Responsibility for Health Care

    Through existing treaties, the federal government assumes responsibility for the health care needs of American Indians.   Few American Indians on reservations have traditional health insurance.  The Indian Health Service is the principal federal health care provider and health advocate for Indian people, and its goal is to raise their health status to the highest possible level. The IHS currently provides health services to approximately 1.5 million American Indians and Alaska Natives who belong to more than 557 federally recognized tribes in 35 states.

Government services respect a blending of both worlds.  The provision of health services to members of federally-recognized tribes grew out of the special government-to-government relationship between the federal government and Indian tribes. This relationship, established in 1787, is based on Article I, Section 8 of the Constitution, and has been given form and substance by numerous treaties, laws, Supreme Court decisions, and Executive Orders.   The principal legislation authorizing Federal funds for health services to recognized Indian tribes is the Snyder Act of 1921. It authorized funds "for the relief of distress and conservation of health . . . [and] . . . for the employment of . . . physicians . . . for Indians tribes throughout the United States."

Congress passed the Indian Self-Determination and Education Assistance Act (Public Law 93-638, as amended) to provide tribes the option of either assuming from the IHS the administration and operation of health services and programs in their communities, or to remain within the IHS administered direct health system. Congress subsequently passed the Indian Health Care Improvement Act (P.L. 94-437), which is a health-specific law that supports the options of P.L. 93-638. The goal of P.L. 94-437 is to provide the quantity and quality of health services necessary to elevate the health status of American Indians and Alaska Natives to the highest possible level and to encourage the maximum participation of tribes in the planning and management of those services.

Over the last twenty years the Indian Health Service has shifted its focus from acute care to programs directed at health promotion, disease prevention, and chronic health conditions.  While health promotion and disease prevention is a major focus of the IHS, these programs are often in conflict with American Indian values.  The use of traditional healing practices is explained to physicians practicing on the reservations, but if clients perceive reluctance to accept these practices, they do not reveal their use.  This is especially true among the elderly who seek hospital or clinic treatments only when their conditions become life threatening.  Younger generations seek treatment sooner and use the health care system more readily than do elderly people. However if their patents are traditional, they may combine native traditional medicine with Western medicine.

Photo Courtesy of the Indian Health Service/U.S. Department of  
   Health and Human Services.

Health-Seeking Beliefs and Behaviors

Traditional American Indians beliefs influence health-care decisions.  For example, for many elderly people, the germ theory is nearly impossible to comprehend.  In addition, asking clients questions to make a diagnosis fosters mistrust.  This approach is in conflict with the practice of traditional medicine men, who tell people what is wrong without their having to say anything.

            Cultural perceptions of the sick role for the American Indian are based on the ideal of maintaining harmony with nature and with others.  Ill people have obviously done something to place themselves out of harmony.  Support of the sick role is generally not accepted, but rather support is directed at assisting the person with regaining harmony.

Diseases and Health Conditions

    Historically, most disease affecting American Indians were infectious.  In the past, contact with settlers who had communicable disease eliminated entire tribes because they had not acquired immunity for many infectious diseases which were common among other American populations.

    Most American Indian tribes exhibit high-risk behavior related to alcohol abuse, along with its subsequent morbitiy and mortality. Alcohol use is more prevalent thatn any other form of chemical abuse.  Although alcohol is illegal on most reservations, many purchase alcohol off the reservation.  The higher alcoholism rate is often attributed to a high unemployment rate.

    Comparing the 1994 to 1996 Indian age-adjusted death rates with all races of the US population in 1995 reveals the following higher death rates in the American Indian population:

Alcoholism                              627% higher  

Tuberculosis                            533% higher  

Diabetes Mellitus type II        249% higher  

Unintentional Injuries             204% higher  

Suicide                                  72% higher  

Pneumonia and Influenza       71% higher  

Homicide                                63% higher  

Infant Mortality                      22% higher  

Heart Disease                          13% higher