inroads had been made, however, in most of these areas by the late 1980’s.

For example, there has been a drop in infant mortality from 22.2 per 1,000 live births to 11.1, a rate very near that for the “U.S., all races” category. Improvement of both health services and living conditions has also diminished the absolute numbers of deaths from the main diseases that kill modern Indian adults. Contemporary deaths from accident, alcoholism and related problems, diabetes, homicide, influenza/pneumonia, suicide, and tuberculosis still exceed those in the “all races” population by 185, 388, 169, 91, 42, 480, and 52 percent, respectively. One yardstick of this relatively at-risk status for the American Indian is the 1981 observation that 37 percent of all Indian deaths occur before age forty-five, compared with 12 percent of “all races” deaths.

The Indian Health Service has attempted to diminish the extent of these health problems in a variety of ways. Among efforts directed toward accident reduction is an injury prevention program that includes motor vehicle aspects such as child passenger protection, the promotion of seat belt use, and the deterrence of drunk driving. Furthermore, educational programs on such topics as smoke detector use and drowning protection are widespread.

Another aspect of disease prevention among Indians is a widespread nutrition and dietetics program in which clinical nutrition counseling and general health aspects are promoted. This aspect of Indian Health Service activity is viewed as possessing a very high potential for success, having had more than 200,000 contacts per year with patients in the early 1990’s. Also important is the provision by the Indian Health Service of modern sanitary facilities for many Indian homes. Between 1960 and 1991, almost 200,000 homes were provided with modernized sanitary facilities by the service. This assistance has included water and sewage facilities, solid waste disposal, and the development of local organizations to maintain the new systems. Yet much more help is needed in these ventures.

Shamanic and Modern Health Care

A particularly intriguing aspect of modern medical treatment is the combination of conventional Western treatment with the activities of the traditional tribal shaman. This combination of treatments may be found in many Indian Health Service facilities and elsewhere. Its use is partly attributable to the fact that shamanic treatment is comfortable to many Indians. Many of today’s physicians find that the shamanic ceremonies and medicinal treatments are a useful complement to their ministrations. These procedures are deemed to be particularly important in resolving mental health problems of Native Americans, but they have also found wide utility in problems ranging from heart disease to dermatitis to cancer.

Bibliography

Gregg, Elinor D. The Indians and the Nurse. Norman: University of Oklahoma Press, 1965. Points out problems, shortcomings, strengths, and other interesting aspects of federally funded care of American Indians from 1922 to 1937. Provides much insight into physicians, nurses, and Indian patients.

Hammerschlag, Carl A. The Dancing Healers: A Doctor’s Journey of Healing with Native Americans. San Francisco: Harper & Row, 1988. Various aspects of a psychiatrist’s experience with Indian healing are described. Includes examples of syntheses of Indian and Western medicine that produce useful, interactive processes are carefully explored.

Hultkrantz, Ake. Shamanic Healing and Ritual Drama: Health and Medicine in Native North American Religious Traditions. New York: Crossroad, 1992. A detailed survey of Indian practice and belief in health, medicine, and religion. Both the historical and modern aspects of shamanic ritual are covered. Also included is a copious set of valuable references.

Kane, Robert L., and Rosalie A. Kane. Federal Health Care (with Reservations). New York: Springer, 1971. Indian Health Service strengths, problems, and shortcomings are described knowledgeably. Included are the capacity to respond to patient needs and conflicts engendered when health providers and consumers have different cultural backgrounds. Kane was a director of the Indian Health Service Navajo service unit at Shiprock, New Mexico.

Torrey, E. Fuller, E. F. Foulkes, H. C. Hendrie, et al. Community Health and Mental Health Care Delivery for North American Indians. New York: MSS Information Corporation, 1974. This interesting multiauthored book covers mental health problems of North American Indians. It includes articles on general problems, cultural conflicts, alcoholism, drugs, suicide, and Indian mental health care needs. Shamanic aspects are also described.

U.S. Department of Health and Human Services. Indian Health Service. Division of Program Statistics. Trends in Indian Health, 1989-. This report briefly describes the Indian Health Service and its history and gives many modern statistics about Indian health care. Included are organizational data, handy health statistics, and statistics on many related issues.

U.S. Office of Technology Assessment. Indian Health Care. Washington, D.C.: Government Printing Office, 1986. This substantive book covers, in depth, many aspects of Indian health care. Included are the federal-Indian relationship, a population overview, American Indian health status, the Indian Health Service, selected special health topics, and extensive references.