American Indians 1

American Indians Health Care

Tanner Banks
Felicia Byers
Julia Lerdahl
Kale Mohar
University Of Utah

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American Indians have history, traditions and beliefs unique to their culture which have
made it difficult for them to obtain optimal health care from the modern American health care
system. This has led to many disparities in their health as compared to the health of the nonHispanic White population. Some of these disparities include higher rates for cancer, type two
diabetes, and alcohol abuse. It is important to note that these disparities have strong connections
to the previous health traditions of the American Indian people. If the health status of American
Indians is to be improved it is critical that a more culturally competent health care system be
developed.
Health Traditions and Population History
Historically American Indians have viewed medicine in a more holistic aspect, rather
than an allopathic view, however, when living in the United States a more allopathic medicinal
view is practiced. When American Indians were promised free healthcare for the rest of their
lives, they didnt necessarily realize that their views of medicine would have to change (Wright,
2009). Due to this change in medicinal practice, they are, and were skeptical of physicians when
they have their own cultural traditions that have yet to be proved untrustworthy. Illness or
disease were treated by natural elements and game in which American Indians gathered and
killed (Vogel, 1970). American Indians suffered through a lot of illnesses that were brought over
by the Europeans when they were colonizing the United States (Beauvais, 1998), and
unfortunately did not understand the illnesses they experienced and thus unable to diagnose
and/or treat.
The Europeans settled and ended up colonizing what is now the United States of
America. A huge influence that was brought over with the white settlers is what the world refers
to as alcohol (Beauvais, 1998). American Indians used alcohol as a means for ceremonial

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purposes and were therefore less educated on the effects of alcohol before the colonization of the
white man. Due to their lack of knowledge, the American Indians were in some ways taken
advantage of and therefore led to physical and emotional issues. The white man provided what is
known as the social model of drinking, where it is commonly used during social gathers such
as trading posts (Beauvais, 1998). Unfortunately the social model didnt stop there, it traveled
as the country colonized from east to west, affecting most, if not all, Indian tribes. Due to having
no drinking regulations and an early onset, the tradition of heavy alcohol consumption has
been passed down to generations, which is why alcohol related problems are at such a high level
in the United States amongst American Indians (Beauvais, 1998).
American Indians were self-sufficient when it came to nature and how it brought the
people together as a tribe. Their diet consisted of the crops in which they grew with the help of
irrigated ground water from the rivers and rain. Unfortunately water became scarce when dams
were created to diverge the rivers to white settlers farms, and not those of the American Indians.
The damming of the rivers led to the starvation and suffering of American Indian tribes, along
with the absence of water production for 100 years (Adelman et al., 2008). Through the absence
of water, the American Indians were not able to grow their crops and were literally starving to
death. Once the Untied States government realized what was happening, they distributed aid to
the American Indians with the means of processed food. The food provided did not correspond
with American Indians traditional diet of fresh natural foods that they were accustomed to. With
that being said, this was the beginning of type 2 diabetes or bad sugar amongst the American
Indian populations (Adelman et al., 2008).

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Health Disparities
There are many ongoing healthcare disparities and epidemiological issues when
comparing the American Indians to the non-Hispanic white population. When looking at current
epidemiological status of Native Americans, the authors of this paper decided to focus on three
major current issues: cancer, type 2 diabetes, and alcoholism. Much of the data presented is
collected from the Census data and the Center of Disease Control (CDC) and focuses on the
American Indian population. The CDC reported in 2009, that cancer and type 2 diabetes ranked
2nd and 4th in cause of death for American Indians (CDC, 2009). The authors explore current
disparities in terms of health and healthcare when comparing non-Hispanic Whites to American
Indians.
Among the three major focuses of health status on American Indians, the most
devastating and also the most prevalent cause of death is cancer. The Office of Minority Health
reported that in comparison to non-Hispanic Whites, American Indian men were twice as likely
to have liver cancer and 1.6 times more likely to have stomach cancer. American Indian women
were 2.6 times more likely have liver and Intrahepatic Bile Duct cancer and were found to be
40% more likely to have kidney/renal pelvic cancer compared to non-Hispanic White women
(Office of Minority Health, 2013).
The CDC reports that American Indians suffering from type 2 diabetes have a mortality
rate of 182% higher than non-Hispanic Whites (IHS, 2007). One particular study focused on
prevalence of type 2 diabetes in young American Indians from birth to 34 years. The study found
that type 2 diabetes in the studied group increased by 46% from 6.4 to 9.3 per 1000
people(Acton et al., 2002). Many organizations are recognizing type 2 diabetes as a significant
problem in among American Indians and have seen a steady increase in prevalence in their

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communities in the past 40 years. There are other studies that look at prevalence of type 2
diabetes in American Indian communities and have found that many communities have some of
the highest prevalences of type 2 diabetes in the world (Acton et al., 2002). American Indians
were 2.1 times more likely to have type 2 diabetes or be diagnosed with type 2 diabetes
compared to white American adults.
The third health care disparity explored was alcoholism among American Indians.
Statistics show that nearly 1 in every 10, or 12%, of the American Indian populations pass away
from alcohol related issues (Winkel, 2010). The CDC states, In 2009, [American Indians and
Alaskan Native] adults were among those with the highest prevalence of binge drinking (CDC,
2013). According to the CDC, American Indians who suffer from alcoholism die at higher rates
(552%) compared to Americans (IHS, 2007). In 2009 American Indians reported the highest
rates of binge drinking episodes per individual (CDC, 2013).
Reasons for Disparities
As we have looked into cancer, type 2 diabetes, and alcoholism, the question arises, why
are American Indians at such a high risk for these epidemics? To understand why American
Indians have a higher percentage of each, this section of this paper will discuss how each disease
is related to health care availability, history, and traditions of American Indians.
As mentioned earlier, American Indians have the poorest survival rate for cancer (Cancer
in Our Communities: American Indian/Alaska Natives and Cancer, 2014). The reason for higher
cancer rates among American Indians is complex and is likely a combination of several factors.
Some of these factors could be low awareness of cancer risks, distrust of medical systems and
research, underfunded health systems, limited availability of prevention programs, cancer

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screenings, and specialist care (American Indian Cancer Facts, 2014), and background history or
traditions of American Indians that have disregarded (Reuben & Freeman, 2003).
For many American Indians, lack of cancer screening and treatment, or dangerously
delayed care, is commonplace (Reuben & Freeman, 2003). The reason is quite simple for this
factor, except for a small number of tribal members who have private insurance or coverage
under a plan for tribal employees, American Indians must rely on the Indian Health Service.
Primary care is usually administered by the tribe; specialty care (the care pertaining to cancer)
facilities are operated by Indian Health Services. This is a problem because not only are both
primary and specialty care facilities underfunded to meet the health care needs of the population,
but many reservation residents live far from the nearest Indian Health Service or tribal primary
health facility. These problems can result in many American Indian cancer patients to be
diagnosed only when their disease is advanced and untreatable. This situation reinforces the
belief held by many American Indians that a cancer diagnosis is a death sentence causing many
to avoid seeking care for suspicious symptoms out of fear (Reuben & Freeman, 2003).
Some background history can play a role in the distrust of American Indians and some
traditions of American Indians can also contribute to the higher percentages of cancer. American
Indians have been known to fish, hunt, and gather for their foods. However, it is believed that
the U.S. Government has failed to honor its treaties that allow American Indians to continue this
tradition. An example is the Treaty of 1855 with the Yakama that guaranteed the right to fish at
all the usual and accustomed places, but this treaty has been threatened by a series of dams built
over the last half century. The continuation of the tradition of fishing has proved to be harmful
because of the chemicals released into the rivers. In 1988-1989, the U.S. Environmental
Protection Agency conducted a national survey of water contamination that determined fish in

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the Columbia River were found to be heavily contaminated with dioxins. These dioxins have
been proven to damage the human immune system (Reuben & Freeman, 2003). Other risk
factors for cancer include heavy alcohol use and diabetesconditions that tend to be more
common among American Indians according to the Center for Disease Control (Cancer in Our
Communities: American Indian/Alaska Natives and Cancer, 2014).
To understand diabetes in American Indians, it may be easier to first understand the
causes of type 2 diabetes and then relate these causes to American Indian culture and their
attributes. Type 2 diabetes can be caused by certain genetic markers, obesity, diet, and a prenatal
hyperglycemic environment (Dabelea, et al., 1998).
Along with American Indians lack of health care and opportunities to receive care
(Gohdes, Kaufman, & Valway, 1993) their diet may play a crucial part in type 2 diabetes
diagnoses. Nationally, only a minority of American Indians still obtain most of their meat from
hunting and fishing (Young, Reading, Elias, & O'Neil, 2000). Reasons for this may be the many
dams that have been put up as mentioned earlier, but also when areas became more settled in the
1880s and early 1900s, American Indians became more reliant on other sources of food because
farming was no longer possible. They became reliant on trading posts and government food
programs and eventually very little food came from subsistence farming, hunting, and gathering
(Boyce & Swinburn, 1993). The change in American Indian diets over the last century has
mainly been from high complex carbohydrate/high fiber foods to high-fat modern foods. This
change is corresponded to the increase in type 2 diabetes and also to obesity which is a cause of
type 2 diabetes (Boyce & Swinburn, 1993)
The use and/or abuse of alcohol for American Indians has a strong historical background.
Some abuse may be tied into the health services available and genetics, but it also is strongly

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supported by time and history (LaFromboise, 1988). Before colonization American Indians used
alcohol substances mainly for ceremonial purposes. When Europeans came to the area, they
introduced and suddenly made large amounts of distilled alcohol and wine to the American
Indians (Beauvais, 1998). Well-defined population such as American Indian tribes are often
more genetically and environmentally homogeneous than the general population. They are
geographically restricted and large families are common. This has played a strong role in
genetics and alcohol abuse (Long, et al., 1998; Beauvais, 1998). Beauvais research (1998) has
also shown that socioeconomic factors, boarding school experiences, and loss of culture
contribute to the abuse of alcohol among American Indians.
Cancer, diabetes, and alcohol abuse have similar things in common, in that they may
result from diets, weight, and the health insurance and care provided to American Indians. Indian
Health Service funding is appropriated annually at the discretion of Congress and is not adequate
to meet the health care needs of American Indians. This ongoing funding deficit is a major factor
in cancer-related and other disparities experienced by American Indians (Reuben & Freeman,
2003).
Increasing Cultural Competencies
Increasing cultural competency in healthcare can help resolve or decrease the
disparities in the healthcare of American Indians (Betancourt, 2005). There are numerous ways
that a more culturally competent healthcare system could be achieved for the American Indian
people. Some suggestions include: educating current health care providers on communication
skills, reimbursing traditional healers, and increasing funding for the Indian Health Services.

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In order to increase the cultural competency of healthcare providers it can be crucial to

educate them on the communication styles of the people that they serve. If a provider
understands how to effectively communicate with their patient, they are much more likely to
build trust and credibility with their patient. Some things to take into consideration when
speaking with American Indian patients include: speaking pace, patience when listening,
physical proximity and boundaries, and what kind of questions should be asked (Hendrix, 1999).
First, many American Indians tend to speak slower and less directly than most nonIndians. For instance when speaking to their doctor an American Indian may describe issues
they have had over the past ten years rather than discussing only the recent incidents. This may
seem tedious or not relevant to their doctor, yet, as discussed previously, American Indians view
health from a more holistic approach. Many believe that even the weather, eating habits and
taboos all affect their health. It would then be very important to listen to these details rather than
disregarding them. Careful listening is very important because if the patient is interrupted they
may feel that the doctor does not care about them or the doctor does not know what they are
doing. It is also important to note that speech organization for American Indians is often
different than non-Indians. The main point or conclusion of their explanation may be heard in the
middle of a paragraph rather than at the end (Hodge, 2000). This is another reason why it is
critical for health care providers to listen carefully without interruptions. This may require
carefully allotting enough time for the appointment.
Second, body language is also very important when speaking with an American Indian
patient. Gentle handshakes are usually welcome, as are smiles. Eye contact is important,
although prolonged eye contact can be seen as aggressive and impolite. As for proximity, several
feet is usually a comfortable speaking distance for American Indians. It is important to note that

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females place high value on modesty and may feel very uncomfortable undergoing Pap smear
tests or mammograms performed by a male doctor so, if at all possible, having a female doctor
perform the tests or be present could be very helpful (Hodge, 2000).
Finally, asking questions can lead to communication that may not have happened
otherwise. For instance some American Indians may undermine their pain, refraining from
complaints even if their pain is in fact very high. In that case it would be very important to probe
with more questions. In another situation it could be important for a healthcare provider to know
if the patient is using traditional healing methods, but American Indians may be reluctant to
volunteer that information because of its personal and sacred nature (Hodge, 2000). Health care
providers need to be aware of how to ask about that in a sensitive way. Understanding
communication skills such as these can have a significant impact on the patients relationship
with the physician, thus increasing the chances of the patient seeking timely medical care.
Another suggestion for creating a more culturally competent healthcare system for
American Indians is to reimburse traditional healers (Goodkind, 2010). Traditional healers are
still used by a significant portion of American Indians (Marbella, Harris, Diehr, Ignace & Ignace,
1998). Traditional healers are typically more accessible to American Indians, and seem to help
significantly improve the overall health and wellbeing of their patients (Hamby, Duclos,
McCrimmon, 2009). If traditional healers were reimbursed by the government, it is more likely
that American Indians would go to them for help, thus improving their overall health. Currently
the Indian Health Services has a division called the Contract Health Services (CHS). Indian
Health Service facilities can often only provide primary health care, and if patients wish to
receive additional care, say from a traditional healer, they must apply for CHS funds. There are
not well defined federal regulations for qualifying or certifying traditional healers which means

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that it can be difficult for patients to obtain CHS funds in order to partake in traditional healing
practices (Rhoades, 2009).
Many Indian Health Service facilities have made efforts to include and support traditional
healers in the facility with positive results (Rhoades, 2009). When American Indian patients can
see health providers from their own culture inside the hospital or clinic it often increases their
chances of feeling comfortable receiving care there, and the likelihood of the patient going to
receive healthcare without delay (Gabard, 2007). The authors of this paper believe that
increasing reimbursement and support of traditional healers in Indian Health Service facilities
could significantly help decrease health disparities for the American Indian people by increasing
the chances of catching health issues such as type 2 diabetes and cancer early.
The Indian Health Service is severely underfunded which, if fixed could dramatically
increase medical services available to American Indians which could improve their overall
health. According to the U.S. Commission on Civil Rights, the United States Government is
treaty-bound to tend to the healthcare needs of the American Indian people, yet it has been
falling short. In 2005, the Indian Health Service beneficiaries were allotted $2,130 per capita
while Medicaid and Medicare beneficiaries were allotted $5,010 and $7,631 per capita
respectively (Soeng, 2010). This has not been enough funding for the Indian Health Service
facilities to provide the technical medical care that is needed to diagnose and treat certain
diseases like cancer (Hodge 2000). The Indian Health Services is responsible for providing a
large amount of primary care to the American Indian population and for the services they cannot
provide, patients are required to apply for CHS funds as mentioned previously. However due to
lack of funds, CHS applications are frequently not approved or the funds simply are not extended

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for certain services (Hodge 2000). With better funding, more money could even be allocated to
disease prevention education and services (Hamby, Duclos, McCrimmon, 2009).
In conclusion, the American Indian people have had significant events in their history
which have caused differences in their ability to obtain quality healthcare as compared to the notHispanic white population. These differences have led to the increased chance American Indians
having certain illnesses. In order to begin to address the disparities found in the healthcare of
American Indians, there are three suggestions which could make a dramatic impact. First,
reimbursing traditional healers; second, educating healthcare providers on how to better
communicate with American Indian patients; and third, increasing the funding provided to the
Indian Health Services so that they can provide more and greater quality medical services.

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