What is Clinical Practice Issues in American Indians and Alaska Natives (Healthcare Disparity Among American Indians and Alaska Natives)?
The Native American community, otherwise referred to as the American Indians and Alaska Natives (AIAN), have a rich history dating back to the founding of The Iroquois League of Five Nations in the 1100s. However, their lives drastically shifted upon the arrival of European colonists, leaving them feeling like strangers in their own land. It wasn’t until 1924 that they were granted full citizenship in the United States, and only after another 22 years did the US government finally recognize their tribal sovereignty or their right to self-govern. Following their significant contribution in World War II, the US government created the Indian Claims Commission in 1946, as part of the Indian Claims Act, to address disputes around land ownership. However, issues persisted well into the 21st century, particularly concerning economic, educational, and health disparities, problems which the recent pandemic has only intensified.
Despite progress towards recognizing and improving the rights and wellbeing of the AIAN communities, the disparity between the healthcare provided to these indigenous people and non-Hispanic whites (NHW) is concerning. The arrival of European settlers brought harmful diseases like smallpox and yellow fever, decimating tribal populations. Subsequent healthcare provided by the federal government, under various treaties and executive orders, did not improve matters, with these agreements often broken, leading to high death and disease rates amongst the AIAN community. The Snyder Act in 1921 began a shift toward improved healthcare for this community, marking a clear commitment to addressing healthcare rights issues.
The situation started to notably improve after World War II with global health and human rights advocacy by organizations like the World Health Organization (WHO) and the United Nations. Furthermore, the transfer of health responsibilities from the Bureau of Indian Affairs to Indian Health Services (IHS) in 1955 led to a more integrated approach to delivering healthcare. Notable legislation like the Indian Self-Determination and Education Assistance Act (1975) and Indian health care Improvement Act (1976) brought much-needed improvements to AIAN health.
Through these combined efforts, since the establishment of IHS in 1955, the health status of the AIAN community has significantly improved, as seen in better sanitation, increased immunization rates, and more widespread use of antibiotics. An impressive achievement is the 82% decrease in the infant mortality rate. Yet, this progress has been accompanied by a prominence of non-communicable diseases such as obesity, diabetes, and alcohol abuse. Unfortunately, social issues like poverty, low literacy levels, and unemployment remain higher among the indigenous tribes than the rest of the country, leading to ongoing healthcare disparities. In this review, we will dig deeper into these healthcare disparities as they compare to those experienced by the non-Hispanic White community.
What Causes Clinical Practice Issues in American Indians and Alaska Natives (Healthcare Disparity Among American Indians and Alaska Natives)?
Health care disparities amongst the American Indian and Alaska Native (AIAN) communities usually arise from a mix of policy issues and personal factors. Things like demographic differences within the community, as well as policy failures that have affected health care services for centuries, contribute greatly to these disparities.
Policy Failures
Many years ago, the federal government promised to provide health care to the AIAN community through treaties. However, these treaties were not carried out as expected due to various political interests, which led to the poor execution of these health care policies. Additional policies were also introduced to improve the AIAN community’s living standards, but they often ended up reducing the authority of the indigenous tribes. For example, attempts to end the federal government’s responsibility towards the AIAN community or to relocate the community altogether have increased the burden of health care.
Demographic Differences
High rates of poverty, lack of education, and unemployment within the AIAN community also contribute to the health care inequality. For example, according to 2018 U.S. Census data, the poverty rate for AIAN was the highest amongst all ethnic groups and unemployment was much higher than the national average. AIAN individuals also tend to live in areas with limited access to nutritious food, which can lead to high rates of diseases like diabetes, obesity, and heart disease.
Education levels in the AIAN community are also lower. The most recent census shows that fewer AIAN individuals have high school diplomas, bachelor’s degrees, or advanced degrees than individuals in the white population.
Mistrust in the Federal System
A significant reason for health care disparities among AIAN is their mistrust in federally supported clinics. This distrust has historical roots, as the federal government has inflicted trauma on the community, including efforts to destroy native culture and identity. AIAN’s mistrust is also due to the unethical medical practices and research misconduct performed on the community in the past.
Underfunding of the Indian Health Services
The Indian Health Services (IHS), which is responsible for providing health services to the AIAN community, has consistently been underfunded. As a result, health care services for the AIAN community are more poorly resourced compared to services like Medicare, which are better funded.
The salaries paid to health care providers working with the AIAN community are also significantly lower than the national average. This lack of resources has been a chronic issue for Indian health care services, and despite efforts to increase funding for the IHS, it remains an underfunded organization.
Risk Factors and Frequency for Clinical Practice Issues in American Indians and Alaska Natives (Healthcare Disparity Among American Indians and Alaska Natives)
The Indian Health Service (IHS) has been working since 1955 to boost health outcomes for the American Indian and Alaska Native (AIAN) population. Despite improvements, chronic conditions, cancer, obesity, and diabetes have become more predominant. The latest data reveal significant health disparities within the AIAN community.
Demographically, there are 574 federally recognized Indian Nations in the U.S. Alaska is home to about 229 of these diverse nations and the rest spread across 35 states. Some of the tribes are recognized by their state governments and others are unrecognized. As of 2017, around 5.6 million people identify as AIAN, making up 1.7% of the U.S. population. Of these, 78% live outside of tribal areas.
- The largest concentrations of the AIAN population live in Arizona, California, Oklahoma, New York, New Mexico, Texas, Washington, North Carolina, Florida, and Alaska.
- Insurance coverage data from 2018 shows that the AIAN community has the highest percentage of uninsured individuals amongst all races. Under 65 years old, 34.6% had private health insurance, 32.2% relied on Medicaid or public coverage and 28.8% had no insurance.
- Life expectancy for AIAN is 77.5 years, close to the national average. However, mortality rates vary across different states.
- For example, in Alaska, the mortality rate is almost 3.5 times higher for AIAN than for Non-Hispanic Whites (NHW).
In addition, the Infant Mortality Rate for AIAN is double the rate for NHW at a national level, with even greater disparities in certain states.
- In 2018, 17.4% of the AIAN population reported being in fair or poor health compared to 10% of the NHW population.
- Chronic health conditions are more prevalent within the AIAN community. For example, AIAN adults were almost three times more likely to have diabetes and 2.5 times more likely to die from it than NHW adults. AIAN adolescents are also 30% more likely to be obese than NHW adolescents.
- Tobacco consumption, especially commercially produced tobacco, is particularly high in the AIAN community. It also leads to a higher likelihood of tobacco-related diseases and deaths among the AIAN population, with cardiovascular disease and lung cancer being among the leading causes of death.
- The risk of developing diabetes is almost 40% higher amongst the AIAN community who smoke versus those who do not smoke. An estimated 55.6% of AIAN reported that they want to quit compared to 72.8% of African Americans, 67.5% of Whites, 69.6% of Asians, and 67.4% of Hispanics.
The primary causes of death among the AIAN community are heart disease, cancer, and accidents. Chronic liver disease was the fourth-leading cause in 2018. The AIAN community also experiences higher rates of certain psychiatric issues. For instance, their rate of experiencing trauma and post-traumatic stress disorder is higher than the general population.
- Violence is a significant issue within the AIAN community. Four in five AIAN women experience violence in their lifetime, and AIAN were 1.2 to 1.7 times more likely to experience violence compared to NHW.
- The AIAN community is also severely affected by global pandemics, such as COVID-19. From January to June 2010, AIAN were noted to have 3.5 times higher risk of being diagnosed with COVID-19 than NHW. The risk of mortality amongst the AIAN community was twice as high compared to NHW.
Signs and Symptoms of Clinical Practice Issues in American Indians and Alaska Natives (Healthcare Disparity Among American Indians and Alaska Natives)
The healthcare and social work professionals who are part of the Indian Health Service (IHS) face unique challenges. The American Indian and Alaska Native (AIAN) community has a certain degree of mistrust towards the IHS and the agency’s chronic underfunding often hampers their ability to deliver comprehensive services, creating numerous barriers to providing effective care.
When caring for a patient from the AIAN community, it’s crucial to respect their traditions and history. Many, particularly those residing in rural areas, may employ traditional healers. Having a negative attitude towards this practice could harm the patient-provider relationship. It’s also important to understand the patient’s lifestyle habits (such as alcohol and tobacco use), work history, and family health history.
- Respecting traditions and history
- Recognizing use of traditional healers
- Understanding lifestyle habits
- Examining work history
- Exploring family health history
It’s worth mentioning that the AIAN community frequently experiences post-traumatic stress disorder and various forms of trauma. Therefore, it’s essential to gather a history of any past trauma, particularly in women and children. Also, every interaction with AIAN patients should be seen as an opportunity to advocate for vaccinations and cancer screenings.
Testing for Clinical Practice Issues in American Indians and Alaska Natives (Healthcare Disparity Among American Indians and Alaska Natives)
A complete and thorough check-up is essential for identifying signs of illness. However, given the disparities in healthcare provided by the Indian Health Service (IHS), timely diagnostic procedures can be challenging for some patients. Therefore, a comprehensive medical examination becomes even more critical.
Treatment Options for Clinical Practice Issues in American Indians and Alaska Natives (Healthcare Disparity Among American Indians and Alaska Natives)
Improving healthcare for the American Indian and Alaska Native (AIAN) community requires a multifaceted approach. Over the years, several important legislations have been enacted to help in this regard. These laws have not only brought more clarity to the federal government’s commitment to this cause but also acknowledged the authority of the tribal nations to manage their local health systems. Today, the healthcare delivery system for the AIAN community is known as the “I/T/U” system, where “I” stands for Indian Health Services (IHS), “T” indicates tribal programs, and “U” means urban health centers.
There are four key Acts enacted through the years for the benefit of the AIAN community:
The Snyder Act, enacted in 1921, was the first to allocate funds specifically for the healthcare of the AIAN community. The main funding for the activities of the IHS, a federally funded agency that provides healthcare to the AIAN community, comes from this Act.
The Transfer Act was passed in 1954 and moved the responsibility of the Indian Health program to the Public Health Service. This Act recognized the sovereignty of the indigenous tribes and gave them some power in health policy decisions.
The Indian Self Determination and Education Assistance Act, passed in 1975, is regarded as a significant reform for AIAN healthcare. This Act allowed the tribes to manage Bureau of Indian Affairs (BIA) and IHS programs. It provided the tribes with monetary and administrative benefits, such as the option to carry over the remaining funding to the next year and eligibility for several federal grants.
The Indian Healthcare Improvement Act, passed in 1976, clarified the role of the US federal government in providing healthcare to the AIAN community. With this Act, the Urban Indian Health Programs were established. It also reauthorized the provision for IHS and tribal health programs to bill Medicare and Medicaid. This step was critical in improving access to healthcare for AIAN patients who depend on these programs for medical services.
More recently, the Affordable Care Act (ACA) has brought several advantages to the AIAN community. It led to the permanent reauthorization of the Indian healthcare improvement Act and gave the IHS the authorization to start several new programs and services. Every insurance company is now required to cover the cost of preventive care, including cancer screening, which has significantly improved the healthcare access for the AIAN community.
The IHS has made significant strides in bridging the health disparities. For instance, since its establishment, the life expectancy of the AIAN community has improved by 15 years on average. However, the disparities continue to exist, and several health parameters in the AIAN community continue to show poor outcomes.
To approach care for the AIAN community effectively, it’s crucial to understand the cultural differences and beliefs of each tribe. It’s also important for healthcare providers to be sensitive to the history of trauma, such as the loss of sacred lands and forced assimilation, that this community has endured. Providers should work on building a rapport with the AIAN patients, listening to their stories with sensitivity towards their culture and identity.
What else can Clinical Practice Issues in American Indians and Alaska Natives (Healthcare Disparity Among American Indians and Alaska Natives) be?
The above discussion details various factors leading to unequal healthcare standards in the American Indian and Alaskan Native (AIAN) community.
Preventing Clinical Practice Issues in American Indians and Alaska Natives (Healthcare Disparity Among American Indians and Alaska Natives)
Doctors who work with the American Indian and Alaskan Native (AIAN) community need to understand the unique culture and history of these groups. Despite the fact that many people from these communities have relocated from reservations to cities, they still face notable differences in their healthcare quality and overall health. This is further complicated by the ongoing shortage of resources and funding in the Indian Health Service (IHS), making healthcare inequality even worse. By being adaptable and treating each patient as an individual, doctors may find better ways to navigate challenging circumstances and provide the best possible care.
