American Indian Culture and Research Journal

THE UNNATURAL HISTORY OF DISEASE The health problems Native Americans are confronting today did not arise out of an historical vacuum. Diseases and ill health have a history. Health levels are linked to the social, political, and economic forces present at any historical moment. Thus, in order to understand some of the present day factors determining Native American health levels, it is imperative to examine the historical context from which these health patterns emerged. The medical history of Native Americans since European contact can be characterized as an “unnatural history of disease’’-unnatural because the epidemiology of Native American people changed under the hegemony of European contact. Native Americans, from the sixteenth through the mid-twentieth century, experienced a new set of afflictions which decimated their populations. Epidemics such as smallpox, rubella, influenza, malaria, yellow fever, and cholera ravaged Native American societies, creating societal disorganization. It is not surprising that these epidemic episodes coincided with European expansion and development of the frontier.

The uniqueness of man comes from the fact that he does not live only in the present; he still carries the past in his body and in his mind, and he is concerned with the future. To be really relevant to the human condition, the concept of adaptability must incorporate not only the needs of the present, but also the limitations imposed by the past, and the anticipations of the future. René Dubos, Man Adapting, 1965 Until the arrival of foreigners on the shores of the “new continent,” it appears that Indians were relatively free of infectious diseases, with the exception of tuberculosis. This situation left bands and tribes without any acquired immunity, and they fell appallingly easy victims to diseases brought in by outsiders. Unfortunately, there is a paucity of detailed information available concerning American Indians and Alaska Natives, and the importation of diseases that decimated or annihilated whole populations and tribes.

INTRODUCTION The use and abuse of alcohol and drugs among elementary and high school students are complex phenomena, and race, sex, culture, and economic factors are all interrelated in the development of alcohol and drug use patterns. It is well known that a major health problem for American Indians is alcohol abuse and that prevention of substance abuse is an important health consideration for increasing life expectancy. Such prevention efforts must begin early; often school health curricula include placement of alcohol/drug health teaching towards that end. Is a curriculum effort aimed only at health practices a sufficient target to prevent substance abuse? This article will review the results of survey data gathered from a stratified random sample of 2,234 students, grades 6-12, to review the differences in the social network of American Indian and non-Indian students with regard to alcohol use. The extent to which differences between student group exists will determine the effectiveness of any one classroom prevention program designed by school educators for the student population.

INTRODUCTION The prevalence of metabolic glucose disorders in American Indians has been investigated by community survey techniques since the early 1960s for tribes located in the southwestern United States, e.g., Arizona, Oklahoma, New Mexico, Colorado. Very few survey results were published for tribes in other location. In the northwestern United States, only one unpublished survey report from the Warm Springs Reservation exists. The incidence and/or prevalence of diabetes in the tribes studied varied with the specific decade, the specific methods used for the survey, and the tribes involved; therefore, comparisons between decades and tribes are impossible, and generalizations are difficult. The problem during the early years of surveys for diabetes among American Indian groups was to distinguish between two explanations for the comparatively high rates of diabetes. Either the disease was a new epidemic response of a population rather suddenly exposed to a constant food supply, or somehow American Indians had developed a resistance to the effects of hyperglycemia and therefore did not exhibit the same frequency of symptoms and common complications of prolonged diabetes found among other populations. Indeed, early investigators were hesitant to label persons “diabetic” with plasma sugar levels that averaged over 250 mg. percent two hours following a glucose load of 75 grams in spite of confirmation by standard glucose tolerance tests. Such early titles in the literature as ”The High Prevalence of Abnormal Glucose Tolerance in the Cherokee Indians of North Carolina,”’ and ”Hyperglycemia in Pima Indians” (emphasis mine) reflect this bias. These early papers reflect the viewpoint that a “special Indian” diabetes existed, presumably devoid of the complications of blindness, renal failure, amputations, and acidotic coma, although Miller et al. in 1968 did find evidence of early retinal changes, cataract formation, kidney function decrease, and other secondary complications from diabetes of long duration.

It is well known that the health status of American Indians is below national averages and has been for many years. Identified health difficulties include a pattern of social problems, poverty, and disease that is unparalleled among other ethnic and racial minorities in the United States. The disabled American Indian, however, faces additional disadvantages in the form of major barriers to care and rehabilitation services. Further, the incidence of several serious disabling conditions among some tribes is thought to be well above that reported for the United States population as a whole. Fetal alcohol syndrome (FAS), bacterial meningitis, otitis media, diabetes, accidents/trauma, alcohol/drug abuse, and mental and emotional disorders cause disabilities among Indians at significantly higher rates than among non-Indians. Major disabilities include seizure disorder, developmental delay, language and speech delay, mental retardation, pulmonary disorders, vision problems, hearing loss, trauma from accidents, diabetes-related disabilities, and alcoholism. The severity of each problem, however, varies from one Indian group to another. Fetal alcohol syndrome (FAS) and fetal alcohol effect (FAE), disabling conditions which have been identified and categorized only since 1973, consist of a group of physical and developmental abnormalities present in infants, which are caused by maternal alcohol consumption during pregnancy. Characteristics of the disorder include impaired intrauterine and postnatal growth, abnormalities of facial development, and mental retardation. Cleft palate and health defects are often present as well. In the state of Alaska, to give just one example, the incidence of FAS among the native population was found to be 4.2 per 1,000, twice that reported on the Navajo reservation and in the urban Seattle, Washington area.

INTRODUCTION . . . politics is medicine on a large scale. -Rudolphe Virchow Although Virchow's often-quoted declaration was made over a hundred years ago, the statement summarizes the current health dilemma faced by Native Americans. Native American health, like so many other aspects of their lives, is intimately intertwined with a legal and political-economic structure which often determines individual and societal well-being. The health problems faced by many Native Americans today are a result of their political-economic status vis-a-vis the dominant society. For example, the current epidemics of substance abuse, diabetes, violence, and suicide, to name a few, are rooted in the political and economic relationships American Indians have with the federal government. The solutions to such health problems transcend the boundaries of medical technology and treatment, requiring political change, not just an administrative restructuring in current health policy or an infusion of the latest medical technology. This is not to deny that tremendous progress has been made in American Indian health. Most of the diseases that plagued pre-twentieth century Indian people have been controlled or nearly eradicated through massive public health efforts, but their treatment has remained largely reactionary or crisis oriented, addressing only the clinical manifestations of the disease rather than its causes. Certainly, medical technology and public health efforts have gone far in controlling infectious and environmental diseases, but these efforts have not made significant inroads into certain health problems that are firmly anchored in the political and economic spheres of contemporary American Indian life. One such health problem is infant mortality.

INTRODUCTION In contrast to the exhaustive ethnographic and ethnohistoric literature on American Indian life generally, there has been, until the last decade, limited ethnographic description of the quality of life and possible career paths available to Indians in old age. The dearth of research findings that describe what it means to be old in contemporary American Indian society is due, in part, to the relatively small size of this subsection of the ethnic group. In 1980, 1.5 million American Indians lived in the United States. Of this number only 116,606 were over 60 years of age. This figure represents a considerably smaller proportion (7.6 percent) of the total American Indian population when compared to the 16 percent of the general population who are over 60 years of age for the nation as a whole. Those findings about American Indian old age which have been developed in the last decade can be broadly divided into six categories: demographic profiles, definitions of Indian old age, condemnation of the current deplorable state of the older Indian, needs assessments with their findings and recommendations, ethnographic descriptions of roles and functions of elders in nineteenth-century Indian societies, and ethnographic descriptions of positive and enhanced status and roles for contemporary Indian elders vis-a-vis their ethnic community.

Composed of over three hundred tribes, the American Indian population now numbers more than 1.5 million and consistently has had a birthrate twice that of the United States population. In their attempts to obtain adequate and equitable health care and alcohol and substance abuse services, whether on reservations or in urban areas, American Indians tend to rely upon the American institution called the Indian Health Service (IHS), which is a branch of the Public Health Service located within the United States Department of Health and Human Services. Based on the 1980 census, ”59 percent were included in IHS’s estimated service population” and were located in the thirty-two reservation states. In 1970, over half (54 percent) lived in rural areas and only one-fourth resided in urban areas but by 1980 ”almost two-thirds of [those] identifying themselves as [American] Indians lived off reservations, tribal trust lands, or other Indian lands,” over half (54 percent) lived in metropolitan areas, and nearly “10 percent were on or near reservations that were in or contiguous to metropolitan areas and were served by IHS urban or tribal facilities." In addition, the estimated IHS service population for fiscal year (FY) 1990 of 1,103,608 American Indians represents a 33 percent increase from 1980 and a 140 percent increase since 1970. Not only service population increases, but also issues of poor planning, mismanagement, escalating and “catastrophic” health costs, federal budget constraints, and other problems have resulted in smaller delivery, and consequent increased pressures for possible IHS program elimination and change.

Over the last twenty-five years, there has been a significant migration of American Indian people from reservations and rural areas to cities. The 1980 census reported that almost two-thirds of the 1.5 million persons identifying themselves as Indians live off reservations, tribal trust lands, or other Indian lands. Fifty-four percent of the total United States American Indian population lived in metropolitan areas. In 1976, the United States Congress passed Public Law 94-437, the Indian Health Care Improvement Act, in part due to their recognition that urban American Indians were a population group that continued to lag behind others in access to primary health care. Access, Congress found, was severely curtailed by a lack of knowledge or understanding of available medical services in most urban areas, and a lack of income or health insurance to pay for medical care. Thirty-seven urban Indian primary medical and dental clinics have been established as a result of this legislation. These programs offer a variety of social services, and may appropriately be characterized as "human services organizations." However, only 32 percent of the reported urban program encounters (approximately 55,000 encounters) in 1984 were medical, while 27 percent were health related (health education, nutrition, etc.), and 31 percent represented other community service contacts.

INTRODUCTION Today slightly over half of the 1.5 million American Indians and Alaska Natives live in towns, cities, and other off-reservation communities in the United States. This migration to the urban areas has increased dramatically during the last two decades. The increase began during the 1950s and 1960s with the relocation of Indians to the cities, and was partially financed by the federal government. Indian families were encouraged to leave the reservations and migrate to the cities to obtain jobs and to avail themselves of other economic opportunities. In many instances, leaving the reservation meant also leaving behind the support of kin and access to free medical care. Once in the cities, most Indian families found themselves living in urban ghettos with few resources to cope with the new environment and its foreign institutions and rules. In time of sickness, many Indian relocatees found themselves denied, declared ineligible for, and/or unable to afford medical care in the cities. As more and more Indians migrated to the cities, their health problems increased, and concerns over their access to health care escalated. Fortunately, with the advent of consumer health movements in the 1960s, a number of “store front” free clinics serving Indian clients sprang up in cities across the country. Over a period of time, many of these initial “store front” clinic operations became eligible for federal funding as part of a network of urban-based Indian health clinic.

INTRODUCTION In the Tewa Pueblo world, health is thought of as a state of balance or a state of harmony between the human and natural environments. John Collier, in the 1930s, described the search for harmony between the human and natural environments by the Pueblo people as not altogether unique but so very special that he knew of nowhere else where a more perfect flowering of the man-society and man-society-nature relationship had happened. The Pueblo people recognize that they live in a world of polarities-life and death, man and woman, weak and strong, black and white, and winter and summer-which create unity. They believe that past and future come together in the present-or in the center. The center is where harmony, balance, and grounding happen. It is where opposites come together to create cyclic movement and flowingness-or healing.

Recent initiatives implemented by the Indian Health Service target health promotion and disease prevention as service goals for the 1990s. In partial support of these initiatives, the Indian Health Service sponsored a research planning meeting in September 1988. The meeting was intended to initiate thought on research priorities consistent with the initiatives, to identify a cadre of American Indian scholars interested in health promotion and disease prevention, and to frame a research training agenda for a follow-up meeting with the identified scholars. Budget constraints led to cancellation of the second meeting as originally planned. However, in collaboration with the National Institute for Drug Abuse, the Indian Health Service sponsored an alternative meeting in September 1989. Unfortunately, the focus of the meeting shifted from priorities in health promotion and disease prevention to training for research careers in the field of drug abuse. At first glance, one cannot argue with the change in focus. Drug abuse is certainly a vital research concern. Little is known or written about its extent and impact in Indian communities. Dr. Joseph Trimble, an American Indian psychologist, noted that through September 1989 only fifteen research articles had been published on American Indian drug abuse and that nine of these were reviews of literature. Dr. Trimble built a compelling case supporting a need for drug abuse research. However, few of the presentations were as culturally germane and enlightening as Dr. Trimble’s. Most presenters harped on application procedures in efforts to hone individual skills for writing research grants. While useful, this approach did not satisfy the aspirations of the visiting scholars. Midway through the meeting, in a polite and refreshing manner, American Indians objected to research paradigms that failed to account for unalterable cultural factors which are essential conditions overlooked by most research. While this diversion did little to influence the direction of research at the National Institute for Drug Abuse, it does serve as important commentary for health-related research.