Report on Indian health : final report to the American Indian Policy Review Commission

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Title:
Report on Indian health : final report to the American Indian Policy Review Commission
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vi, 264 p. : ill. ; 24 cm.
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English
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United States -- American Indian Policy Review Commission. -- Task Force Six
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Indians of North America -- Health and hygiene -- United States   ( lcsh )
Indians of North America -- Health and hygiene   ( lcsh )
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bibliography   ( marcgt )
federal government publication   ( marcgt )
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Bibliography:
Bibliography: p. 197-204.
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Also available in electronic format.
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At head of title: Committee print.
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Reuse of record except for individual research requires license from Congressional Information Service, Inc.
Statement of Responsibility:
Task Force Six: Indian Health.

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University of Florida
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aleph - 020662285
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Full Text








[COMMITTEE PRINT]


REPORT ON INDIAN HEALTH

TASK FORCE Six: INDIAN HEALTH





FINAL REPORT TO THE

AMERICAN INDIAN POLICY REVIEW COMMISSION


Printed for the use of the
American Indian Policy Review Commission


U.S. GOVERNMENT PRINTING OFFICE
WASHINGTON : 1976


78-188


For sale by the Superintendent of Documents, U.S. Government Printing Office
Washington, D.C. 20402 Price $2.55

























REPORT ON INDIAN HEALTH
AMERICAN INDIAN POLICY REVIEW COMMISSION
Senator JAMES ABOUREZK, South Dakota, Chairman
Congressman LLOYD MEEDS, Washington, Vice-Chairman
Senator LEE METCALF, Montana JOHN BORBRIDGE, Tlingit-Haida
Senator MARK HATFIELD, Oregon LOUIS R. BRUCE, Mohawk-Sioux
Congressman SIDNEY R. YATES, Illinois ADA DEER, Menominee
Congressman SAM STEIGER, Arizona ADOLPH DIAL, Lumbee
JAl WHITECROW, Quapaw-Seneca-Cayuga
ERNEST L. STEVENS, Oneida, Executive Director
KIRKE KICKINGBIRD, Kiowa, General Counsel
MAX I. RICHTMAN, Professional Staff Member

TASK FORCE 6: INDIAN HEALTH
DR. EVERETT R. RHOADES, Chairman
LUANA REYES, Member
LILLIAN MCGARVEY, Member
ALAN CAYOUS, Task Force Specialist
RAJINDA CHANDA, Consultant
DR. GILLIAM MARSDEN, Consultant
PETER SCHNURMAN, Consultant
DR. JOSEPH POTTS, Consultant
THOMAS LUBBEN, Consultant
MARCIA WILSON, Consultant
DON FISHER, Consultant
SHERI SCOTT, Staff Member
ALICE CLARK, Editor
EVA SMITH, Staff Mnember
(II)



















AMERICAN INDIAN POLICY REVIEW COMMISSION,
CONGRESS OF THE UNITED STATES,
July 1976.
To THE COMMISSION: Attached is the final report of the Task Force
on Health. This report represents the best efforts of several persons
and is directed at those areas most urgently demanding attention. The
unfortunate constraints under which the Task Force labored pro-
hibited a more comprehensive analysis. Particularly needed are dis-
cussions of an expanded biomedical research capability for the Indian
Health Service, the role of the Department of Health Education and
Welfare as a Trustee for Indians, Indian Health Manpower, an Indian
School of Medicine and Allied Health Sciences, and an international
comparative study of Aboriginal inhabitants' health status. The role
of Indian in a proposed National Health Insurance program had to be
attached as an appendix.
Since submission of the draft of this report, the President has
signed into law the Indian Health Care Improvement Act. If Congress
now fulfills its responsibility under this Act, many of the problems
outlined herein will be ameliorated.
Respectfully submitted,
EVERETT R. RHOADES, M.D.,
Chairman.
LILLIE McGARVEY,
LUANA REYES.
(Ill)




















Digitized by the Internet Archive
in 2013














http://archive.org/details/reindianhe00unit















CONTENTS


Part One
THE TASK FORCE ON HEALTH OF THE AMERICAN INDIAN POLICY REVIEW
COMMISSION
Chapter: Page
1. Introduction------------ ----------- ---- 1
2. Methodology and approach9-------------------9
3. Summary and recommendations----------------------------- 12
Part Two
HISTORICAL AND LEGAL REVIEW
4. The history of Federal involvement in health care to Indians..-- 27
5. The legal basis of Federal health services to Indians--------- 33
Part Three
HEALTH STATUS OF AMERICAN INDIANS
6. The status of Indian health--------------------------------- 39
7. Environmental services--------------------- 60
8. Nutrition------------------------- 63
9. Mental health..------------------------ 68
10. Traditional Indian medicine--------------------------------- 74
Part Four
THE DELIVERY SYSTEM
11. Indian Health Service-its role as primary provider of health care
for American Indians------------------------- 85
12. Indian Health Service-clinical workload and utilization of
services.----- ----------------------- 88
13. Indian Health Service-organization and management---------- 94
14. Transportation and access to the system--------- --- -103
15. Contract health care--------------------------- 105
16. Training and technical assistance ---------- --- 114
17. Community health representatives--------------------------- 118
18. A guaranteed health care benefit package---------------------- 121
Part Five
THE INDIANS-SPECIAL PROBLEMS
19. Indian preference--------------------- -------- 127
20. Indian involvement and self-determination-------------------- 131
21. Discrimination and civil rights--------- ----------137
22. Problems of health care of urban Indians------- ------142
23. Oklahoma Indians-------------------------150
24. Special problems of California Indians--- -----------159
25. Special problems of Alaska Natives -------------------166
'V)







VI

Part Six
BIBLIOGRAPHY
Part Seven
APPENDICES
Page
I. Transcript Index_-------------------------- ---- 205
II. Field Data Analysis--------------- ------207
III. Health Care For The Alaska Native People- -------- --213
IV. The Impact of National Health Insurance on Indian Health Issues- 243












Part One


THE TASK FORCE ON HEALTH OF THE AMERICAN
INDIAN POLICY REVIEW COMMISSION
Chapter 1
INTRODUCTION
Foreword
The aboriginal inhabitants of the American continent are not known.
Whether they had a direct lineal relationship with present day In-
dians is not known. Certain archeologic evidence suggests that perhaps
anthropologically distinct people occupied the continent before present
Indians did. Certainly the paleo-hunters possessed certain attributes
that were clearly distinctive. It is possible, and even plausible, that
intercontinental travel was relatively commonplace for centuries prior
to the history-shattering first voyage of Columbus, as has been sug-
gested by Thor Heyerdal and others. Be that as it may, the American
continent was populated by the near ancestors of all present Indians.
The civilization they possessed, the social organization, the freedom,
and their attitudes towards health were manifestly superior to that
brought to this continent by the Europeans. It has not been possible
in the present study to lay the American historical basis for under-
standing the relationship of Indians to the federal government. This
is unfortunate because it is not possible to really understand the place
of American Indians in American society without understanding the
very peculiar and special people who literally overran the continent
between the early 1600's and the late 1800's.
The reader is referred to two delightful recent histories of the United
States. The first is the popular volume "America" by Alistair Cooke.
Mr. Cooke points out that the most important date and event for
America prior to its "discovery" by Columbus (and therefore for the
American Indian) was the fall of Constantinople in 1453. The capture
of this key cross-roads city cut off the important overland route to
the orient, forcing exploration by sea. This led inevitably to Columbus'
voyage of discovery. The second is the in-depth three volume study
by Daniel Boorstin entitled "The Americans." Few accounts can
match the special genius of these volumes in capturing the uniqueness
of non-Indians who came to these shores. The portraits drawn by
Dr. Boorstin help one understand the inevitability of domination of
Indians by non-Indians during the critical years after 1600. Bitterness
is assuaged somewhat by the realization that the non-Indians coming
to this country were just as helpless in altering their behavior as were
the Indians. An .overwhelming historical tide sweeping over the land
touched all alike, although in different ways.
Unfortunately, one of the most serious side effects of the non-Indian
immigration was the impact it had upon the health of American In-
dians. That is what the present study is about.
(1)







The American Indian Policy Review Commission
The experience of the task force members during the past year has
not been pleasant. The fears expressed by all in the initial stages that
the function of the commission was poorly conceived and designed,
combined with the obviously prohibitive time and budget constraints,
p roved to be all too true. In 1955 at the time of the transfer of Indian
health Service from the Department of Interior to the Department
of Health, Education and Welfare, a study of Indian health was
authorized. For this study a sum of $250,000 was appropriated and a
large task force conducted a study over a period of about 18 months.
The task force on health was originally budgeted for approximately
$95,000 and was to prepare a "comprehensive" report of Indian
health with special attention to federal-Indian relationships. In terms
of inflationary costs, it is obvious that the present task force was
really being asked to do an impossible job. In spite of numerous
requests for time and budgetary extensions by several task forces,
the commission proved to be adamantly rigid to the point of expressing
willingness to accept a substandard report if that is all that was avail-
able at the end of one year.
In effect the design provided for two groups to produce recommenda-
tions. The commission itself with its own staff was to be in existence
for two years during which it carried on a variety of activities which
theoretically were to supplement task force findings. The main bulk
of work was to be performed by eleven task forces who would make
reports to the commission. Subsequently, the commission would then
make its report to Congress. The defects of such a plan of procedure
are obvious. Was the commission going to do nothing until the task
forces were finished or was the commission also going to perform
investigations during the time the task forces were investigating?
The confusion resulting from the latter persisted throughout the life
of the task force.
A major difficulty in task force operation was the inability of task
force members to devote their entire attention to task force activities.
Some of the task forces had members who were able to devote their
entire time to task force work and in general these were most successful.
The task forces, however, were assured that it would not be neces-
sary to have full time task force members because an extensive com-
mission core staff would be available for research, clerical and adminis-
trative support and editing. Indeed, PL 93-580 establishing the
commission states "(d) The Commission shall, pursuant to section 6,
insure that the task forces are provided with adequate staff support
in addition to that authorized under section 6(a), to carry out the
projects assigned to them." This was never done, putting the com-
mission in violation of the very law which established it. This failure
proved very costly in terms of lost time and wasted effort.
The Task Force on Health
Although the American Indian Policy Review Commission was set
up in Jan. 1975, the Task Force on health was not appointed until
July 1975, after exactly one-half year had elapsed. The Task Force
members were Dr. Everett R. Rhoades, Kiowa; Luana Reyes, Col-
ville, and Lillie McGarvey, Aleut. Each had years of experience in
Indian affairs with a special, but not necessarily exclusive, background
in health.







Dr. Rhoades has served as Vice-Chairman of his tribe and on a
number of tribal and intertribal organizations, as well as participating
in the organization of the Oklahoma City Urban Indian Health
Board.
Luana Reyes is one of the pioneer leaders in urban health care for
Indians and is the director of the Seattle Indian Health Center. She
has played a leading role in securing recognition for urban Indians
and obtaining appropriations from Congress.
Lillie McGarvey served as Health Aide in her native village of
Unalaska before there was a formal health aide program. She was
Chairman of the Alaska Area Health Board and a member of the
National Indian Health Board, and continues to be a leading advocate
for Indians and Alaskan natives.
Other factors than those mentioned above have interfered with the
smooth functioning of the Task Force:
1. The short lead time between appointment and operation did not
permit the reassignment of each person's already heavy obligations.
This year witnessed many national activities relating to Indian health
such as the Congressional add-on appropriations, the budget rescissions,
and introduction of the Indian Health Care Improvement Act. Task
Force members, because of a heavy previous commitment to these
and other kinds of activities, were often torn between other responsi-
bilities and task force duties. Had there been a longer period of time
before assuming duties, it would have been possible to arrange for
coverage of other obligations, and consequently each task force mem-
ber could have devoted more time to the duties of the task force.
The employers of some task force members were not always sympa-
thetic to the demands of the commission, and in an occasional instance
even attempted to get the task force member to resign.
2. The extreme geographic separation of task force members created
a serious interference with communication and coordination. The
expense of meeting ultimately proved to be a serious limiting factor
in the functioning of the task force.
An example of inadequate prior planning and coordination was the
fact that the task force was expected to be at a briefing in the new
commission offices in Washington, D.C. on July 28-29, 1976, after
only two weeks' notification. Because of the short notice, only two
members were able to attend. At this briefing, the task force en-
countered its first ominous warning that it would be difficult to operate
under the unsatisfactory arrangements of commission staff. The task
force learned that a decision had been made to create an eleventh
task force, to be concerned with alcoholism. The alcoholism and health
task forces were expected to share a task force specialist. This specialist
was to be the "key person" for each task force, being responsible for
research activities as well as administration. This had the effect of
draining funds from these two task forces. The arbitrary assigning of
budgets and tasks represented an additional defect of planning. A
great variety of task forces were apparently presumed to achieve their
goals and objectives in an identical fashion-hence instructions,
budgets, etc. were basically identical.
As pointed out by the Task Force Chairman at the initial briefing,
in planning a research effort one defines a problem, reviews literature,
formulates a protocol for investigation, carries out the research, and
prepares a report. After the plan of investigation is formulated, a







budget is prepared that will be sufficient for carrying out the study and
preparing the report. In the case of the commission, the process was
set up just backwards. The task force was given a budget and told to
do a "comprehensive" study. Such a backward plan is programmed to
fail, and several task forces warned the commission of this defect.
Not only was the commission staff unresponsive to objections by
both the alcoholism and health task forces that one specialist could
not serve two distinct and separate entities, but the commission pro-
vided no consistent advice to the task forces, finally declaring that the
task forces "must work the problem out themselves." This attitude
reflected another fundamental defect in the operation of the com-
mission.
The task forces were told that they would have a free hand and
would operate as complete entities with no interference from the
Commission or its staff. However, in practice, this was not the case.
The initial briefing was spent in a detailed, convoluted description of
"matrices" and "plans" that not only had no relation to task force
study, but on the contrary proved to be an impediment. Elaborate
instructions were given for the development of a "scope of work" and
"plan of operation," presumably with a desire to simplify the final
commission report. Unfortunately, these instructions were vague,
duplicatory, and irrelevant. Attempts to make health research fit the
"matrix" made no sense. As if this were not enough, the commission
several weeks later issued an entire new set of instructions for a new
"matrix" necessitating additional lost time in again attempting to
get the task force plan to fit someone else's arbitrary formulation.
In spite of these fundamental defects the task force made every effort
to comply with the directives from the commission, even though the
commission conveyed little familiarity with the requirements of this
type of research.
Attempts to reach an accommodation on a task force Specialist
between the two task forces occupied another few weeks of precious
time but failed when it became clear that the needs for task force
Specialist support for each were fundamentally different. In the
absence of guidance from the Commission, the Task Force on Health
thereupon elected to give the total task force position to the Alcohol-
ism Task Force and seek an alternative source of support for a separate
specialist for itself. The Task Force on Health sought the services of a
specialist from the Indian Health Service to be assigned to the Task
Force on detached duty. Further delay resulted from the need to in-
vestigate the legality of such an assignment and the need for ad-
ministrative clarification required by the United States Senate. This
was finally obtained and approval was given by the commission and
Mr. Alan Cayous was selected as the Task Force Specialist, but was
unable to begin his assignment until after the middle of September,
1975. Again the time frame provided to the commission for these
inevitable organization requirements was completely unrealistic. The
selection of such a key person as Task Force Specialist could easily
have required several weeks.
Another administrative difficulty arose from the fact that the Task
Force Chairman had a part-time appointment as a physician with the
Veterans Administration. Consultation with the Veterans Adminis-
tration indicated that there would be no difficulty in the Task Force
Chairman working as a Consultant for Congress since his obligation






5

to the Veterans Administration was to provide only 25 hours per week
of work. Indeed, the Task Force Chairman had served as a con-
sultant to several governmental agencies during his employment by
the Veterans Administration. However, the U.S. Senate personnel
policies prohibited this and another valuable few weeks were lost in
seeking clarification from the U.S. Senate personnel office.
The above factors could have been adequately planned for. It is not
unusual for three or four months to be required for setting up such a
task force and making it operational. However, an unreasonably short
period of time was available for the development and carrying out of a
major research problem. As was repeatedly pointed out by the task
force members, it was unreasonable to expect a significant accomplish-
ment within the time constraint of one year. The collection and
analysis of unknown data, to say nothing of the preparation of a
"comprehensive report," simply cannot be adequately performed
within one year. The commission remained strangely insensitive to
concerns about this voiced by virtually all the task forces.
It was obvious by the time of the second plan of operations that the
activities of the task force were going to be interfered with in a major
way by commission staff. At the first meeting of all the task forces
assembled with the Director of the Commission (which incidentally
was the only such meeting held throughout the entire project), the
Director stated explicit that he did not intend in any way to in-
terfere with the task forces which were to exercise their activities
free and independently of the commission staff. In spite of this, the
task force received a continual series of requests, demands and
evaluations, some of which seriously interfered with task force work.
An example of this was the demand that the task force provide a
briefing to Congressional members and staff at a time when all findings
could only be preliminary.
Cooperation of Indian people was not always easy to obtain and in
fact in some instances the task force was advised that it was not
welcome to come into certain areas. The All Indian Pueblo Council
of New Mexico refused to meet with the task force. Mr. Howard
Tommie, Chairman of the Seminole Tribe in Florida, made it clear
that he did not want the task force doing any studies in his area.
Finally, the Chairman of the National Indian Health Board, Mr. Mel
Sampson, made it clear that he did not consider the task force com-
petent to evaluate Indian health.
The task force plan
Because of the multiplicity of studies relating to Indian health over
the last fifty years, the number of publications in scientific journals,
and the considerable number of congressional hearings, all relating to
Indian health, it was felt that the most efficient use of the task force
members' efforts would be to review these studies, test them against
the common experience of the task force members, develop a scholarly
and systematic approach to the definition of Indian health problems,
following which, depending upon deficiencies discovered, a series of
site visits would be held in certain areas of the United States that
would permit acquisition of additional information. It was believed
by the task force that even though there was strong urging by the
commission to have field hearings to "gather grass roots information,"
such hearings were not an adequate way to obtain scientifically valid







information. First, there is no assurance that such hearings do provide
input from true "grass root Indians." Second, such hearings too often
simply are a recitation of individual experiences which are often highly
biased and frequently misleading. Third, there was a strong concern by
task force members that such hearings were in large part planned to
provide a degree of visibility for the commission. However, the com-
mission staff became insistent upon having field hearings and as a
result of this insistence, the task force set up a series of hearings in
Phoenix, Albuquerque, Portland, Billings, South Dakota, Oklahoma
and Alaska.
It was originally thought that the task force could provide two
unique approaches to the desired goal of making an evaluation of
Federal-Indian relationship in the field of health. The first had to do
with the need for some basis for making a true evaluation of the
Federal-Indian relationship, with the need for some standard that
could be used for comparison. That is, can one really understand the
United States Federal-Indian relationships without some comparison
to similar relationships in other countries? Fortunately, there are a
number of situations in the world which provide for such a comparison.
Such situations exist in New Zealand, Scandinavia, Finland, Australia
and throughout North, Central, and South America. Thus, there are
a number of "natural experiments" taking place in the world with a
multiplicity of relationships between national governments and
aboriginal people. An analysis of these relationships would undoubted-
ly provide excellent comparison for the United States, and undoubted-
ly yield substantial data relating to Indian health proposals for the
United States for the "next fifty years." It is even possible that a
discovery might be made which would show that the United States is
actually doing a reasonable job of providing Indian health care. Such a
conclusion would surely be worth while. Unfortunately, the same
shortsighted original planning, insufficient funding, and time con-
straints prevented this valuable study. It is hoped that such a study
can be developed and performed by some appropriate group in the
future.
The second special technique planned by the task force was that of
convening a recognized group of original creative thinkers, Indian and
non-Indian, who would meet during the third quarter, review the
findings of the task force, then make recommendations for innovative
plans, programs, and legislation. Again, time and budgetary con-
straints prevented this from taking place. It would seem that such a
seminar should be supported, particularly in view of so many changes
taking place in American society that have an impact on Indian health.
Task force staff and consultant
The task force was extremely fortunate in obtaining staff assistance
from Sheri Scott, with previous experience with the Coalition of
Eastern Native Americans and the InterTribal Council of California.
Sheri was invaluable in coordinating task force activities, conducting
hearings, working with consultants and preparing data on nutrition
and mental health for the final report.
Mr. Rajinder Chanda provided excellent consultation and insights
into government and tribal operations. Mr. Chanda has a master's
degree in economics with emphasis on municipal planning and urban
management. He added considerable expertise in the evaluation of
information gathered and iD preparing the final report.








Mr. Dan Press, ali attorney and consultant with R.J. Associates of
Washington, D.C., provided important studies relating to the Indian
Health Service and its role as provider of health services, and the
concept of a Guaranteed Health Care Package for Indians.
These individuals, under the supervision of the Task Force Specialist
Alan Cayous, were functioning as a well-coordinated effective team by
the end of the Task Force life. Unfortunately, funds were not available
to permit this team to meet with the task force as planned for the
last month in order to formulate final recommendations.
Dr. Gillian Marsden of Seattle provided a study of the impact of
National Health Insurance. Peter Schnurman, of Seattle, provided a
study of urban health problems. Dr. Joseph Potts very kindly "loaned"
to the task force by Searle laboratories of Chicago, provided an analy-
sis of management within IHS. Thomas Leubben and Marcia Wilson of
Albuquerque prepared a study of contract care. Eva Smith, a medical
student assisted with preparation of the Traditional Medicine Sec-
tion and of the final report. Alice Clark provided valuable editing
and preparation of the final report. Juanita Stewart of Oklahoma
City donated valuable secretarial support at no expense to the Com-
mission. Dorothy Tiger also proved invaluable in Oklahoma City in
the preparation of the final report. Special thanks go to the Associa-
tion of American Indian Physicians, its Director, Don Jennings, and
Administrative Officer Bill Wilson for considerable clerical and ad-
ministrative support.
It is worth remarking that through task force efforts a number of
persons were obtained at no additional expense to the Commission.
These include Mr. Alan Cayous, The Task Force Specialist, Dr.
Joseph Potts, Juanita Stewart, and Dorothy Tiger. This is men-
tioned to dispel the mistaken impression that the task force abused its
budget allowances. A comparison of final costs with each of the other
task forces is invited.
The final report
The above discussion is submitted in part to explain why the final
report is not as complete as one would wish. The task force strongly
considered dissociating itself from the report because of a concern
that Indian people had been ill-served by the entire process. However,
by the time it became certain that a less than satisfactory document
would be produced and that the commission would be satisfied with a
less than satisfactory document, it was felt that a mass resignation
by the task force would not only be an admission of defeat but would
also probably be destructive.
The question arises: why, in the beginning, did the task force agree
to take on a task which had such a likelihood of failure? In the first
place, there was the continued hope that something of value could
perhaps be contributed even if it were not all that one might hope for.
Second was a sense of responsibility that one had to make every
effort, however forlorn, to try once again to do a job which might
help Indian people. There was a real anticipation that the task forces
would probably receive a six month extension with a modest addition
in funds to permit them to really produce an outstanding document.
At the very least, it was expected that by the final month it would
have been possible to have a knowledgeable group working together
that could make the desired recommendations. The task force was








never under the illusion that it was the best possible for the job at
hand but because of its background, that it indeed could make a
substantial contribution. Likewise, the task force was never under the
illusion that any grandiose change would necessarily follow its report.
The risk that the report would simply gather dust on a shelf still
exists. With these defects and deficiencies in mind, the task force
believes that there is sufficient merit to the report to submit it-
with appropriate apologies to Indian people. The recommendations
are made against the background knowledge that if Indian Health
Service were adequately funded, most of the problems would not
exist today.
The arrangement of the final report called for by the commission
made no sense whatsoever. It was recommended that a list of problem
areas be given and in a separate section a list of recommendations
based upon the problem areas be listed. This produced a terribly dis-
continuous discussion, virtually unreadable. Here, the task force has
arranged the topics according to subject interest, containing all the
discussion and recommendations. Out of deference to the commission,
the recommendations have been gathered into a separate chapter. A
more serious defect is the demand by the commission that references
cited should not be located with the appropriate chapter but instead
again compiled separately. The editor dutifully did this, and the lapse
of time has prohibited correcting this serious mistake.
Even with the disappointments and frustrations, the task force is
grateful for the experience. A great deal has been learned. The recom-
mendations, we believe, are pertinent, provide for newer opportunities
and emphases for Indian health for the future, and in some instances
represent significant departures from previous programs. Not the
least important fact learned is that bureaucratic difficulties and prob-
lems do not occur only in the executive branch of the government;
the same problems are found in the legislative branch. This is a sober-
ing thought for those who automatically blame Indian Health Service
for the ills besetting Indian people.












Chapter 2


METHODOLOGY AND APPROACH
The Health Task Force developed a comprehensive methodology
for studying the problem of Indian health, identifying key issues, and
developing recommendations for use by the Congress, Executive
Branch and the Indian community. The primary purpose of this study
was to assess the level of health of Indians, determine the causes of
their low level of health, and develop recommendations in order to
improve the health status of Indians.
The basic philosophy behind the methodology developed by the
Task Force was to utilize the existing data and information from
various sources, and to obtain fresh inputs both in quantitative and
qualitative terms from diverse groups of people, in order to develop a
wide spectrum of views, and to get a balanced perspective of Indian
health. With this basic philosophy in mind, the following methodology
was used.
1. Review of existing literature and studies.-The Health Task Force
conducted an intensive review of existing studies undertaken by the
federal government and private agencies. The Task Force reviewed
the Congressional hearings conducted by the Senate and the House
over the past several years. The Task Force reviewed the relevant
publications of Department of Health, Education, and Welfare, De-
partment of Interior and other federal agencies. In addition, studies
conducted by Indian tribes were reviewed. The complete list of all
studies and publications reviewed by the Task Force is contained in
the bibliography of this report.
2. Review of state plans and policies.-Each state was requested by
the Task Force to supply all pertinent information dealing with state
policies, legal opinions, departmental directions, and specific programs
dealing with the issues and problems of Indian health in their respec-
tive states. The Attorneys General and the Health Departments of
every state were contacted. This was done to determine the extent and
level of state involvement with special health problems of Indians and
to determine the benefit that Indians are deriving from federally
funded and state operated health care programs.
3. Public hearings of Indian Health Service at headquarters.-Since
Indian Health Service is the focal point of health care to Indians at
the federal level, two public hearings were conducted at Indian Health
Service headquarters in Rockville, MIaryland, to receive input and
interpretation of the level of Indian health, progress made over the
past twenty years, mode of operation of the service delivery system,
and Indian Health Service opinions and suggestions to improve the
level of health of Indians.
4. Eight regional public hearings.-Public hearings were held by the
Health Task Force at Portland, Oregon; Aberdeen, South Dakota;
Billings, Montana; Window Rock, Arizona; Oklahoma City, Okla-
(9)







homa; Anchorage, Alaska; Phoenix, Arizona; and Albuquerque, New
Mexico. These public hearings were conducted in order to receive
inputs from the Indian Health Service area offices, Indian Health
Service units, state and county officials, tribal leaders, individual
Indians and anyone else who wished to testify.
This was done to provide an opportunity for dialogue between the
Health Task Force and people in the field, and to receive first hand
input from diverse sources. The people testifying were specifically
questioned about their feelings and experience with the conditions of
Indian people, and the kind of services they were receiving. The Task
Force solicited their views with respect to ways and means of improv-
ing the health level of Indians. The results of these hearings are con-
tained in the appendices to this report.
5. Site visits at Indian Health Service facilities and Indian com-
munities.-The Task Force made various site visits, listed in the table
of contents of this report, to determine the actual conditions there, and
to solicit the view of those people who could not present their testi-
monies and views in the public hearings.
6. Review of facilities on the reservations and views of tribal leaders.-A
questionnaire was developed to determine the kind of facilities that
exist on the reservations. The Task Force asked opinions of the tribal
leaders with respect to the quality of health care facilities on their
reservations. Their views were solicited with respect to the adequacy
of services, and the ways and means to improve the level of Indian
health. These questionnaires were sent out to thirty-two selected tribes
based on population size, geographical location, distribution by states.
In the selection process, the federally recognized as well as non-
federally recognized tribes were selected.
7. Survey of community health care representatives (CHR).-Since
CHR's are the "grass roots" providers of health and social services to
the people and are closest to the problems, their views were solicited
to determine the adequacy of health services. At the same time, the
ways and means of improving the services were sought. 270 Community
Health Representatives from all over the country were interviewed.
8. Survey of individual Indian households.-In order to obtain
direct input l regarding basic demographic characteristics of Indians,
determine the level of their health and the services they are receiving,
as well as their views regarding those services, 500 randomly selected
households were surveyed. These households were surveyed on the
basis of size of tribe, geographical location, and federal and non-
federal recognition. These households covered all Indian Health
Service areas and represented 32 tribes. The size of the sample
within the tribe depended on the population of the tribe, ensuing
that at least ten households were surveyed from each of the solicited
tribes.
9. Survey of Indian Health Board members.-Since health boards
provide advisory services to the Indian Health Service at national,
regional, and local levels, the Health Task Force surveyed 52 active
members of the health boards. Members surveyed included persons
serving on national, area, and local health boards. Their views were
solicited in order to determine the role they are playing and their
suggestions for improvement of the level of the health of Indians.








10. Special studies.-Certain special problems which concern the
Task Force were dealt with by conducting special studies. These
special studies were conducted for contract health care, impact of
national insurance, study of national Indian health boards, Urban
Indians, and Oklahoma Indians.
11. Analysis, conclusions, and recommendations.-On the basis of
information obtained through the above sources, a detailed analysis
was performed and conclusions drawn. These analyses and conclusions
led to the development of a series of recommendations to be used by
the United States Congress, Executive Branch and the Indian com-
munity, in order to improve the level of Indian health.


78-188-76-----2












Chapter 3


SUMMARY AND RECOMMENDATIONS
SUMMARY
During the course of its investigations, the Health Task Force
concluded that while the level of Indian health has improved since
Indian Health Service assumed the responsibility in 1955, Indian
health is still significantly below the level of the general United States
population. This disparity is not only manifest in terms of incidence of
illness and disease, but also in terms of the severity of the diseases.
Among the major health problems identified among Indians are
tuberculosis, gastroenteritis, otitis media, pneumonia, influenza,
gonorrhea, trachoma, chickenpox, mumps, dysentery, strep throat,
and rheumatic fever. These contribute to a shorter life expectancy of
65.1 years for Indians compared with 70.8 years in the general
population.
The Health Task Force identified the following areas of deficiency
in Indian health care.
1. Inadequate policy to solve the problems of Indian health.-Indian
Health Service has a comprehensive list of its areas of responsibility.
These include provision for training and technical assistance; co-
ordination of available health resources through federal, state, and
local programs; serving as principal federal advocate for Indian
health; provision of comprehensive health services including hospital
and ambulatory medical care; preventive, rehabilitative and environ-
mental services. However, there is no clear overall direction or policy
for implementation of the various programs. As a result, Indian Health
Service operates primarily an emergency and crisis oriented service.
For the remainder of its areas of responsibility, the response is often
slow and inadequate. This has resulted in increased prevalence of
certain health deficiencies which are virtually unknown in the general
population. Examples are plague and tuberculosis. Some of the other
health problems, such as otitis media, can be cured or prevented
medically but continue to be widespread among Indians.
2. Inadequate appropriations.-The method of funding for Indian
Health Service is totally unsatisfactory. Fixed limits of funding
result in denial of services to many who are entitled to them. Under
the current funding method, Indian Health Service is forced to
drastically curtail or suspend the delivery of services when it runs out
of funds. Inadequate funding also results in the provision of only
crisis-oriented services, and other significant areas of Indian Health
Service responsibility, especially preventive programs, do not receive
attention.
3. Lack of adequate mechanism for delivery of services.-It was found
that the mechanisms for service delivery are not as strong as they
could be. This results in less than optimal utilization of resources.
(12)






13


A management evaluation found several areas within Indian Health
Service to be poorly administered. These occurred in the areas of
responsibility and authority between the central office, area office and
service unit; mechanisms for continuing planning, monitoring and
evaluation; establishment of measurable objectives and development
of the best mix of strategies for efficient and effective delivery of
health care services.
4. Lack of responsiveness on the part of state and local agencies
toward Indians.-While Indian Health Service is regarded as a residual
or supplementary service to the Indian people, in reality it is the
primary provider of health care to Indians. Most state and local
agencies are not responsive to the needs of Indians, often because they
believe that health care for Indians is the primary responsibility of
Indian Health Service. This places Indian Health Service, with
limited funding, in a very difficult position.
5. Lack of oversight and accountability at all levels of Indian Health
Service.-There is no adequate system of accountability at the various
levels within the Indian Health Service. The goals and objectives are
not defined in quantifiable and measureable terms. As a result, no
one can be held accountable for progress or the lack of it. This holds
true at service unit, area office, and central office levels. Unless a
system for accountability can be set up, it will be very difficult to
measure the efficiency and effectiveness of Indian Health Service
programs.
MAJOR RECOMMENDATIONS
The Health Task Force believes that the entire approach to Indian
health problems is inadequate, as is the level of total effect. It is
believed that unless major reorientation in terms of Indian health is
undertaken, the level of Indian health will continue to be substantially
lower than the health of the general United States population. With
this basic philosophy in mind, the Health Task Force makes the
following major recommendations:
1. Cabinet level Indian agency.-In order to create a focal point in
the Executive Branch of the government and consolidate all Indian
programs, including health and environmental services, it is recom-
mended that a cabinet level Indian agency be created. Indian health
then would become one of various functions of this agency. The Task
Force feels that current interagency agreements, such as the one
between Indian Health Service, HUD and the Bureau of Indian
Affairs, are not working satisfactorily. Consolidation of all programs
affecting Indians will be a more effective instrument for providing
services to those needing them.
2. Basic health care guarantee package.-The Task Force recom-
mends that a basic health care package be available to all Indians.
Such a package should not have an arbitrary funding limit, as presently
exists. Such a guaranteed package will ensure that every Indian
receives health care. The gap between American Indian health and
that of the general United States population should be closed within
a specified realistic time frame.
3. Preventive and environmental health program.-Environmental
conditions were found to be far below an acceptable level, with a high
incidence of diseases related to water supply and waste disposal. The
Task Force recommends high priority for preventive and environ-






14


mental health programs. It is certainly more desirable and less
expensive to prevent illness than to provide medical care after an
illness occurs. Unless a massive preventive and environmental health
program can be undertaken, curative measures will improve the level
of Indian health only slightly. These programs must be conceived with
provision of safe and adequate water, sewer and waste disposal
facilities, and proper health education.
4. Urban Indians.-The vast majority of Indians residing in urban
areas are deprived of their entitlement to Indian Health Service sup-
ported contract health services. This represents an abrogation of
federal responsibility previously established. The Task Force recom-
mends that all health services be made available equally to all Indians
previously entitled regardless of place of residence.
5. TV satellite channels for Alaska and remote parts of the United
States.-Unreliable communication is a major impediment to delivery
of health services in Alaska and other remote areas of the United
States. The HEW/NASA experiment (using the AT5-6 Satellite)
demonstrated that lives could be saved and travel costs reduced by
improved communications. We recommend that this experiment be
the basis for an ongoing program.
6. Management of Indian Health Service.-It is recommended that
the lines of authority and areas of responsibility between the central,
area, and service unit offices be more clearly defined. A new improved
system for data collection and analysis should replace the present
inadequate one. A review should be conducted of administration
requirements for records and reports, including: a) elimination of
useless reports, b) elimination of backlog of medical summaries and
indexing, c) insurance that providers contributing to data system will
receive data results for return. A unified system for program planning,
monitoring and evaluation should be developed.
7. Indian involvement and self-determination in health.-It is recom-
mended that an Indian Health Service policy be established for the
Indian Health Boards relating to organization, membership, operation
and relationship to Indian Health Service. Indian Health Boards
should be strengthened to make them more effective with respect to
policy making and establishment of priorities at all levels. Indian
health Service should develop a time-phased program with adequate
training and technical assistance for full implementation of self-
determination, gradually shifting the authority and responsibility to
the tribes as they so desire.
8. Community health practitioners and health aides as primary pro-
viders of medical care.-The Alaska experience indicates that Commu-
nity Health Aides provide a high level of health care, frequently with-
out direct medical supervision. We recommend that this program be
expanded and developed to a point where licensure would not require
a physician preceptor, and the Community Health Practitioner could
function autonomously, seeking consultation as deemed necessary.
Fully trained para-medics should form the core delivery system to all
Indians.
9. Contract care.-Eligibility criteria for contract care should be
made simple and uniform. Indian Health Service should negotiate
rates of payment for contract services to avoid paying more than other
federal or state programs pay. Coordination with contractors should
be improved to insure continuity of care. Evaluation of contract







services should be continuous at the service unit level. Funding for
adequate contract Indian Health Service staff should be provided. The
contractor's record on each patient should be made part of the patient's
Indian Health Service record.
10. Tribal based nutrition program.-Malnutrition is one of the
major problems among Indians, and the food assistance programs
provided to them, such as food stamps and food commodities, are not
responsive to Indian needs. Both quality and quantity of food from
these programs is extremely low. Because Indian people in many cases
depend upon these programs as their primary food source, the Task
Force recommends that all available food assistance programs be
consolidated into tribally controlled and operated Nutrition Assistance
Centers. These centers will insure that Indians receive adequate food,
together with education pertaining to proper nutrition, meal planning,
and diet control.
11. Indian Health Service as the primary provider of health care to
Indians.-Indian Health Service should be recognized as the primary
provider of health care to Indians. There is a current conflict in which
Congress views Indian Health Service as a supplementary provider,
and state and local agencies regard it as a primary provider. This
causes, in effect, denial of services to many Indians. It is recommended
that Indian Health Service should be viewed by the Congress as the
primary provider and fund it adequately.
12. Mental health.-Although a mental health program has been in
existence for more than ten years, there has been no significant
improvement in the mental health of Indians. There has not even
been any significant progress made in terms of identifying mental
health needs in an appropriate way. It is recommended that the mental
health program be strengthened; however, the first step has to be an
identification of the nature of mental health problems facing Indians,
and the development of an orderly program to meet those needs.
13. Health, education, housing, economic development and poverty.-
Health problems are related to overcrowded and inadequate living
conditions, lack of adequate resources to maintain sanitary environ-
ments, lack of adequate education to acquire economic resources. In
effect, most Indians are caught in the cycle of poverty and deprivation.
In order to have a lasting impact on Indian health, it is imperative
that a coordinated strategy be implemented to raise the standard of
living. It is recommended that preference be given to Indian enter-
prises for all health related construction projects. Preference should
also be given to Indian enterprises in the maintenance and operation of
health facilities. This would assist Indian organizations in becoming
viable economic enterprises.
14. An American Indian school of medicine.-Other priorities pre-
cluded developing an entire chapter on this important topic which
touches upon Training, Indian Preference, and Indian Self-Determi-
nation. The American Indian School of Medicine has been well publi-
cized and possesses important attributes not possessed by standard
medical schools. The Executive Dean, Dr. Taylor McKenzie, is a
noted Navajo surgeon. The Task Force strongly recommends support
for the American Indian School of Medicine as recommended by the
Department of Health, Education, and Welfare feasibility study.






16


STATUS OF INDIAN HEALTH
Recomm endat ions
1. Additional funding for sanitation and home improvement pro-
gramis is immediately needed to extend present benefits to all federally
recognized tribes. No new legislation wuold ne necessary for this,
simply adequate funding for present and planned programs.
2. Legislative authorization for a study not to exceed one year,
comparing the relationship of American Indians to the federal govern-
ment with that of other aboriginal groups in other countries. This
study would be carried out by an appropriate panel of Indian and
non-Indian health professionals.
3. Legislative authorization for a feasibility study designed to
determine the possibility of a program to compare the health status of
Indians of "recognized tribes" with those of "non-recognized" tribes.
This study would accomplish a number of objectives, one of which
would be an evaluation of the effect of the Indian Health Service.
4. Legislation authorizing and funding Indian Health Service to
actively develop and implement programs designed to combat the
personal and social pathology manifested by increasing rates of alcohol-
ism, suicides and accidents. This would mean placing a responsibility
on Indian Health Service to participate in programs of economic
improvement, family support, and self esteem. It is the position of
the Task Force that this is well within the support systems needed
to improve Indian "well-being."
5. A comprehensive program of research by Indian Health Service
into the causes and prevention of Indian alcoholism and suicides
should be implemented immediately. Data is needed in areas such
as drinking patterns, for example.
6. The Indian Health Service must be immediately funded to a
level permitting elimination of the backlog of unmet needs.
7. Comprehensive programs must be greatly strengthened to pro-
vide an attack on family disruption, disintegration and anomie.
8. It is imperative that studies be done comparing those receiving
Indian Health Service benefits with those who have not received any.
9. It is imperative to do comparative international studies relating
"aboriginal" groups to their respective predominate societies.
This would greatly enlarge the present scope of understanding of
Indian health.
ENVIRONMENTAL SERVICES
Recommendations
1. Consolidation of responsibility and authority.-The tri-agency
agreement is not working, and its chances of working are rather
slim. The responsibility for water, sewer, solid waste disposal, streets,
housing construction and housing rehabilitation should be within the
new cabinet level Indian Affairs Agency. This would save time,
effort, and resources, and decrease the number of agencies with whom
tribes have to deal.
2. Aicximnum resource ,utilization.-There are several federal agencies
which have funds for environmental services. While Indian Health
Service services are "residual" in theory, in actual fact they are the
primary environmental health services to Indians. It is recommended
that Indian Health Service be recognized as the primary provider






17


of these services and be funded adequately for both existing and
newly built houses.
3. Improved planning and design of Indian homes.-Conventional
standards of HUD and other federal agencies are not suitable to the
highly diversified conditions in the various areas where Indians live.
An attempt to impose such standards may destroy the very spirit
of the community it is supposed to be building. This could have a
significant impact on traditional cultural and family systems. This
in turn could have a negative influence on mental health. Otherwise,
the authority to decide on the standards, design, and approach to
human settlement should rest entirely with the tribes. Federal agencies
can provide advisory services. Tribes should not be forced to follow
arbitrary standards which are contrary to their basic patterns of living.
4. Training in maintenance of sanitation facilities.-Training in
the maintenance of sanitation facilities is seriously deficient. On the
other hand, Indian Health Service cannot devote enough funds to
this area, because of financial constraints. At the same time, this
results in frequent breakdown of facilities, resulting in a return to
the previous unsanitary conditions, thus imposing an additional
burden on IHS. It is recommended that training and technical
assistance for maintenance of sanitation facilities be expanded to
insure adequately trained personnel in each community.
5. Economic development and environmental services.-Construction
of water, sewer, solid waste disposal systems, streets and housing
generates a significant amount of economic activity. It is recommended
that first preference be given to tribal construction resources, even at
the expense of some inefficiency, so that Indian people can develop
and improve their skills and participate in the economic activity,
thereby improving their standard of living.
6. Time frame for improvement of sanitation facilities.-At the present
time, the level of water, sewer and sanitation conditions is far below
the accepted normal standard of health and safety. It is the responsi-
bility of the Federal government to bring these facilities to parity.
Funding for this program must be provided so that facilities in Indian
communities will equal those in non-Indian communities within 5
years.
NUTRITION
Recommendations
1. The Task Force recommends that the American Indian be allowed
to share with the general population the privileges of feeding his own
family rather than having an institution do it for him.
2. The Task Force recommends that American Indians themselves
conceive and administer their own plan to feed and nourish their
people.
3. The Task Force recommends as a minimum a drastic upgrading in
offered programs. It strongly recommends the creation of a new, inno-
vative system which eliminates the weaknesses and combines the best
features of all previous and existing programs.

MENTAL HEALTH
Recommendations
1. Services aimed specifically at families and children are generally
provided in a piecemeal fashion, when what are needed are therapeutic
and residential treatment centers, together with family therapy work-







shops staffed by specially trained professionals. Family and clan are
strong traditional elements in Indian culture, and half the Indian
population is under twenty, with most of that half under the age of
fourteen.
2. A model dormitory project in one Area has been a successful alter-
native to the traditional Bureau of Indian Affairs boarding school sys-
tem, which is generally insensitive to emotionally disturbed children
and is not sufficiently staffed to cope with them. In the Bureau of
Indian Affairs boarding school in Window Rock, Arizona, when the
mental health facility provided additional staff trained to work with
children, the results were impressive. Successful use of BIA schools for
severe cases, as an alternative to distant reform schools, has also been
used in areas when it is feasible. There is need for a special treatment
program aimed at troubled Indian youth and their families.
3. There are many in the Indian population who are retarded, handi-
capped, partially or totally deaf or blind, with special problems of
adaptation and survival. In addition to surgical restoration when
appropriate, these sensory-deprived Indians, and their families, need
special counseling and support in coping with their unique problems.
Specially-trained staff is needed to carry out such programs.
4. Mental health staff sees as one of its important functions consulta-
tion with personnel in other federal agencies providing services other
than health to Indians. Mental health staff indicates a readiness of
consultation and training, but constant personnel turnover in these
other agencies is a continual obstacle, and the little guidance which
mental health staff can provide is usually limited to a single contact
involving a single case. We recommend a program of interagency
consultation, coordination, and training.
5. Integration of traditional Indian medicine with non-Indian psy-
chotherapeutic methods is being tried in a special Navajo project
funded by NIMH. In other areas, however, this approach has met with
limited success because of resistance on the part of both Indians and
non-Indians, and because not all tribes have a reserve of medicine men.
But there is little doubt that traditional Indian therapy is an effective
mental health tool in the Indian culture. "Traditional healers have
been treating people for thousands of years," writes psychiatrist
Claudewell Thomas in an NIMH publication, "and they come from
a tradition considerably older than medical practice. Whether they
become a natural resource for mental health workers depends on
whether we pay attention to their existence." Or as Jerome Frank
phrases it, "the American Indians themselves want to heal their
people, using their own religious and cultural resources. But they need
access to federal resources, appropriate to them and chosen by them,
until this is accomplished."
We recommend that medicine men be added to the staff of each
Area Mental Health Program.

TRADITIONAL MEDICINE
Recommendations
1. A strong, effective program to train traditional medicine men
living in the milieu of a foreign, dominant, other-oriented society, is
mandatory. Medicine provides one of the relatively few effective
mechanisms for preservation of those inherently precious values






19


collectively making up the Indian view of the universe. This training
would include faculty and student financial support.
2. Present training funding mechanisms, because of ignorance and
a different orientation, are unable to provide a stable source of
training support, as shown in the difficulty of funding for the Navajo
training program. Therefore, a separate funding mechanism must be
sought. It is recommended that the Congress specifically appropriate
funds for training medicine men, either through the Indian Health
Service or through an Institute of American Indian Medicine. Such a
program could easily be administered through a cabinet level agency
of Indian Affairs.
3. An active program appropriately funded should be set up
within Indian Health Service whose responsibility is the development
of closer working relationship between medicine men and physicians.
This program would serve as a catalyst, increasing understanding of
each group by the other. This program should be the responsibility of a
single individual.
4. Medicine men should be paid contract consultation fees. These
medicine men would be selected by each service unit director through
a committee made up of tribal representatives and other medicine
men. The effectiveness of each medicine man could be evaluated by
case review and success rates.
5. An ethnobotanical research program appropriately funded
through the Indian Health Service or a proposed Institute of American
Indian Medicine should be established at once. Its purpose would
be to investigate commonly known medicinal herbs for pharmacologic
effect, and also to discover hitherto unknown plants.
INDIAN HEALTH SERVICE MANAGEMENT
Recommendations
1. The goals of IHS which involve elevating Indian health to the
highest possible level and assisting the tribes to manage their health
programs should be changed. A more appropriate goal statement
which integrates the concepts covered in these original goal statements
is "to assist Indian people in elevating their health to the highest
level they can seek."
2. Based on historical, cultural and geographical considerations, the
Task Force concludes that there is a need for a separate Indian
health system. However, there is a need for more "hard" data regard-
ing the issue of segregation versus integration. One portion of IHS
is already integrated into the non-Indian community-the Portland
Area, where half of the outpatients and all of the inpatients are cared
for by contract care, utilizing private physicians.
To provide the hard data needed to evaluate the comparative bene-
fits of a separate versus integrated approach, IHS should conduct an
in-depth comparison of the Portland area with another comparable
area, measuring such factors as quality of care, patient satisfaction,
costs, levels of health and tribal participation in health care. These
data should be used to make intelligent decisions which can be docu-
mented, regarding the benefits of a separate health system.
3. The management structure of IHS must change to fit the present
and anticipated needs of the Indian people. The major change which





20


is recommended is that the administrative branches of the area offices
be reorganized. Many of the individuals in the area offices should be
reassigned to the service units, based on their talents, with new job
functions almost entirely devoted to program and project manage-
ment. This would provide the additional staff personnel which are
so desperately needed to develop management systems, to facilitate
communication between headquarters and the service units, to
transfer technology from one area to another, to monitor programs
and contract services, to develop more appropriate budgeting tech-
niques, to implement R & D programs, to develop useful management
reports based on actual data, and to provide training and consulta-
tion to tribes wishing to contract for services.
4. The service unit directors must receive adequate management
training before being assigned to posts. The present trend toward
non-medical directors is indicative of the need for good leaders in
this role. Many physicians are capable of filling the role of director
if they are provided appropriate training and they are not heavily
involved in clinical practice.
5. Position descriptions must be written for all jobs within the IHS
management structure. These descriptions must include the responsi-
bilities for the position in terms of decision making and policy setting.
If some decisions or policies are to be made by groups of individuals,
these must be clearly defined in a "charter" document for that group.
6. The IHS director must develop equitable and consistent rewards
based on actual job performance. A peer review of promotions and
rewards (other than salary increases) should be implemented. Thus,
a service unit director would implement rewards only after approval
by other service unit directors and the health board in that area. IHS
should investigate HMO systems to determine if their reward system
can be adopted to the IHS.
7. The budget should not contain a "position" limit. This type of
limitation is not useful since the monetary aspects of the budget will
necessarily control the number of positions. The removal of position
ceilings has been successfully accomplished by other federal agencies.
This new IHS budget must also take into account the "guaranteed
benefit package" that is discussed elsewhere in this report. The concept
of such a package means that the emphasis plan concept, currently in
existence, will be a meaningful way to develop the budget.
8. A useful data system which allows the evaluation of the effect of
a program must be assured. Performance standards for the service
unit director, the clinical director, area director, and director of IHS
must be established. Performance standards must also be developed
for each service unit.
Periodic independent auditing of the programs, the service units,
the area directors, and headquarters staff performance must be con-
ducted by the General Accounting Office to evaluate the effectiveness
and efficiency of IHS planning and management efforts in relation to
produced results. Under Section 236 of the Legislative Reorganization
Act of 1960, the head of the agency utinder evaluation must respond to
the audit findings to the Government Operations Committee, and
the appropriate House and Senate Appropriations Committees. The
findings of the audit should also be released to the general public and
appropriate tribal groups at the same time the agency is notified. In






21


the case of IHS, response should be required by the House and Senate
Interior and Insular Affairs Committees, the Senate Labor and
Public Welfare Committee, and the House Interstate and Foreign
Commerce Committee.
9. Continuing training of all IHS personnel should be a requirement
of the job and not considered as a reward. Attendance at National
professional meetings is considered appropriate continuing education.
It may not be possible to implement all of the recommendations in
this section simultaneously, but it is strongly suggested that a single
plan to implement them be developed. This plan should include times
and identify the persons responsible for implementation. It is the
feeling of the Task Force that optimum success will result if all recom-
mendations are implemented. Implementation of only part of the
recommendations will not insure the best management for IHS.

CONTRACT MEDICAL CARE
Recommendations
1. Since in a few years, financial access to health care will be avail-
able for all Americans, since the distinction between Indians living
on and off of reservations is divisive and artificial, and since the diffi-
culty of developing defensible regulations distinguishing the rights
of on and off reservation Indians promises to keep Indian Health
Service tied up in litigation for years to come, it is the recommendation
of the Task Force that Indian Health Service regulations make all
federally recognized Indians eligible for contract care, and that the
funding provided Indian Health Service reflect the federal obligation
to give services to this population. While the cost will not be great
and should only continue for a few years, until National Health
Insurance is in place, the benefits to Indian Health Service and to the
Indian community strongly argue for such a policy.
The only relevant question for eligibility should be whether a
particular person is eligible for Indian Health Service services at all-
i.e., whether he or she is an Indian member or descendant of a
federally recognized tribe. Once that is established, then the question
becomes one of medical need and actual availability of alternative
resources-the priority criteria which are already being routinely
applied by the Indian Health Service.
Congress must relieve Indian Health Service and Indians of the
dilemma imposed upon contract services by fulfilling its obligation to
Indian people.
2. Indian Health Service should be required to review i!s contract
care program in order to find ways to conserve its contract care funds.
Testimony to the Task Force indicated that, at present, Indian
Health Service is not getting the most for its contract care money. For
example, little effort appears to have been made to use Indian Health
Service purchasing power to bargain for lower rates from medical
facilities. HMO's, Blue Cross and other major purchasers of care are
able to obtain lower rates from hospitals on the basis that they are
large purchasers of service and that they guarantee payment to the
hospital. Indian Health Service appears not to do so and ends up
paying more for its contract care patients than it needs to. For
example, at the Bernalillo County Medical Center, Indian Health
Service pays the average daily rate for all patients at the hospital
and, therefore, gains no benefit from its purchasing power.






22


3. The review should also consider whether there are certain services
now purchased through contract care which could be provided more
economically through direct care. For example, in the Albuquerque
Area, eye care was the most common reason for the provision of
contract care. It might, therefore, be more economical for Indian
Health Service to employ its own ophthalmologist.

TRAINING AND TECHNICAL ASSISTANCE
Recommendations
1. A reorganization of training functions with a central office in
charge of providing information about training programs and coordi-
nating training activities should be instituted.
2. The requirements of training Indian Health Service personnel are
sufficiently unique and sufficiently specialized that the training and
technical assistance activities of Indian Health Service should be
greatly expanded'.

COMMUNITY HEALTH REPRESENTATIVE PROGRAM
Recommendations
1. Indian Health Service should negotiate with NASA to make a
satellite television channel available to provide communication for
remote areas in Alaska and other parts of the nation.
2. Some CHR's should be trained and their skills upgraded to serve
as physicians' assistants. They could then take some of the patient load
off the doctors who could then spend their time in more complex prob-
lems. Another group of CHR's should be trained to become general
purpose outreach workers. These would perform a variety of functions,
including provision of transportation for patients.
3. CHR's who are charged with the responsibility of transporting
patients should be reimbursed fully, and adequate automobile accident
liability insurance provided.
4. Ambulances should be provided to tribes where justified. Indian
Health Service should expand their program to contract with tribes for
provision of ambulance services.
5. Indian Health Service should perform an overall evaluation of
mobile clinics and the various other service delivery systems. It is
recommended that since permanent facilities cannot be provided at
all locations, a mobile clinic network could be developed, so as to
make the most effective use of limited resources.

INDIAN INVOLVEMENT AND INDIAN SELF-DETERMINATION
IN HEALTH CARE
Recommendations
1. The principle of self-determination requires that each tribe possess
the option of exercising as much authority and control over the
Federal programs now serving them as they desire. For this reason,
the recommendations made herein are strictly optional. They should
be made available only to those tribes that want to use the new
mechanisms. However, tribes should have the right not to do so, to
continue to use the mechanisms they are presently using, or to do
nothing in regard to Indian involvement in health.






23


2. Congress should enact legislation giving Tribal Health Agencies
(THA) specific policy authority over Indian Health Service and
provide adequate funding to those agencies so that authority can be
properly exercised. The legislation should require that the Tribal
Health Agencies meet certain minimum standards before they can
exercise that authority and obtain funding. If a tribe decides to
continue with its existing health involvement mechanisms, it may do
so. However, it would, of course, not be eligible for funding or be
permitted to exercise. the authority granted under the legislation.
This approach is consistent with the principles of self-determination
and at the same time protects the government's responsibility
when it delegates policy authority. Congress should enact legislation
that would provide for the establishment of Tribal Health Agencies
by tribes desiring them. The structure of the Tribal Health Agency
would be left to the tribe except that:
a. It should be established through resolution by the appropriate
tribal governing body.
b. It would have a governing board including tribal members who
use Indian Health Service services. This board could be the existing
tribal health board or a new entity created by the tribal governing
body.
c. It should have one or more professional staff persons knowl-
edgeable in health and in the health concerns of tribal members.
d. It should be given authority by the tribal governing body to
oversee and coordinate the various health programs administered by
the tribe (CHR's alcoholism and nutrition programs, etc.) and
generally have the authority to act as the tribal government's admin-
istrative arm on health matters.
The THA that meets these conditions should be given the following
authority:
a. To develop a comprehensive tribal health plan and to require
all health agencies including Indian Health Service to develop their
plans within the parameters established by the overall tribal priorities
and plan.
Sb. To develop the Service Unit budget jointly with Indian Health
Service and to approve that budget and accompanying Service Unit
plans before they are submitted to the area director. This approach
will succeed only if the present crisis environment is eliminated through
Congressional approval of a guaranteed health benefit package for
Indians. Under the benefit package concept all the basic inpatient and
outpatient services to be provided should be established and fully
funded by Congress. This would permit attention to long-range
preventive outreach education and other programs administered by
tribes. In developing the Service Unit plan and budget the THA shall
have the authority to begin with a "zero based" budget and not be
locked into existing Indian Health Service programs. Since funding
will always be finite, this is the: only way tribes can insure that their
priorities are carried out.
c. To set standards for the Service Unit and to monitor the activi-
ties of the Service Unit so that it is accountable to the Indian
Community.
d. Within general Civil Service requirements, appoint the service
unit director for the service unit; and when justifiable grounds are






24


demonstrated, give THA the authority to initiate action, through
Civil Service procedures, to obtain removal of the service unit director.
The THA would have no authority regarding the employment pro-
cedures of any other Indian Health Service employee.
To insure that THA's have the power to enforce their decisions,
formal appeal mechanisms would be established. When a THA
believes that a service unit is not complying with its directives, the
THA would have the right to a formal hearing with the area director,
and then the Indian Health Service director, requiring them to show
cause why they should not order the service unit to comply with the
THA's directives.
3. Building on the Area Health Boards, Area Indian Health Agencies
(AIHA's) should be established with federal funding and be composed
of representatives of the THA's. AIHA's should be adequately
staffed and be given responsibility for:
a. Evaluating (not monitoring) the activities of the service units
in its area.
b. Monitoring and evaluating the area office.
c. Appointing the area director.
d. Providing technical assistance and training to the THA's.
4. The National Indian Health Board should be federally funded to
serve as an Indian Center for Health Planning. It should be responsi-
ble for training, technical assistance, and the development and dis-
semination of innovative programs and approaches for THA's. It
should also be responsible for monitoring and evaluating the per-
formance of the Indian Health Service headquarters.
The Task Force believes that this approach resolves many of the
problems regarding Indian involvement that were raised during our
hearings and investigations. It clarifies the relationship between
tribal governments and tribal health boards in a manner consistent
with the Self-Determination Act; it gives tribal health agencies clear
roles and specific authority over Indian Health Service; it creates a
single agency to speak for the tribe about health and to coordinate
all health programs, both federal and tribal, on its reservation. It
provides adequate and dependable funding for tribal health policy-
makers as well as necessary staff, training, and technical backup to
permit them to carry out their responsibilities competently.
.DISCRIMINATION
Recammendat ions
1. A special office for civil rights should be created within the pro-
posed cabinet level agency for Indian Affairs, with authority and
responsibility for investigating charges of discrimination against
Indians. In addition to responding to specific complaints of discrimina-
tion, it will have responsibility to aggressively seek out potential
areas of discrimination and take appropriate remedial measures.
HEW should also require all HEW funded programs to collect data
on Indian utilization. This data should be sent to the Indian Agency
Civil Rights Office, which has the responsibility of reviewing it and
determining which programs were underserving Indians, and, through
the Secretary, require such agencies to take the necessary action to
correct the problem.






25


2. In the absence of such an agency, the newly staffed HEW intra-
departmental council on Indian Affairs should be given the authority
to monitor the Memorandum of Agreement and to compel the partici-
pating agencies to take necessary action to meet their responsibilities
under it.
3. Grant to Indian tribes and urban Indian organizations the power
through legislative amendment to require OCR to follow up on all
charges of discrimination to their satisfaction.
4. Require IHS to expand and strengthen its information and edu-
cation programs to better inform Indians as well as state and local
officials regarding concepts of dual entitlement and the tri-agency
Memorandum of Agreement.

URBAN INDIANS
Recommendations
1. Congress should declare its intent, through specific legislation,
authorizations and appropriations, to accomplish expansion of its
health care systems to include non-reservation and/or urban Indians
without any loss of quality or other benefits to reservation Indians.
2. A timetable should be set up to implement the establishment of
a health care system for all Indians.
3. The Indian Health Service should begin to establish Indian
health care facilities in urban areas where they are needed and do not
now exist, and in addition, should move immediately to strengthen
those that are currently in operation.
4. Health services for urban Indians, as for all other Indians, must
be comprehensive and of high quality.

SPECIAL PROBLEMS OF OKLAHOMA INDIANS
Recommendations
1. The United States Congress must be careful to avoid passing
general legislation which inadvertently or deliberately discriminates
against Oklahoma Indians as such.
2. The Indians of the State of Oklahoma must be able to approach
federal agencies directly without the need for review, and possible
disapproval, by state agencies.
3. The Indians of Oklahoma must be accorded a designation, at
least for certain designated purposes, as reservation tribes.
4. Greater orientation of incoming personnel must be given because
of the diverse nature of Indians in Oklahoma.
5. Since the Area Advisory Board serves as the only statewide
unifying organization of tribes, it serves a dual role, and must be
supported more strongly. This support should be generated outside the
usual Indian Health Service channels.














Part Two


HISTORICAL AND LEGAL REVIEW

Chapter 4
THE HISTORY OF FEDERAL INVOLVEMENT IN HEALTH
CARE TO INDIANS
INTRODUCTION
It is believed that the Indian race was remarkably disease free
before European settlers came to the new world. But with the foreign
invasion, Indian health began to deteriorate. The natives had no
immunity to the disease germs carried by Europeans. Their health
was further impaired when they were forcibly removed from their
traditional habitat and denied the practice of their customs, one of
which was the use of the medicine man and his herbs for healing.
The federal government made sporadic attempts over the years to
attend to the poor health of Indians, but the cumulative effects of
confining, unsanitary reservation life, combined with government
rations, put the population into a cycle of deteriorating health and
increasing susceptibility to still further illness. Nothing short of a
comprehensive, coordinated health program could have corrected
the situation at any given time.
But such a program was never designed. The health care which
Indians actually received in the first 100 years was delivered in a
piecemeal, inconsistent fashion, and the few appropriations made
were never large enough to meet the overwhelming need. There was
always an on-going shortage of hospitals, clinics, nursing homes,
convalescent centers, equipment, doctors, nurses, dentists, tech-
nicians, administrative and maintenance personnel, and staff housing.
Preventive or general health care was not possible under these cir-
cumstances. Generally, health service was solely of the crisis type.
A number of different agencies have been responsible for Indian
health care, beginning with the War Department, in 1803; the In-
terior Department, in 1849; and, finally, in 1955, the Department of
Health, Education and Welfare, the agency currently responsible.
Each of these agencies was always limited by insufficient funding,
inadequate statutory basis, and lack of commitment by the federal
government. Moreover, each time a new agency assumed responsi-
bility, it inherited a backlog of unmet needs and the unchanging,
depressed environment in which dispossessed Indians lived.
The result today is an Indian race whose health is at a level below
that of the general U.S. population. What the Brookings Institute
reported after surveying Indian health in 1928 is still true today:
Although in tlhe medical work of the Indian Service the variation between the
best and the worst is wide, taken as a whole practically every activity undertaken
(27)


78-188-76----8






28

by the national government for the promotion of the health of the Indians is
below a reasonable standard of efficiency. The health work of the Indian Service
falls markedly below the standards maintained by the Public Health Service, the
Veterans' Bureau, the Army and the Navy, and * local governments.
The beginnings
When the federal Government assumed responsibility for the edu-
cation of Indians, some degree of responsibility for their health was
incidentally involved, and the first expenditures for Indian health were
made from funds appropriated for education and "civilization." Early
expenditures for health and medical care were made from tribal funds
under treaties and from general appropriations for education or "inci-
dentals." These appropriations were allotted among various religious
and philanthropic societies already active in educational and mission-
ary work among the various Indian tribes.
While the superintendency of Indian Affairs was under the War
Department, it was only natural that dispensation of medical care
and sanitary regulations went to Indians in the immediate vicinity of
military posts. It was also natural that this care be given by members
of the army medical staff. The War Department's involvement with
Indian health lasted almost half a century, from 1803 to 1849. During
this period, its activity was minimal and its appropriations small. Its
main function was to see that Indians were vaccinated for smallpox,
more for the protection of military personnel and the white population
than for the Indians themselves. Characteristically, the delivery sys-
tem was inefficient: vaccines often did not arrive and there was a
shortage of doctors to administer them, in spite of the fact that Indian
agents wrote frequently to Washington seeking both.
Even many years later, Indian health care was only incidental, and
there was no guarantee that it would continue. Article 9 of an 1868
treaty with the Sioux nation is typical:
At any time after ten years from the making of this treaty, the United States
shall have the privilege of withdrawing the physician, farmer, blacksmith, car-
penter, engineer, and miller herein provided for * *
No treaty ever provided for anything more than a hospital, medi-
cines and vaccines, and a physician or two sometimes for a tribe of
several thousand persons. An 1855 treaty with the Yakima tribe reads
in Article 5:
* * to erect a hospital, keeping the same in repair and provided with the nec-
essary medicines and furniture, and to employ a physician; and to erect, keep in
repair, and provided with the necessary furniture, the building required for the
accommodation of the said employees.
Of about 400 treaties made between 1776 and 1858, only about 30
provided for either a physician or a medical facility. About the same
number carried general clauses promising such provisions as "the sup-
port of poor, infirm persons," or "the support and comfort of the aged
and infirm, and the helpless orphans of said Indians." In most cases,
the insubstantial obligations of these treaties were never actually met.
The treaty period was characterized, as were subsequent stages in
Indian health service, by frequent shifts in responsibility and policy.
In 1824, for example, the War Department abolished the post. of Super-
intendent of Indian Trade, and in its place created the Bureau of
Indian Affairs. It was the first of many administrative structures to
be created over the years, always with the hope of improving and






29


facilitating dealings with Indians. The head of the new agency was
the Commissioner of Indian Affairs. He was given one chief clerk, one
assistant, and a staff of superintendents, agents, and subagents to
work in the field. His function was: "to direct and manage all Indian
affairs."
Ten years later, inefficiency within the Bureau led to the reorgani-
zation act of 1834, which provided for "the organization of the De-
partment of Indian Affairs." However, the Act neither altered the
status of the Bureau of Indian Affairs nor changed the power of the
War Secretary or the Commissioner. It abolished certain agencies and
established others and provided for the employment of subagents,
interpreters and other employees, and authorized the purchase of
supplies.
In 1849, when the Department of the Interior was established,
medical care of Indians under the Bureau of Indian Affairs passed
from military to civil control. Under this department, agency physi-
cians on the reservation at first gave little attention to the Indians
and acted more in the capacity of doctors for the government em-
ployees, or in connection with Indian schools. In 1873, measures were
taken towards furnishing organized medical facilities and an education
and medical division which continued until 1877. By 1874, about one-
half of the Indian agencies were each supplied with a physician. After
1878, physicians on Indian reservations were required to be graduates
of medical colleges. Between 1880 and 1890, several hospitals were
established.
In 1909, prevalence of trachoma among the Indians had become so
devastating that funds were appropriated for investigation, treatment,
and prevention of this disease. In 1912, money was allotted to the
Public Health and Marine Service for a survey of trachoma and
tuberculosis. After 1921, appropriations under the heading "relief of
distress and prevention of contagious diseases" were greatly increased
and were spent on correspondingly increased medical care and hospital
facilities.
Near the close of 19th century, federal policy changed in two ways.
Treatymaking was terminated in 1871; and the movement for Indian
assimilation was intensified by the General Allotment Act of 1887.
On the theory that individual land ownership would automatically
bring about "civilization," each Indian person was allotted a single
parcel of land. The rest of what the tribe "owned" was given to white
homesteaders, except for small plots reserved for schools, hospitals
and agency use.
The final and orderly Indian assimilation envisioned by policy-
makers never actually occurred. At the beginning of the 20th century,
the Indian population was in a severe state of deterioration and
distress. Many Indians subsisted on deficient diets, lived in crowded,
confining homes. Sanitary facilities were essentially non-existent.
By the end of the 19th century, public outrage was growing over
the condition of Indian health. The next few decades brought forth
many government sponsored studies: the American Red Cross and
the National Tuberculosis Association in 1922; the Public Health
Service in 1913 and again in 1936; the Brookings Institute in 1928;
and the American Medical Association in 1929-all carried out field
investigations of Indian health. The Meriam Report issued by the
Brookings Institute was the most comprehensive of the studies.






30


Some of its findings are as follows: High general death rates; high
infant death rates; high childhood death rates; high tuberculosis
death rates; high incidence of blindness-causing trachoma; low level
of general health at all ages; inadequate health facilities and equip-
ment; shortage of health facilities and equipment; improperly qualified
health personnel; shortage of health personnel; inadequate salaries
and housing for personnel; inadequate and incomplete vital statistics;
no comprehensive presentive-medicine program; inaccessibility of
health facilities; deficient diets among Indians; ignorance of preventive
health among Indians; poor general health, deficient diets, over-
crowding in Indian schools; lack of conventional utilities (running
water, sewage disposal, waste disposal, flushing toilets) in Indian
homes; and substandard overall living conditions in Indian homes.
Faced with problems of this magnitude, the Federal government
began at last to pass legislation directed towards Indian health needs
in contrast to former treaties and agreements in which health care
was an incidental. The Snyder Act, in 1921, was the first Indian Act
having a specific clause relating to health. Not an emergency appro-
priation for vaccination or other crisis, it called instead for "the relief
of distress and conservation of health," and the employment of
physicians and other health workers. The government increased its
health activity in the first half of the 20th century more than at
any time in the past. Much of it centered solely on crash programs
to control widespread trachoma and tuberculosis. The appropriations
during this period, although larger, were never enough to repair the
effects of a century and a half of deteriorating health. Health services
provided after 1900 were generally so culturally inappropriate that
Indians could not derive maximum benefit from them. The white
doctors with their strange behavior appeared foreign and frightening.
Recruitment and retention of personnel was a chronic problem
because of low salaries, excessive patient loads, isolation, lack of
modern equipment, grossly inadequate living quarters, and lack of
opportunity for advancement. To overcome these personnel deficien-
cies, Interior Secretary Hubert Work turned for help in 1926 to
the Public Health Service, authorizing it to supervise and direct
health work with Indians. Since Public Health Service was an estab-
lished career service, recruitment became easier from that time on.
Lack of jobs during the depression years also meant that more medical
professionals came to Indian Health Service in search of work.
By the 1930's Congress began to enact legislation aimed at reversing
the destructive policies of the past. The Johnson O'Malley Act of
1934 gave the Bureau of Indian Affairs authority to contract for
medical services from states, local governments and private organi-
zations. The Indian Reorganization Act of the same year was designed
to restore tribal sovereignty and Indian Self-Determination. But,
by and large, the Bureau of Indian Affairs continued to be the principal
source of health care, and it continued to operate inefficiently with
inadequate funds.
More and more, the Division of Indian Health (BIA) relied on
outside help to supplement its critical shortages. Whenever possible,
it made use of state and local agencies, and even a few tribal facilities,
who were reimbursed for the care they provided to Indians. Many
federal agencies were by this time offering specialized health-related
services. But it was PHS which brought about the most and best





31


improvements in health care delivery, and it now seemed feasible
to transfer Indian health care from Bureau of Indian Affairs to the
Public Health Service under the Department of Health, Education
and Welfare.
Public Health Service, it was argued, was experienced in public
health work. Public Health Service traditionally had more funds
than DIH; Public Health Service, being a career service, was more
successful in recruiting and retaining personnel; Public Health
Service had access to the research facilities of NIH and other groups
and to marine hospital facilities.
The Bureau of Indian Affairs, it seemed, would never be able to
compete in hiring practices with the career services of the military, the
Veterans Administration and Public Health Service. And, finally,
Bureau of Indian Affairs and Public Health Service, both performing
parallel functions, represented an unnecessary and expensive duplica-
tion in services and administration.
Moreover, since 1926 when Public Health Service was called on to
help out the Bureau of Indian Affairs, conflict developed between the
two organizations over administrative and hiring procedures, and it
was felt that a merger would eliminate such problems. The fear of
integration focused primarily on the effect it would have on Indians
themselves. Opponents to the plan feared that the grass-roots relation-
ship which Bureau of Indian Affairs had built with Indians over the
years would be lost, and that Indians would resent being forced to deal
with a new agency.
For almost twenty years the debate continued. When a bill provid-
ing for the transfer from Interior to HEW was introduced in 1954,
there was a wide range of opinion at the hearings which followed.
Officials from Interior, the Budget Bureau, and Health, Education,
and Welfare all testified, as well as Congressmen, and Indians from
many tribes. Those from the Budget Bureau felt that the merger was
not justified on the basis of "economies, improvements in efficiency or
more effective administration." Officials from HEW felt it would not
solve, and might accentuate, existing problems. Representatives of the
Department of Interior, which would continue its responsibility over
many other areas affecting Indians' welfare, opposed the transfer for a
long time, but finally reversed their position. Congressional opinion
was mixed, and Indians on the whole were against the transfer because
they felt DIH in the Bureau of Indian Affairs had an understanding
and sympathy for their problems which they did not wish to lose.
Congressmen advocating termination saw the transfer of health serv-
ices to Health, Education, and Welfare as being in line with their effort
to repeal laws that set Indians apart from other citizens.
Thus, an incongruous coalition of those advocating termination of
reservation status and those advocating improved health services to
Indians pushed through the Transfer Act and in 1955 federal responsi-
bility for health services to Indians was transferred to the newly created
Division of Indian Health, under the U.S. Surgeon General in the
Public Health Service, Department of Health, Education, and Welfare.
When the bill ultimately became law in 1955, the House Committee
on Appropriations in its report on the bill asked the Interior Depart-
ment for a comprehensive survey of Indian health problems in order to
determine needs and necessary measures to satisfy them. The Commit-
tee wrote:





32


The American Indian is still the victim of an appalling amount of sickness. The
health facilities are either non-existent in some areas, or, for the most part, obso-
lescent and in need of repair; personnel housing is lacking or inadequate; and
workloads have been such as to test the patience and endurance of professional
staff. This all points to a gross lack of resources equal to the present load of sick-
-ness and accumulated neglect. Difficult and severe as the problem may be, it can
-and must be solved.
Since 1955 the Division of Indian Health has been retitled the
Indian Health Service (IHS). The functions of the Surgeon General
have now been abolished, and the health service programs in Health,
Education, and Welfare have gone through several administrative
reorganizations. Indian Health Service is now a division of the Public
Health Service in the Health Services Administration (HSA) of
Health, Education, and Welfare. Despite its inception in a termina-
tion atmosphere, Indian Health Service has grown rapidly since 1955.
From a budget of $34.5 million and a staff of 2,900 in 1955, it now has a
staff of 8,000, and an annual budget of approximately $300 million.
While much progress has been made since 1955, the basic structural
problems which keep Indians from achieving health equity with the
remainder of the country remain. As a result, the conclusions of this
Task Force Report in many ways parallel those of the past.
The lessons provided by the history of Indian health are quite
-simple. Until the federal government mandates, through authorizing
-statute and through appropiration, for a comprehensive and fully
funded Indian health system, the histoTry of the past 150 years will
repeat itself into the future.












Chapter 5


THE LEGAL BASIS OF FEDERAL HEALTH SERVICES TO INDIANS
INTRODUCTION
As indicated by the historical overview, the special federal responsi-
bility for health services to Indians emerged, not from a specific
legislative Act or particular legal liability, but from a combination of
factors. These include certain treaties, in which Indians were promised
health and other services in return for the Indian land, water, and
other resources that were being taken from them. Obligations were also
created by the destruction of Indian civilization and the poverty and
disease that followed in its wake. In addition, responsibility was in-
curred as a result of the recognition of the Indians' right to self-
determination consistent with their unique needs and values. This
basic legal obligation of the Federal government to Indians was
reaffirmed by the United States Supreme Court as recently as 1974,
when it stated:
The Court has described the origin and nature of the special relationship: "In
the exercise of the war and treaty powers, the United States overcame the Indians
and took possession of their lands, sometimes by force, leaving them an uneducated,
helpless, and dependent people, needing protection against the selfishness of others
and their own improvidence. Of necessity, the United States assumed the duty of
furnishing that protection and with it the authority to do all that was required to
perform that obligation and to prepare the Indians to take their place as independ-
ent, qualified members of the modern body politic." Board of County Commissioners
v. Seber, 318 U.S. 705, 715 (1943).
While there is now a general acceptance of the federal obligation to
provide separate and special health programs to Indians, the exact
legal nature of, and rights created by, that obligation are still unsettled.
In general, there is some legislative recognition that the special obliga-
tion does exist, but almost no legislative or legal definition of the
nature or extent of that obligation. The legislative Acts addressing
Indian health are summarized below:
1. The Snyder Act of 1921. 25 U.S.C. 13
The Snyder Act, which is the primary authorization statute for
Indian Health Programs, provides that the Bureau of Indian Affairs
shall expend "such money as Congress may from time to time appro-
priate for the benefit, care, and assistance of the Indians throughout
the United States for the following purposes: . For relief of distress
and conservation of health." The Snyder Act is the only authorization
Act which defines, in any way, the population Indian Health Service is
to serve, i.e., "Indians throughout the United States." It does not,
however, provide any definition of the kinds or extent of services
Indian Health Service must provide to those Indians. The reason for
this is that the Snyder Act was not a well thought out, comprehensive
effort to spell out legislatively the federal responsibilities to Indians.
(33)






34


Rather it was adopted only because Congress had been appropriating
money for Indian services without an authorization Act. In 1921, a
point of order to an Indian appropriations bill raised this issue, requir-
ing Congress to hastily pass an authorization Act so that the appro-
priations could be made. As a result, the Act is short and extremely
general. It has never been reworked since that time to provide specific-
ity. To a large degree, it is this initial and subsequent failure by Con-
gress to legislate comprehensively in the area of Indian health and to
define legal rights and responsibility that has contributed to the
inadequacies, paternalism, and controversy that have plagued the
programs since 1921. Even though the Snyder Act was passed while
Indian health was administered by the Bureau of Indian Affairs, the
Transfer Act of 1955 did not carry any further authorization for
Indian Health Service. Therefore, even today the language of the
Snyder Act is employed by Indian Health Service.
Since the Transfer Act was passed during the termination period, it
also authorized Indian Health Service to turn over Indian hospitals to
states, local governments or non-profit institutions. It set certain
conditions for the transfers:
1. That the new operators of the facilities agree to give the health
needs of Indians priority over those of non-Indians.
2. That the transfer first be approved by the tribes) for which
the hospital was build or maintained. It appears that the authorities
provided by this section of the Transfer Act have never been used.
2. The Indian Health Facilities Act (P.L. 85-151) 1957 42 USC 2005
This Act was passed for the limited purpose of authorizing Indian
Health Service to contribute to the construction costs of community
hospitals, where doing so would be a "more desirable and effective"
method of making needed hospital facilities available for Indians than
would the direct construction of Indian facilities.
3. The Indian Sanitation Facilities and Services Act (P.L. 86-121) 1959
42 USC 2004
This Act substantially expanded the scope of the Indian Health
Service programs by authorizing it to provide sanitation facilities to
Indians, including domestic and community water supplies and facili-
ties, drainage facilities, and waste-disposal facilities for Indian homes,
communities, and lands.
4. The Indian Self-Determination Act, 1975
This was the first major legislation affecting Indian health since the
Transfer Act. But like the Transfer Act, it addressed questions of
who would be the administrators of the Indian health programs
rather than the nature and extent of the program. The Act authorized
Indian Health Service to turn over full administrative responsibility
for all or parts of the Indian Health Service program to the tribess.
served by that program, upon the request of the tribes) using the
legal mechanism of contracting. The Act also authorized Indian
Health Service to make grants to tribes for the planning, development
and/or operation of health programs.
5. The Indian Health Care Improvement Act (Pending in the 94th
Congress)
The major purpose of this bill is to authorize a significant increase
in appropriations for Indian Health Service. (Since no appropriation





35


limitations were contained in the original Snyder Act, a new authoriza-
tion was not a formal necessity.) However, if adopted, it will break
new ground in that it also begins to fill in some of the gaps left by the
prior Indian health legislation. In its Preamble, its Findings state:
(a) Federal Indian health services to maintain and improve the health of the
Indians are consonant with and required by the Federal Government's historical
and unique legal relationship with, and resulting responsibility to, the American
Indian people.
This is the first specific legislative acknowledgement of the special
federal responsibilities in regard to Indian health.
The Declaration of Policy in the Act states:
SEC. 3. The Congress hereby declares that it is the policy of this nation, in
fulfillment of its special responsibilities and legal obligations to the American
Indian people, to meet the national goal of providing the highest possible health
status to Indians and to provide existing Indian health services with all resources
necessary to effect that policy.
This Declaration of Policy provides the first legislatively established
goal for federal Indian health programs, and the first legislative effort
to begin to define the extent of resources that the federal commitment
involves. On the basis of previous legislation, the only congressionally
established goal was "to relieve distress," and the extent of the federal
commitment was only to such monies as "Congress may from time to
time appropriate."
The Bill also would authorize funds for urban Indian health pro-
grams. While certain restrictions are placed on those funds, this will
be the first time legislation has ever specifically authorized funds for,
and thereby recognized the legitimacy of, urban Indian health
programs.
In addition to these provisions, the bill would:
1. Authorize Indian Health Service to obtain reimbursement from
Medicare and Medicaid when it provides covered services to eligible
Indians.
2. Establish new scholarship and other programs to increase the
number of Indians going into health professions and to encourage an
increased number of health professionals to go to work for Indian
Health Service and other Indian health programs.

ANALYSIS
While the federal responsibility to provide health services to Indians
has its roots in the unique moral, historical and treaty obligations of
the Federal government, no court has ever ruled on the precise nature
of that legal basis nor defined the specific legal rights for Indians
created by those obligations. Similarly, the authorizing legislation,
while acknowledging the responsibility and obligation, has never given
more than vague definition to the nature, extent, or coverage of those
rights.
To the greatest degree, the nature and extent of the Indian health
programs, and, therefore, the Indians' right to good health, have been
defined by the appropriations process and by the day-to-day operation
of the Indian Health Service program.
SAs has been the case throughout most of Indian history, the health
services that are available when an Indian appears at an Indian Health
Service facility depend almost completely on:
a. the amount of money appropriated





36


b. the conditions tied to those appropriations by the Appropriations
Committees
e. the policy decisions (not spelled out in regulation) made by
Indian Health Service headquarters, Area and Service Unit officials on
what kinds of services should be provided with appropriated funds.
When a person joins a Health Maintenance Organization, she/he
obtains the right to receive (when medically required) each of the
specific services listed in the Health Maintenance Organization's
benefit package. If the Health Maintenance Organization fails to
provide that service when needed, the person may sue for violation
of his or her rights. Similarly, when a person enrolls in Medicaid or
Medicare, she/he obtains legal rights to have specific services paid for
by those programs. An Indian, on the other hand, has a general right
to a federal health presence; but the specific services available to him
will vary from dlay-to-day and year-to-year, depending on unpublished
discretionary decisions made by Indian Health Service officials and
the commitments and conditions contained in often voluminous ap-
propriation hearings. Similarly, the determination on which class of
Indians is eligible for Indian Health Services services is also made
through the appropriation hearings. While the Snyder Act refers to
"Indians throughout the United States," the Supreme Court has
ruled, in a case involving Indian welfare programs, (Ruiz v. Morton
415 US 199 (1974) that this broad eligibility standard can be limited
by Congress solely through comments and testimony made during
appropriation hearings.
Use of the appropriation hearings, which are so loose and imprecise,
and of day-to-day decisions by Indian Health Service officials, which
are unpublished, variable and not subject to Indian scrutiny, are not
the best methods for shaping legal rights and responsibilities. The
failure of the authorizing legislation to provide specific definition to
the Indian Health Service program or to set specific objectives for it,
and the concomitant use of the appropriation process and day-to-day
decisions of Indian Health Service staff to fill this gap, have created
a number of serious legal and operational problems. These'problems
are discussed in detail in various sections of the Task Force report.
They are summarized below:
1. The above methods for determining Indian legal rights, as a
matter of fact, deny Indians specific health rights to a specific service,
only giving them a right to whatever services Indian Health Service
provides in a given Area or Service Unit within its available funds
and within the limitations established by that year's appropriation
Act. Even the information about available services is so inaccessible
except to Indian Health Service officials that it makes the Indian a
supplicant rather than a legal equal in his or her dealings with Indian
Health Service.
2. The absence of a legislative definition to Indian Health Service
programs has promoted the "historical" budget, which supplies
Indian Health Service with about 50% of the resources it needs to
deliver adequate services. Without legislation or even regulations
specifying what services Indian Health is required to provide, the only
measure for the Indian Health Service budget that Congress can use
is last year's. As a result, the Indian Health Service budget consists
of the inadequate amount provided in 1921 when it all began, plus





37


the increases Congress provides to Indian Health Service each year,
which are always arbitrary since there is no legal standard against
which to measure the funding needs of Indian Health Service. As
mentioned in the historical section, this simply perpetuates all the
problems of the past, so clearly delineated in the scores of studies
conducted since 1921, onto the present generation of Indians and the
present administrators of Indian health programs. Changing the
administrators of Indian health, whether it be from the Bureau of
Indian Affairs to Indian Health Service or Indian Health Service to
tribes, will never solve these problems until Congress (or even Indian
Health Service through regulation) defines the legal scope of the
Indian health program and then determines the appropriations on the
basis of this definition. (See the section on the Guaranteed Benefit
Package.)
3. Defining health rights through the appropriations process,
particularly as to eligibility, prevents clear resolution of issues and
thereby encourages lawsuits and dissension among Indians. This is
an inefficient method of defining legal rights and is unfair to the Indian
people. (See the section on Contract Care Eligibility.)

CONCLUSION
The rights of Indians to health services from the Federal government
is now well established. The challenge for the future is to clarify and
specify the nature and extent of that right so that Indians will know
what they are entitled to and will thus be able to interface with
Indian Health Service on the basis of a clear legal relationship and
not as health supplicants.















Part Three


HEALTH STATUS OF AMERICAN INDIANS
Chapter 6
STATUS OF INDIAN HEALTH
As mentioned elsewhere in this report, observers remarked that
at the time of initial contact with Indians they enjoyed a remarkably
good state of health. A study of the status of Indian health in 1955,
however, noted that the health of Indians was appalling, citing in
decreasing order the following conditions as the most urgent: Tuber-
culosis, pneumonia and other respiratory diseases, diarrhea and other
enteric diseases, accidents, eye and ear diseases and defects, dental
disease, and mental illness. It is prophetic perhaps that these same
conditions, even though the rank may be altered, still remain the most
urgent. This section will evaluate the present status of Indian health.
What is health?
The term "health" is not easily defined. Health obviously means
different things to different people. In traditional Europeo-American
thinking there has been a preoccupation with organ or tissue failure as
representing the absence of health, (a concept oriented to "dis-ease")
and mechanical failure. This narrow view is found wanting especially
in terms of considering the whole person. For the present discussion,
we will use the term "health" to mean a state of "well-being." This
concept is much more encompassing and holistic than the disease
orientation. Because it is much easier to deal with disease processes
than to deal with the multivariable and subtle influences of this more
holistic approach, it is not surprising that most of the data in the past
have dealt with disease categories.
The source of data
The Indian Health Service is basically the only source of data re-
lating to the overall health status of American Indians. Data collec-
tion relating to health needs in the Indian Health Service is elaborate,
and probably among the most accurate for any specific group in the
United States. It must be recognized, of course, that many data re-
lating to incidence or prevalence rates are subject to considerable
error, such as inaccurate diagnoses by physicians being fed into the
collecting system. There is no reason to suspect that the error for the
Indian Health Service is greater than that for the United States as a
whole, and indeed in some areas it is probably more accurate. The
Indian Health Service operates a computer data center at Tucson
which tabulates statistics from all the Indian Health Service areas.
This system is so successful that it has been frequently studied as a
model -for- other health care systems. It must be remembered that the
Indian Health Service, because of the fraction of the population
1 (39)






40


served, provides data on somewhat less than one-half of the Indians
in the United States. Important groups on which there are incomplete
data include the Indians of California, Maine, New York, South
Carolina, Michigan and others. The Indian Health Service has de-
pended upon studies conducted by local Indian groups for data related
to Indians in urban areas. In general, these data have been compiled
questionnaires administered by "outreach type" workers with limited
training or experience in research techniques. The urban surveys,
however, have attempted to gather data on utilization of alternative
health care systems, the economic base of the urban Indian popula-
tion; and has been able to make estimates of health not readily avail-
able for Indian Health Service facilities. The need for data relating to
"non-recognized" tribes is obvious.
The basis for formulation of a concept of the state of Indian health
One must define Indian health in terms of comparison to something
else. For example, one might evaluate Indian health in terms of
Indians themselves in their own milieu as opposed to Indians in a
white milieu. That is, morbidity, mortality, death, longevity, etc. of
Indians may be compared to what that respective level would be if
there were no white people. Or for example, what the level of Indian
health might have been at the time before the arrival of the white
man. Such a comparison, even in view of almost no hard data, is not
necessarily a waste of time. Historical data suggest that Indians are
certainly much worse off than before the advent of the Europeans.
A legitimate concern for investigation is what the situation might
have been without any federal program. Unfortunately, the critical
experiment cannot be performed since it is not possible to study two
groups of Indians, one which has lived for five hundred years with the
white man and one which has not. Too often, an argument against
federal programs does not consider this unsatisfactory alternative.
Another way to estimate the status of Indian health would be to
compare the health status of Indians in the United States with that of
Indians in other countries, such as Canada and Central and South
America. Again, the critical observations have not been made, at
least in a comparative way. Personal experience of a brief nature with
other countries suggests that Indians in other countries may live under
certain adverse conditions not shared by those in the United States.
Comparative studies of Indians (and other aboriginal groups) between
different countries is certainly feasible in the field of health.
It is likely that valuable new insights could be obtained by such
comparative studies. Such a study will be a recommendation of the
Task Force on Health.
The most desirable evaluation would undoubtedly be a comparison
of health to some ideal that might be achieved if all conditions were
optimal. This ideal, of course, is as elusive for Indians as it is for non-
Indians. Further, it is unlikely that any consensus could be achieved
defining what that ideal might be. A comparison to such a hypothetical
ideal state of health would have certain inherent value, nevertheless.
For example, it would permit more definite long-term planning, rather
than a crisis-responsive system. A drawback of such a plan might be
the discouragement which would ensue over failure to achieve a
remote goal. It is not surprising in view of the problems associated
with the above systems that the standard technique for evaluating








the status of Indian health has been to compare indices of Indian
health with similar indices for the general population of the United
States. Such a system demands simply the most accurate data avail-
able for both groups. Such a comparison does not necessarily imply
differences between the two groups. At any rate, the only body of
data available is that which compares the Indian status to that of the
general population of the United States.
Demographics of Indian people
In general the Indian Health Service provides services to the Indians
"recognized" by the Bureau of Indian Affairs, or those specifically
listed by Congress as being beneficiaries of appropriated funds. The
basis of Federal recognition has been discussed elsewhere and will
not be pursued here.
Although Indian Health Service is attempting to move towards
providing services to Indians not ordinarily recognized, such as in
California and in urban settings, this movement is still rudimentary.
It is safe to estimate that since only about one-half of the Indians in
the United States are "federally recognized" and since about one-half
live in urban areas, the Indian Health Service may be providing serv-
ices to no more than about one-fourth of the Indian population.
According to the Indian Health Service,' as of July, 1971, it was pro-
viding services to approximately 469,632 persons. Of these, 85% live
in the 24 so-called reservation states.
In addition to fundamental cultural differences, Indians differ from
the entire United States population in other important demographic
ways. For example, Indians are being born at a rate nearly twice as
fast as the general population. In 1971, the birth rate of Indians was
33.0/1000 compared to 17.3/1000 for the entire United States popu-
lation; a ratio of 1.9. This ratio has actually increased slightly since
1955 even though the birth rate of Indians has declined from a rate
of 37.1/1000 in 1955. Thus, the birth rate for Indians has declined
since 1955 but not as rapidly as has that for the entire population.
Actually, for the past 5 years the birth rate of Indians has remained
basically constant.
A comparison of the ages at which Indians die compared to the
total United States population is also instructive. The ratio of age
adjusted death rates of Indians to the total population is 4.1 (table 1).
In Figure 1 is shown a distribution of death by age, comparing
Indians to the total population for 1971.2 Deaths in Indians under
the age of 1 year constitute 10% of the Indian deaths compared to
only 4 percent for that of the total United States population. Similar
ratios hold for the proportions accounted for by the age groups 1-4
years. What these data show is that a much greater proportion of
Indians die in their early years than is true for the total United States
population. A particularly heavy toll occurs among Indians in the
group aged 5-24 years. Stated another way, these data indicate that
death rates during the same periods are also greater for Indians,
indicating that during these periods Indians die faster (or are more
likely to die) than the total united States population by a factor of
about twice to three times. (See Table 1).
lindian Health Trends and Services. Indian Health Service, 1974 edition. U.S. Dept.
HEW. -
*Report' to the Congreas. Progress and Problems In Providing Health Services to In-
dinms, by' Co40mtrol ler General of U.S. Dept. of HEW: March 11, 1974. -'






42


Nearly two-thirds of the deaths in the total United States population
occurred in the age group 65 years or older, compared to only one-third
for Indians. (Fig. 1). Thus, one may conclude that a disproportionate
loss of youth and young adults is occurring among Indians. The
impact of this drain of resources cannot be calculated but is reminiscent
of the toll of young French men during World War I.
In spite of the disproportion in death rates, when compared to the
United States population, the Indians are on the average younger.
The median age of Indians is 18.4 years compared to 28.1 years for the
United States; conversely, only 11.8 percent of Indians are 55 years
of age or older. This compares to the United States population in
which this age group makes up 19 percent. A comparison of age
distribution of Indians to the United States is shown in Figure 2.
All these data support the fact that Indians have a smaller chance of
living to an old age than do all other United States citizens as a group.
Because of the enormous differences between Indian tribes and
groups extending from Alaska to Florida, from extremely remote areas
to metropolitan cities, and because Indians are a relatively mobile
group of people, it is not possible to attempt further demographic
description of the population.
Life expectancy
A frequently used index of health status is often taken as the life
expectancy of a group of people at the time of birth. The short life
expectancy of Indian people has been widely discussed.
In Figure 3 is shown a. comparison of life expectancy for Indians
and whites in the United States for the years 1950, 1960 and 1970.
Between 1950 and 1970, the life expectancy of Indians increased from
60 years to 65.1 years, an increase of 8.5 percent. During the same
period the life expectancy for whites in the United States, although
starting at a higher level of 69.1 years in 1950, increased to 71.7 years,
an increase of 2.3 percent. Thus, the life expectancy of Indians in-
creased over three times more rapidly than whites. Between 1950
and 1960, the life expectancy of Indians increased by 2.8 percent
compared to an increase of 5.5 percent for the next decade. This
suggests an acceleration in longevity by Indians not shared by United
States whites. The increase in longevity of whites during this period
actually slowed slightly from 2.2 percent to 1.6 percent. Longevity of
Indians seems to be increasing more rapidly also than groups in the
United States excluding whites, suggesting that Indians are doing
better perhaps than other minorities.
There can be little doubt that the increase in longevity of Indians
results from successful efforts to decrease the mortality from acute
infectious diseases, especially in childhood. As the mortality rate for
these diseases goes down, the increase in longevity of Indians wil
probably slow. Although predictions about future rate of change in
longevity are not warranted, it is of interest to note that if the increase
in longevity for Indians and United States whites continues unchanged,
one would expect the longevity of Indias to reach that of whites
within the next decade.
An important factor related to Indian longevity will be 'the be-
havior of death rates caused by heart disease, cancer and strokes.
Present data suggest that Indians are in a relatively favorable position
in respect to these diseases. Unless the difference is negated by con-






43


tinued increased mortality from accidents and alcoholism, it is possible
that Indians born in the year 2000 may live longer than non-Indians.
These optimistic forecasts must be tempered by the realization that,
the present life expectancy of Indians was reached by whites in 1944.
In summary, the longevity of Indians is increasing more rapidly
than is that of whites. This increased life span undoubtedly is a
result of special programs designed to decrease infant and children's
deaths from acute communicable diseases. Still, the life expectancy
of Indians born in 1970 was 6.6 years less than for whites. For an
important discussion of the use of longevity statistics, the reader is
referred to Hill,3 who points out the errors of using such terms as
"average age of death" and "lifespan." The average age of death of
Indians in 1967 was 45.7 years compared to the total United States
population, which was 64.7 years. The gap between these two is
narrowing. Hill argues that the average age of death concept is
subject to several objections and is not necessarily a useful concept.
Death rates
In Table 1 are shown death rates adjusted for age of Indian popula-
tion served by the Indian Health Service compared with the death
rates for the total United States population and the total United
States white population. In the last column is shown the ratio of
deaths in those served by the Indian Health Service compared to that
of the United States as a whole. The death rates of Indians from all
causes is 968.8 per 100,000 population, which compares to the total
death rate in the United States of 701.8 per 100,000 population for a
ratio of Indian deaths to the general population of 1.4. This indicates
that Indians die at a rate nearly one and one-half times greater (150%)
than the total United States population. However, there are certain
death rates which are lower among Indians than in the general popu-
lation. These include deaths from diseases of the heart, cerebro-
vascular and major cardiovascular diseases of which the ratio of
Indians to the general population is either 0.7 or 0.8. However, deaths
associated with hypertension occur as commonly among Indians as
among the general population. It is of some interest that Indians have a
much lower frequency of deaths from hypertension than those classed
as "all others" in the United States (exclusive of whites). For example,
the death rate of Indians from hypertension is 2.9/100,000 population
compared to 7.5/100,000 population for the category classed as "all
other." Some of the most startling figures are those associated with
accidents in which the death rates of Indians exceed the total United
States population by nearly 4 times. If one considers motor vehicle
aocidenata as the cause of death, the rate among Indians is slightly over
4 times as great as the entire United States population. All other
accidents also cause a greater rate of death among Indians than among
the general population.
Indians die less frequently from malignant neoplasms than do non-
Indians. The Indian death rate is only slightly more than one-half that
of the general population. Likewise, deaths due to bronchitis, emphy-
sema, and asthma occur only about one-half as frequently among
Indians as among the general, population. Indians continue to die
somewhat more than twice as frequently from influenza and pneu-
U, CbaziseaM A., Measurem ot Longevity of American Indians. U.S. Public. Hith. RIep.
T8-188--76----






44


monia as the general population. The death rate from tuberculosis is 5
times more frequent in Indians. An ominous finding is that Indians die
4 times as often from cirrhosis of the liver.
These data suggest that there may be some sort of protective
mechanism existing in Indians related to cardiovascular disease and
malignancy. It has been generally assumed that this relative advantage
is a reflection of a decreased life span of Indians. However, this may
not be the complete explanation.
Another method of evaluating death rates of Indians is to compare
crude death rates of certain diseases within the Indian population
for the years 1955 with 1973 (Table 2). In 1973, the leading cause of
death of Indians was accidents, followed by diseases of the heart
and malignant neoplasms. The raw data for death rates is more impres-
sive if one examines the changes that have occurred during these
years. The overall death rate decreased from 927.2 to 772.5/100,000
population, a decrease of 17 percent. Decreases in mortality rate
occurred for tuberculosis, congenital anomalies, influenza and pneu-
monia. Increases in mortality rate occurred from accidents, cirrhosis,
diabetes, homicide, and suicide. It is evident that not only do deaths
associated with accidents and cirrhosis of the liver and diabetes
exceed that for the general population, but these have increased by
12 percent, 22 percent and 47 percent respectively among Indians
between 1955-1973. This has occurred at a time when the overall
death rate of Indians has decreased by 17 percent. The most striking
decreases in mortality for these two periods have occurred with
tuberculosis, which has dropped by 89 percent, and certain neonatal
causes, which have dropped by 71 percent. There has been a substantial
decrease of 54 percent for crude death rates associated with influenza.
Equally important is the decrease in death rates from cerebrovascular
disease and diseases of the heart. One would have anticipated that
deaths associated with degenerative conditions such as cardiovascular
and cerebrovascular diseases would have increased as the population
aged; yet this did not occur. When one considers the common associa-
tion of diabetes with cerebrovascular and cardiovascular deaths this
finding becomes even more significant. Deaths associated with diabe-
tes increased by nearly 50 percent. There also is an increase in
malignant neoplasms of 5 percent, an increase that one would expect
as the age of the population increases.
Alcoholism
A comparison of deaths and death rates for alcoholism for each year
from 1966 to 1973 is shown in Table 3. Although some of the data
are perhaps biased by differences in reporting, it does not appear
that differences in reporting of alcoholic psychosis or cirrhosis of the
liver would be as affected by changes in reporting over the years.
The term "alcoholism," of course, is one which is subject to wide
variations in interpretation and hence, in reporting. In 1966, there were
55 deaths from alcoholism among Indians and Alaskan Natives. This
increased to 159 by 1973. This increase is shown more strikingly in
Fig. 4. It is of interest that although deaths associated with alcoholism
have increased by nearly 300 percent, there has not been a correspond-
ing increase in deaths associated with alcoholic psychosis. The signifi-
cance of this finding is not clear. The same finding holds true of all
races in the United States; 'The nuhiber of deaths associated with






45


cirrhosis of the liver has increased from 128 in 1966 to 235 in 1973, or
an increase in death rate from 20.7 to 30.5/100,000 population. It is
of interest that the increase in deaths due to cirrhosis also lags behind
the overall death rates from alcoholism during this period. It would
be dangerous to draw definite conclusions from this data, but the
individual consumption of alcohol may be so great that Indians are
dying as a result of direct toxicity before developing the complications
and sequelae such as cirrhosis of the liver.
Maternal and infant deaths
Maternal and infant death rates are useful indices of health care
and widely publicized between countries of the world. In Fig. 5 is
shown the maternal death rates from 1958 to 1973. There are fewer
categories in which such a dramatic decrease has occurred. The rate
in 1973 had also fallen to the same level as for the entire United States
population.
The infant death rate likewise has steadily decreased from just over
600/1000 live births to less than 20/1000 live births by 1973. the
latter comparable to the death rate for the total population (Fig. 6).
However, an analysis of infant death rates by age at death is
instructive. For infants under the age of one month, the death rate
of Indians equals or is less than that for the general population.
Yet, for the next ten months the death rate for Indian infants is
more than twice that for the general population. (Fig. 7). Thus,
after leaving the hospital, the Indian spends a hazardous year in the
home. Much of this mortality is undoubtedly related to acute con-
tagious diseases which could be decreased by improved sanitation
programs.
One may make the following projection about the life expectancy
of an average Indian person. At the present time, an Indian child
will be born in a hospital and enjoy a level of health and safety
equivalent to that of the general population. The Indian child may
expect to have fewer congenital anomalies, but in many instances
the child may be expected to be born of a woman with little under-
standing of health or hygiene and who has a high likelihood of having
iron deficiency anemia or other evidence of malnutrition. In spite of
this, the Indian child receives a reasonable initial start in life only
-to find residence in a home of one or two rooms, where the several
members average four to six respiratory infections per year. Thus, the
Indian child will have an increased likelihood of developing an acute
-gastrointestinal infection with a higher than average expectation of a
fatal outcome. The Indian child may also expect to die in a traumatic
death during this period of time. Should the Indian child survive these
physical dangers, it must still dwell in a home with severe social
pathology. The child has a high likelihood of being raised by a person
*other than the natural parents or spending a considerable part of
time away from home. The Indian child may expect to have some
Degree of sequelae from respiratory infections of which perhaps the
most disabling would be deafness associated with middle ear disease.
At the time of beginning high school or even earlier, the Indian child
would have enormous .pressures brought to either begin consuming
alcohol or abusing other types of drugs. The Indian child would have a
better than 50-50 chance of dropping out of school and exhibiting
.self-destructive behavior in one of a variety of ways. During the






46


early adult years, the Indian would be more apt to die by murder or
accident than from any other causes; the Indian likewise will have an
unsatisfactory house to live in, with inadequate water and sanitation.
Finally, should the Indian survive all of the vicissitudes of living andc
look forward to an old age, the Indian will find that he or she cannot.
remain a useful or even wanted member of the community and may
live out his or her declining years in a foreign environment away from
home. It is against this profile that one must deal in planning programs.
for health care.
Prevalence of certain diseases among Indians
Although death rates from various causes give important infor-
mation about the health status of groups of people, it is necessary to
also have some estimate of the prevalence of diseases within each group.
Incidence rates are susceptible to the same inter-group and intra-
groups comparisons and intra-group comparisons over time as are
rates for most diseases.
In Table 4 are shown incidence rates for selected diseases for the
year 1973. Data for Alaskan Natives are shown separately. The inci-
dence rate for cases of otitis media is incredibly high for Indians
as well as for Alaskan Natives. It is not surprising that acute com-
municable diseases such as gastroenteritis, streptococcal pharyngitis,
and influenza are very high. Only measles has an incidence rate
less than 100/100,000 population.
An idea of the nearly astronomical occurrences of communicable
diseases and changes between 1962 and 1971 is obtained by exami--
nation of Table 5. The total number of communicable diseases has
actually increased faster than could be accounted for on the basis
of population growth during this time.
A conclusion that this increase represents a worsening of conditions
cannot be excluded. However, it is likely that the increases for certain
of those diseases is accounted for on the basis of more vigorous diag-
nosis, screening programs (as for otitis media), and differences in
reporting between years. Different conditions certainly behave dif-
ferently during these years also. For example, one cannot compare
the rates for hepatitis with syphilis from the standpoint of drawing
conclusions about Indian Health Service programs. Likewise, it has
been noted that the death rate from gastroenteritis (Fig. 8) has been
decreasing during these years when the incidence rate appears to have
been increasing.
A tabulation of cases and incidence rates for various communicable
diseases for the calendar year 1971 for various Indian Health Service
areas is shown in Table 6. Because of differences in population, the total
number of cases may be very misleading. The most striking finding
in this data is the sharp contrast between the incidence of gastro-
enteritis and dysentery in Alaska compared to other Indian Health
Service areas. In Alaska these diseases are not considered significant
problems.
Otitis Media
Incidence rates for otitis media from 1962 to 1974 are shown in
Table 7. The steady increase from 1962 through 1972 undoubtedly
results from more aggressive case finding and more extensive reporting.
Otitis has for some time been the leading notifiable disease for Indians,_






47


and exceeds the rate for non-Indians by manyfold. Morbidity from
otitis is an important problem for the young because of its tendency
to be associated with recurrent attacks and because it is often associated
with hearing loss.
Otitis media most often is a bacterial complication of upper respira-
tory infections precipitated usually by swelling of mucous membranes
in the nasopharynx, which obstructs drainage of the eustachian tubes.
Pressure is placed on the tympanic membrane, resulting in the typical
"earache." Pus may develop behind the ear drum, and without
drainage may spontaneously rupture the drum with resulting drainage
from the ears. Because the small passages in the very young are easily
obstructed, otitis is especially a problem under the age of two years.
Although surgical procedures are effective in restoring lost hearing,
it is obvious that better programs of prevention would result in great
savings of time, personnel, facilities and money.
The magnitude of the problem of otitis media led to lobbying efforts
by groups such as the Association of American Indian Affairs. These
efforts led to legislation permitting the beginning of a program in FY
1971 designed to attack this problem. In 1975, the number of reported
cases again decreased. In spite of these programs, there is a backlog
of needed surgery of several thousand cases. In Billings area alone, in
FY 1975 there were 154 tympanotomies with insertion of PE tubes.
On the Navajo reservation large numbers of persons continue to be
treated for the first time with middle ear disease.
Control depends upon intensive education of parents, prompt and
adequate therapy of upper respiratory infections, and better living
conditions to decrease the chance of exposure to infecting organisms.
Thus, most of the information needed is at hand. What is needed is
funding sufficient for action to reduce to zero the incidence of deafness
associated with otitis.
Gastroenteritis
Diarrhea and gastroenteritis, an inflammation of the alimentary
tract, in most instances result from infections associated with poor
environmental and sanitation facilities which permit fecal-oral trans-
mission of microbes. Gastroenteritis may rapidly lead to dehydration
which can be dangerous to the very young. Infants may become seri-
ously ill very quickly and inadequate transportation to health facilities
can be a significant factor in increasing mortality. Control measures to
a large extent depend upon improved sanitation and an increased
standard of living. There are few areas in which IHS activity in the
social sphere would result in more substantial improvement in inci-
dence rates than in gastroenteritis. Vaccines are not available or effec-
tive for most cases of acute gastroenteritis. An important program for
clinical assessment of infant dehydration has been developed at the
Sells Service Unit of the Office of Research and Development but
does not appear to have been adopted in other areas.
Tuberculosis
The decline in incidence rates for tuberculosis is shown in Table 8.
The decrease for Alaskan Natives has approached that of Indians. The
incidence rate for Indians still is about ten times that for all races in
the U.S.





48


Tuberculosis is an infection usually of the lungs, spread by airbornea-
particles, which sometimes affects the brain, kidneys, liver and bones
and joints. Crowding and poor ventilation contribute to the spread of
the germ. Knowledge of techniques for controlling tuberculosis has
grown in the last twenty years and depends upon either the use of a
vaccine or the administration of prophylactic antimicrobial drugs.
Improving the standard of living is also an important adjunct in
decreasing the rate of tuberculosis. The excessive incidence rate of
tuberculosis of Indians compared to non-Indians can be largely ex-
plained on this basis. Therefore, it is clear that along with case detec-
tion, and use of prophylactic antibiotics, the role of Indian Health
Service in improving the standard of living of Indians will have a
direct effect on the incidence of tuberculosis. It is recommended that
additional funding for Indian Health Service specifically directed at
tuberculosis eradication be provided.
Gonorrhea and syphilis
The startling increase in gonorrhea in Indians in the recent past has
exceeded even the steady increase occurring in the general population
(Table 9). These differences may be explained in part because of
different rates of detection and reporting in the United States. The
cause of the nationwide epidemic is not clear and usual explanations
do not adequately explain the outbreak. It is dangerous to assume that
only the disruption of Indian life is responsible for the excess rate for
both gonorrhea and syphilis. It is of interest that the increase in In-
dians of gonorrhea has occurred at a time when gonorrhea has also
been increasing in the general population; however, syphilis has been
increasing among Indians while decreasing in the general population.
Control measures have included vigorous case finding and treatment
of contacts. Little is known about immunity to either gonorrhea or
syphilis. Although it is possible that the traditional control methods
are less effective than assumed, there is practically no funding for a
real attack on the problem through the Indian Health Service.
Causes of hospitalization
A listing of the three leading causes of hospitalization for each Indiau
Health Service area for 1973 is as follows:
Aberdeen (excluding Bemidji)
1. Accidents, poisonings and violence.
2. Respiratory diseases.
3. Complication of pregnancy, childbirth, and the puerperium.
Bemidji
1. Respiratory diseases.
2. Accidents, poisonings and violence.
3. Special conditions and examinations.
Alaska
1. Complications of pregnancy, childbirth, and the puerperium.
2. Accidents, poisonings and violence.
3. Complications of pregnancy, childbirth, and the puerperium.
Billings
1. Complications of pregnancy, childbirth and the puerperium.
2. Respiratory diseases.
3. Accidents, poisonings, and violence.






49


Navajo
1. Complication of pregnancy, childbirth, and the puerperium.
2. Accidents, poisonings and violence.
3. Respiratory diseases.
Oklahoma
1. Complications of pregnancy, childbirth and the puerperium.
2. Special conditions and examinations.
3. Respiratory diseases.
Phoenix
1. Accidents, poisonings and violence.
2. Complications of pregnancy, childbirth, and the puerperium.
3. Respiratory diseases.
Tucson
1. Complications of pregnancy, childbirth, and the puerperium.
2. Accidents, poisonings and violence.
3. Respiratory diseases.
Uset
1. Complications of pregnancy, childbirth, and the puerperium.
2. Respiratory diseases.
3. Accidents, poisonings, and violence.
There is a repetitive character that is most striking. It is significant
that in three of the ten areas, accidents, poisonings and violence as a
group are the leading causes of hospitalization. The prominence of
conditions associated with childbirth is also striking. Although data
are not available relative to the cost of these conditions, one can imag-
ine the impact on hospital care costs. It is possible that since the former
group not infrequently engenders some hostility in hospital personnel,
there might be a salutary effect on Indian Health Service morale if
these were decreased. It would appear that the category of accidents,
poisonings and violence should be susceptible to change.

CONCLUSIONS
There have been striking improvements in mortality from diseases
associated with acute and some chronic infections. This reduction has
come about in part because of special emphasis programs, environ-
mental programs of Indian Health Service, improvement in living
conditions and improved medical care. There has also been a slight
improvement in mortality rates from cardiovascular and cerebrovas-
cular diseases, the significance of which is not entirely clear.
These happy results are overshadowed by the very disturbing
increases in deaths associated with accidents, alcoholism, cirrhosis of
the liver and suicides. These findings appear to be related to the
profound changes in life-style continuing to take place, with resultant
extraordinary destruction of Indian people. Because this represents
a more profound disruption of social organization and functioning,
it obviously will be much more difficult to deal with. However, there
must be tremendously increased emphasis placed upon programs
designed to deal with this type of disruption. This will involve expanded
concepts of health care and roles played by the Indian Health
Service.






50


It is clear that the overall health status of Indians as measured by
longevity and death rates is manifesting substantial improvement
in the past twenty years. This improvement is most noticeable in
areas where better health sustaining techniques would be expected
to have the greatest impact, the areas of maternal and neonatal
death rates, tuberculosis and the acute communicable diseases. In
relation to the general United States population, Indians enjoy a
favorable position in relation to death from cancer and cardiovascular
diseases.
However, it is reasonable to ask whether the health of the American
Indian as defined at the beginning of this chapter has indeed improved.
This definition, in essence, has been taken to connote a state of
physical and mental well-being. Although the difficulties of measure-
ment have precluded any real estimate of Indian "health," there are
certain data suggesting that Indian health in reality is deteriorating.
One may reasonably assume that alcoholism and other destructive
behavior to a large extent reflect profound individual and social
"disease" or lack of health.

RECOMMENDATIONS
From the data presented in this section, it is clear that certain
recommendations may be made for future legislation.
1. Additional funding for sanitation and home improvement pro-
grams is immediately needed to extend present benefits to all federally
recognized tribes. No new legislation would be necessary for this,
simply adequate funding for present and planned programs.
2. Legislative authorization for a study not to exceed one year,
comparing the relationship of American Indians to the Federal
government with that of other aboriginal groups in other countries.
This study would be carried out by an appropriate panel of Indian
and non-Indian health professionals.
3. Legislative authorization for a feasibility study designed to
-determine the possibility of a program to compare the health status
of Indians of "recognized tribes" with those of "non-recognized"
tribes. This study would accomplish a number of objectives, one of
which would be an evaluation of the effect of the Indian Health Service.
4. Legislation authorizing and funding Indian Health Service to
actively develop and implement programs designed to combat the
personal and social pathology manifested by increasing rates of
alcoholism, suicides and accidents. This would mean placing a re-
sponsibility on Indian Health Service to participate in programs of
economic improvement, family support, and self-esteem. It is the
position of the Task Force that this is well within the support systems
needed to improve Indian "well-being."
5. A comprehensive program of research by Indian Health Service
into the causes and prevention of Indian alcoholism and suicides
should be implemented immediately. Data is needed in areas such
as drinking patterns, for example.
6. The Indian Health Service must be immediately funded to a
level permitting elimination of the backlog of unmet needs.
7. Comprehensive programs must be greatly strengthened to
provide an attack on family disruption, disintegration and anomie.
8. It is imperative that studies be done comparing those receiving
Indian Health Service benefits with those who have not received any.







51

9. It is imperative to do comparative international studies relating
"aboriginal" groups to their respective predominant societies. This
would greatly enlarge the present scope of understanding of Indian
health.
TABLE 1.-AGE-ADJUSTED DEATHS RATES

Indian United Ratio of
Health States I IHS to
Service Total white All other United States

All causes ---..-- .................--------------------- 968.8 701.8 667.6 965.4 1.4
Major cardiovascular disease----------- 237.0 333.8 324.7 409.1 .7
Diseases of heart -----------------............. 167.7 249.3 244.9 283.1 .7
Cerebrovascular disease-----------........... 53.0 65.0 61.0 101.3 .8
Arteriosclerosis -------------------................... 13.4 8.2 8.2 8.4 1.6
Hypertension-.................... --------------------- 2.9 2.6 2.0 7.5 1.1
Accidents--------------------------...... 202.7 52.0 49.8 68.8 3.9
Motor vehicle..................... --------------------- 117.1 27.0 26.6 30.6 4.3
All other.......-------------------------............... 85.6 25.0 23.1 38.1 3.4
Malignant neoplasms ...------------------.......... 81.6 130.7 128.3 152.2 .6,
Cirrhosis of liver----....--............... --------------- 66.0 14.9 13.5 25.4 4.4
Influenza and pneumonia.............. -------------- 49.9 20.8 19.2 32.6 2.4
Diabetes meilitus---.--...----------------... .... .. 28.4 13.6 12.2 26.0 2.1
Tuberculosis, all forms----.------------. 9.1 1.7 1.3 5.9 5. 4
Bronchitis, emphysema, and asthma--... 6.9 11.0 11.3 8.0 .6

11972 rates (latest available).

TABLE 2.-SELECTED CAUSES OF DEATH OF INDIANS AND ALASKA NATIVES IN RESERVATION STATES

Crude death Percent
1973 rates, 1955 change-

AN causes..............-------------------------------........ --- ------------- 772.5 927.2 -17
Accidents........................................................ -----------------------------------------------174.3 155.6 +12
Diseases of heart.--..-- -. ------------------------------------ 131.0 133.8 -2
Malignant neoplasms -----------. ------------------------------ 62.0 59.1 +5
Cirrhosis of liver--------. ---. --------------.------------------ 45.5 14.2 +220
Cerebrovascular disease-.- -------------------------------------........ 42.8 46.4 -8
Influenza and pneumonia -------------------------------- ---... .. 41.1 89.8 -54
Certain causes of mortality in early infancy -------------------------- 19.6 67.6 -71
Diabetes mellitus .----- --------------.----------------------- 20.4 13.9 +4T
Homicide-.- -------------------------------...... ....... --- ------------- 25.5 15.9 +60
Suicide ..---..-------------------------------------------- 19.4 8.7 +123
Congenital anomalies.----------.....-..------------------------------ 10.1 19.0 -47
uberculosis--...---- ----------------.----------------------- 6.0 55.1 -89
rteriosclerosis-.........---- -...........-------------...- 11.8 (-) .- -
Nephritis and nephrosis.---..------------------------------.. ----- 5.2 (I) --------

I Not available.







52


TABLE 3.-ALCOHOLISM DEATHS AND DEATH RATES
STATES AND


OF INDIANS AND ALASKA NATIVES IN 25 RESERVATION
U.S. ALL RACES


1966 1967 1968 1969 1970 1971 1972 1973

Number of deaths-Indians and Alaska Natives
in 25 reservation States:
Alcoholism-...-...-.. -------- 55.0 51.0 91.0 81.0 97.0 107.0 101.0 159.0
Alcoholic psychoses...------ -------- 5.0 6.0 10.0 7.0 8.0 10.0 8.0 5.0
Cirrhosis of liver with mention of alcoholism. 128.0 126.0 165.0 179.0 167.0 217.0 205.0 235.0
Total .---..----------... ------------ 188.0 188.0 266.0 267.0 272.0 334.0 315.0 399.0
Alcoholism death (ates-Indians and Alaska
Natives in 25 reservation States:
Alcoholism..----------------------- 8.9 8.0 13.8 11.9 13.8 14.8 13.6 20.7
Alcoholic psychoses... ------------------- .8 .9 1.5 1.0 1.1 1.4 1.1 .7
Cirrhosis ot liver with mention of alcoholism. 20.7 19.7 25.0 26.3 23.8 30.1 27.4 30.5
Total ...---.------------..--------- 30.3 28.6 40.3 39.2 38.8 46.3 42.1 51.9
Alcoholism death rates-United States all
races:
Alcoholism.------------------------ 1.6 1.5 2.0 2.0 2.1 2.1 2.1 2.2
Alcoholic psychoses. ------------------- .3 .3 .3 .3 .3 .3 .2 .2
Cirrhosis of liver with mention of alcoholism. 4.8 4.8 5.0 5.2 5.5 5.8 6.0 6.0
Total-- --- -------- 6.7 6.6 7.3 7.5 7.9 8.2 8.3 8.4


TABLE 4.-INCIDENCE RATES FOR SELECTED NOTIFIABLE DISEASES
[Calender year 1973 (rates per 100,000 population)]

Indian and
Alaska Alaska
Diseases Native Indian Native

Otitis media------- -- ---- ---------12, 103.6 12,429.4 9,487.1
Gastroenteritis, diarrhea. ----------- ---- -- 7, 627.8 8,296.2 2, 260.2
Strep pharyngitis..---- --- --- ----- -- 7,445.5 7,766.6 4, 866.9
Pneumonia ---- ------------------------------------- 3,624.2 3,718.1 2,870.4
Influenza ------ ---------------- ---------------------- 3,987.3 4,212.7 2,177.3
Gonococcal infection ---- --------------------------- ----- 1,794.2 1,716.5 2,418.4
Trachoma -...-- -------------------------------------------- 500.7 516.0 17.0
Chickenpox-...--- --- -------------------------------------619.2 659.7 293.8
Bacillary dysentery..------- ---- ------455.7 508.7 24.5
Mumps------------------- -------425.2 432.9 363.5
Infectious hepatitis ------ --- --- ---- 296.1 289.9 346.6
Syphilis, all forms -- -------------------------------------- 149.9 157.6 88.5
Measles----. ------------ ------ 74.5 77.6 49.0
Tuberculosis, new active --------- -----------107.6 102.4 150.7










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55


TABLE 7.-REPORTED NEW CASES OF OTITIS MEDIA AND INCIDENCE RATES FOR INDIANS AND ALASKA NATIVES
CALENDAR YEARS 1962-74

Indian and Alaska Natives Indians Alaska Natives
Number Rate per Number Rate per Number Rate per
of cases 100,000 of cases 100,000 of cases 100,000

Calendar year:
19741 -------------............. 53,549 10,954.3 48,702 11,197.6 4,847 8,991.6
1973-..-------------. 58,036 12,103.6 52,999 12, 429.4 5,037 9,487.1
1972.--------------. 57,781 12,289.8 53,419 12,780.1 4,362 8,361.4
1971..-------------- 49,478 10,742.4 45,283 11,066.9 4,195 8,159.8
1970---.....-...---------- 44,008 9,745.0 41,109 10,253.1 2,899 5,723.2
1969..--------------. 39,351 8,892.3 36,568 9,313.6 2 783 5,577.3
1968--...-----.------- 36,470 8,413.7 33,503 8,717.5 2, 967 6,038.0
1967 -------------- 30,211 7,118.8 27,377 7,281.0 2,834 5,857.6
1966--...------------ 28,224 6, 909.6 25,144 6,968.0 3,080 6,467.2
1965-------.------- 22,614 5,688.2 21,502 6,131.3 1,112 2,372.6
1964------..-------- 22,290 6,243.7 21 267 6,772.9 1, 023 2,379.1
1963--------------. 18,397 5,221.7 17,052 5,500.6 1,345 3,127.9
1962-------------- 13,382 3,801.7 12,383 4,007.4 999 2,323.3

i Provisional

TABLE 8.-TUBERCULOSIS MORBIDITY RATES PER 100,000 POPULATION

Indian and United States-
Alaska Alaska
Natives Indian Native All races White All other

Calendar years:
1973.--------------- 107.6 102.4 150.7 114.8 (2) (2)
1972. --------------- 100.6 94.3 151.4 15.8 10.8 50.3
1971--------------- 157.4 152.0 200.3 17.1 11.7 53.8
1970 ---- ----------- 154.1 154.1 154.0 18.3 12.4 59.0
1969 --------------- 140.8 141.6 134.3 19.1 13.7 59.7
1968 --------------- 133.8 128.0 179.1 21.3 15.3 65.1
1967 .-- ------------- 155.8 152.7 179.8 23.0 16.6 70.2
1966 --------------- 141.7 127.8 247.8 24.4 17.9 71.9
1965 --- ------------ 201.5 160.5 507.8 25.3 18.6 74.9
1964 -----.---------- 237.8 184.1 630.2 26.6 19.9 76.5
1963 .--------------- 234.0 192.3 53. 9 28.7 21.7 81.5
1962 ---------------- 257.7 209.4 604.7 28.9 21.9 80.1
1961---- ----. 318.8 281.8 562.8 37.0 ............................
1960------------. 322.4 292,3 547.5 39.4 --------------.....................
1959--------------- 418.0 338.2 1,048.0 42.6 ------ --------.....................
1958 --------------- 485.0 421.8 978.7 47.5 ---...............------ -......
1957 --------------- 565.2 426.9 1,649.7 51.0 -----...- ..--..............----
l956... ...... 680.6 474.3 2,283.8 54.1 -------- ---- ---.......
1955 ---------------758.1 563.2 2,325.7 60.1 -.....................------------

I Provisional, Morbidity and Mortality, vol. 22, No. 53.
Not applicable.

TABLE 9.-INCIDENCE RATES FOR VENEREAL DISEASES INDIANS AND ALASKA NATIVES COMPARED TO UNITED
STATES ALL RACES
[Rates per 100,000 population]

Gonorrhea Syphilis, all stages
INS United States 1 IHS United States

1960- .---------------------------------------- 727.8 18L 9 89.3 54.4
1965 --- -------------------------- 716.6 169.6 93.0 58.9
.1967 ----------------------------------------- 751.7 207.3 99.9 52.5
1968................ ----------- 842.3 235.7 145.8 48.8
1969 1 ....-------------026. 268.6 161.8 46.3
1970 ....6 ------------------------.------------- 1, 18. 0 297.5 172.1 45.3
-19711 .. ..------------.--- ,647.5 328.2 180.5 47.0
1972. .1....--.--- ---------------- 1 923.6 371.6 207.8 44.2
.1973. ----.- ---------------------------------- 1, 794 2 404. 149.9 42.0

I Reported morbidity.aad mortality in the United States 1973, vol. 22, No. 53, Center for Disease Control.







56

DISTRIBUTION OF DEATHS BY AGE DURING 1971


U.S. TOTAL POPULATION


INDER 1 YEAR
--1 TO d YEARS i.-)
-". 5 TO 24 YEAPS
/'9::.*':.; ,25 TO 44 YEARS


INDIAN


FIGURE 1



PERCENT OF POPULATION BY AGE
INDIAN AND ALASKA NATIVE AND U.S. ALL RACES'-'


PERCENT
16.0
/

12.0 -


8.0


4.0


0 1 1 I I I I I I -I
U") en -1, cn qn!* cn Vr en CD- no-e n CD n ^i t
IC CM M 0)) u'd U CD I
FC ~ ~ ~~~ I l l l l l llI*
Ml 1r) C3? LO C:) 10 M n c) CM ( Lo M:) LM 'n C1
C4- MM co) %J% U-) U- 3i to CD I- r-' cw C
g''''''''' w=


1. S OJ1P..O, 170 CC.lJUS.


AGE GROUP IN YEARS


FIGuRE 2







57


LIFE EXPECTANCY AT BIRTH,
INDIAN & ALASKA NATIVE, U.S. WHITE, U.S. ALL OTHER


1950 1960 1970
CALENDAR YEARS


Data frci, IHS
FIGURE 3



ALCOHOLISM DEATH RATES
INDIANS AND ALASKA NATIVES COMPARED TO U.S. ALL RACES
PER 100,000 POPULATION


1967 1968 1969 1970
CALENDAR


1971
YEARS


1972 1973


FIGURE 4


RATE
"n


DLU


IHS









m_ --- - "U.S.
U.S.
I [ I I


1966


0]






58


MATERNAL DEATH RATES
INDIANS AND ALASKA NATIVES COMPARED TO U.S.
'RATE PER 100,000 LIVE BIRTHS
loo100


1GO0 1032 1964 1966 1968 1970 1972 1974
CALENDAR YEARS


Data from I'S


FIGURE 5



INFANT DEATH RATES
INDIAN AND ALASKA NATIVE, AND U.S. ALL RACES


RATE PER 1,000 LIVE BIRTHS


I


--m--- m------mm-m-- ^
I!
^B>B^^ INDIAN & ALASKA NATIVE


ALL W~ES l^ ^ ^

t
l
. .! I 1 I 1 I 1 I I 1 I 1 !


1960


1965
CALENDAR YEARS


1970


1973


FAQVISC.'AL. ;'O';TII'V V!TAL "TA'TIST:C REPO"TS, ?;C'S VOL. 22 NO. 13 IW,3


Data frcon IHS


FIGURE 6


O0L-
1S53


40


,20


0
19!


55


i I li i l nlI


3U I






59


INFANT DEATH RATES BY AGE AT DEATH

INDIAN AND ALASKA NATIVE, AND U.S. ALL RACES
CALENDAR YEAR 1973
RATE PER 1,000 LIVE BIRTHS
20


15

10 IND:AN & ALASKA NATIVE ....,
10 /Z-------------1--
ALL RACES J


5- -^ __
5_ ,_ _ :_:__ __ /
UNDER 1 DAY 1-6 DAYS 7-27 DAYS 28 DAYS-
AGE 11 MO'S
5G


I ALL ;-%:ES PATES ARE EST.-.IATED ExC;:_T 28 DAYS ",.'.\' S' H'Ci S PF-
VISIC:.-L. M:ONTHLYV;TALSTATiST-CSPEPORT. :C3.'.L 22 .%J 13


FIGURE 7



GASTROENTERIC DEATH RATES*
INDIAN AND ALASKA NATIVE, AND U.S. ALL RACES


RATE PER 100,00i POP.
50

J'i.


0


Data from IHS


" '"INDIA & ALASKA NATIVE l'




ALL RACES

S 1 ; I I 1 I I I I I f 1. 1 l I f


1955


1960


1965


1970


CALENDAR YEARS
* A.IAN AVDU ATiV S S 1 SPA T.RB. 19;2. ALL. CiE- RATEO BASED Q's SI-LE YEAR DATW
.%A NOT AVAILABLE


1973


Data from IHS


FIGURE 8


78-188-76----5


lU


*I











Chapter 7


ENVIRONMENTAL SERVICES
INTRODUCTION
Environment plays a very important role in the maintenance and
improvement of health conditions of Indian people. For purposes of
the present discussion the term "environment" refers to drinking
water, sewer solid waste disposal systems, and housing. The lack of
these elements has been identified as a major health problem of
American Indians and Alaska Natives. More than 37,000 households
are without adequate water supplies or sewer systems. In addition,
according to the 1957 Bureau of Indian Affairs estimates, 51,065 new
housing units are required, representing about one-half of the total
number of Indian houses in the country. In many areas the situation
is much worse. In Alaska, for instance, there are 11,386 housing units
for a population of over 55,000. It is estimated that 8,400 new housing
units, almost 75 percent of the total housing stock, are required to
provide a minimum standard for housing. Discussion of the number of
houses needed does not address the question of the quality of housing
or deal with the issue of whether the housing is suitable to the needs of
the people; whether it fits into the lifestyle of Indians; or whether
people can even afford to maintain the kind of housing that is being
provided to them.
The details of housing conditions have been reported in a separate
study, "Indian Housing Effort in the United States." A significant
number of Indian people do not benefit at all from current federal
housing programs. Even for those who are eligible, the waiting period
for adequate housing is often prohibitive. Poor housing conditions
have had a severe negative impact on the health of Indians. Poor
environmental conditions have contributed in a major way to the
high incidence of many preventable diseases. For example:
1. Gastroenteritis ranked second among the reportable diseases
for Indians in 1972. Its relationship to an unsanitary environment
has been well documented.
2. Among Indians, the incidence rates for amebic dysentery were
2.6 times and for bacillary dysentery 42.1 times greater than for the
United States population.
3. Among Indians, the incidence of infectious hepatitis was 10.8
times greater than for the United States population.
4. The Indian infant death rate was only slightly higher than that
of the United States population. However, for infants who returned
to their home environment after hospital birth, especially for those
one month to eleven months of age, the death rate was over two times
that of comparable age groups of the general population. This con-
dition is in large part associated with lack of suitable sanitary facilities.
5. In 1973, approximately 20 percent of the Indian patients dis-
charged from Indian Health Service and contract hospitals received
(60)





61


treatment for infectious diseases. Most of these diseases are associated
with lack of running water, unsanitary conditions and overcrowded
home environment.
6. Lack of adequate facilities for disposal of human and other
household wastes contributes to the spread of micro-organisms re-
sponsible for many diarrheas and dysenteries and contagion associated
with insects and rodents in Indian homes and communities.
MAJOR ISSUES
1. Lack of adequate resources
Environmental services, including provision of water, sewer and
waste disposal systems, are part of the primary responsibility of the
Indian Health Service. Insufficient funding of Indian Health Service
has seriously interfered with the development of satisfactory sanitation
systems. For example, almost one-third of the total Indian households
are without adequate water, sewer and waste disposal systems. In
addition, water and sanitation facilities must be provided for over
50,000 new units needed to replace existing substandard homes. Under
PL 86-121 program, Indian Health Service must give priority to new
housing. This means many existing homes cannot be provided with
sanitation facilities.
2. Lack of interagency coordination
Although environmental services, including water, sewer and waste
disposal systems are the responsibility of Indian Health Service, other
agencies are involved in the interrelated activities. HUD is respon-
sible for providing houses; the Bureau of Indian Affairs is charged
with the responsibility of providing streets and sidewalks. Thus, min
most housing construction activities, Indian Health Service, Bureau
of Indian Affairs and HUD are involved. To insure proper coordination
and implementation, a tri-agency agreement was signed between
Indian Health Service, Bureau of Indian Affairs, and HUD. This
tri-agency agreement does not appear to be working.
A major problem seems to be lack of coordination at the time of
planning and seeking Congressional appropriations. Often, HUD may
plan for a different number of units than Indian Health Service may
plan for. Since the cost of provision of water and sewer is strongly
influenced by their location, Indian Health Service has no way of
determining exact cost until the housing units are known.
3. Lack of adequate training in maintenance of sanitation facilities
After sanitation facilities have been constructed, they are handed
over to the tribe for maintenance. Indian Health Service is charged
with the responsibility of providing adequate training to the tribes,
so they can maintain the facilities. Although there is some training
provided by Indian Health Service, it is inadequate. As a result, the
facilities deteriorate very rapidly with nobody within the community
properly trained to maintain them.
RECOMMENDATIONS
1. Consolidation of responsibility and authority
The tri-agency agreement is not working, and its chances of working
are rather slim. The responsibility for water, sewer, solid waste dis-






62

posal, streets, housing construction and housing rehabilitation should
be combined under a single authority. This authority should be within
the new cabinet level Indian Affairs Agency. This would save time,
effort, and resources, and decrease the number of agencies with whom
tribes have to deal.
2. Maximum resource utilization
There are several federal agencies which have funds for environ-
mental services. While Indian Health Service services are "residual"
in theory, in actual fact they are the primary environmental health
services to Indians. It is recommended that Indian Health Service
be recognized as the primary provider of these services and be funded
adequately for both existing and newly built houses.
3. Improved planning and design of Indian homes
Conventional standards of HUD and other federal agencies are not
suitable to the highly diversified conditions in the various areas
where Indians live. An attempt to impose such standards may destroy
the very spirit of the community it is supposed to be building. This
could have a significant impact on traditional cultural and family
systems. This in turn could have a negative influence on mental health.
Obviously, the authority to decide on the standards, design, and
approach to human settlement should rest entirely with the tribe.
Federal agencies can provide advisory services. Tribes should not be
forced to follow arbitrary standards which are contrary to their basic
patterns of living.
4. Training in maintenance of sanitation facilities
Training in the maintenance of sanitation facilities is seriously
deficient. On the other hand, Indian Health Service cannot devote
enough funds to this area because of financial constraints. At the same
time, this results in frequent breakdown of facilities, resulting in a
return to the previous unsanitary conditions, thus imposing an addi-
tional burden on Indian Health Service. It is recommended that
training and technical assistance for maintenance of sanitation
facilities be expanded to insure adequately trained personnel in each
community.
5. Economic development and environmental services
Construction of water, sewer, solid waste disposal systems, streets
and housing generates a significant amount of economic activity. It is
recommended that first preference be given to tribal construction
resources, even at the expense of some inefficiency, so that Indian
people can develop and improve their skills and participate in the
economic activity, thereby improving their standard of living.
6. Time frame for improvement of sanitation facilities
At the present time, the level of water, sewer and sanitation condi-
tions is far below the accepted normal standard of health and safety.
It is the responsibility of the Federal government to bring these
facilities to parity. Funding for this program must be provided so that
facilities in Indian communities will equal those in non-Indian com-
munities within 5 years.












Chapter 8


NUTRITION
In general, Indians subsist on diets high in carbohydrates and fats
and low in proteins, vitamins and minerals. Evidence of protein-
caloric deficiency in American Indians is well documented. Many
Indian children are born physically or mentally retarded. Children
and adults alike are often either obese or severely underweight.
Malnutrition often is most noticeable during pregnancy and often
affects the unborn infant. Malnourished children may not mature at
normal rates. Some studies suggest that malnutrition decreases the
number of brain cells. This seems to be associated with poor progress
in school which may never be completely overcome. Physical develop-
ment is likewise adversely affected at every subsequent stage because
of early and continuing malnutrition. Even with subsequent rehabili-
tation, the early growth failures can probably never be fully repaired.
American Indians are also afflicted with a number of nutrition-
related diseases which could often be ameliorated if their victims were
given proper diets. Dental disease is common in all age groups.
Obesity is prevalent.
Nutritional deprivation, alone, causes much unnecessary suffering
for Indian people. But this factor is only one of a whole cluster of
aggravating adverse conditions under which many Indians live.
Inadequate or non-existent sanitary facilities, lack of conventional
utilities, geographic isolation, lack of transportation, low incomes,
unemployment-these are some of the forces which have interacted
over a long period of time to create a situation in which it is difficult for
Indians to practice good nutrition habits.
Many Indians are too poor to buy fresh, nutritious food. Their
homes lack facilities for the storage of healthful foods, many of which
are perishable. When food is accessible, it is often of poor quality and
may cost more than in non-Indian communities. Education relating
to the value of proper diet in maintaining good health has not been
adequately provided to Indian people. Consequently, they often have
developed poor nutritional habits. The dependency status as federal
wards sometimes destroys motivation to overcome the cumulative
effects of all of these many forces.
Finally, societal forces have also interfered with access to or utiliza-
tion of traditional foods with which Indians have had centuries of
experience. Although one can only speculate, it is possible that the
rapid accommodation to a foreign diet has adversely affected the
nutritional status of Indians.
In the complex administrative machinery through which the
government dispenses food to Indians, the intensely personal nature
of eating, and its special social function in the culture have been
ignored and lost. The agency has replaced the family as food-provider.
(63)






64


The job of nourishing American Indians is really threefold: (1)
Getting food to those who are starving; (2) Supplementing the food
food budget of those with low incomes; and (3) Providing specially-
designed, extra rations to high-risk groups such as pregnant women,
infants, preschoolers, the elderly, the chronically ill, and the physically
handicapped.
In Indian communities, both rural and urban, the population is
dispersed over a broad geographic expanse, often isolated and unac-
cessible both culturally and literally. Reaching them calls for meticu-
lous decentralization, and this is lacking among the several agencies
charged with carrying out their three-fold task. Those responsible do
not necessarily coordinate their activities in food supply, and they
often operate food programs in conjunction with numerous other
unrelated programs. County governments, Indian-village banks, pri-
vate organizations, state governments, the United States Department
of Agriculture-all are involved in the complex logistics of feeding
American Indians.
The programs which these agencies have managed at one time or
another are: School lunch program; Head Start Program; Nutrition
for Elderly Program; Supplementary Food Program for women,
children, and infants; Day Care program; food stamp program; and
USDA family commodity program.
Distribution of surplus commodity food to American Indians began
in 1935 primarily because USDA had surpluses available at the time.
The limited, temporary nature of the offering is reminiscent of treaty
provisions for food made over a century ago. Typical is Article 10
from an 1868 treaty with the Sioux:
Each Indian * (with certain limitations) shall be entitled to receive from
the United States, for the period of four years * one pound of meat and one
pound of flour per day * *
Or a treaty with the Ute Tribe dated March 2 of the same year:
ART. 12. That an additional sum sufficient, in the discretion of Congress, (but
not to exceed thirty thousand dollars per annum) to supply the wants of said
Indians for food, shall be annually expended under the direction of the Secretary
of the Interior, in supplying said Indians with beef, mutton, wheat, flour, beans
and potatoes, until such time as said Indians shall be found to be capable of
sustaining themselves.
Now, as then, the commodity food distributed to Indians is some-
times their primary source of food, despite the fact that there was, and
is not now, enough of it to go around. In addition, it lacks adequate
nutritive value. By any standard, USDA foods are a poor replacement
for the traditional Indian diet of grains, roots, nuts, berries, game,
fish, and breast milk.
USDA has a list of twenty-two commodities representing a nutri-
tious balance; but few distributive warehouses serving Indian country
ever stocked all twenty-two items, and the bulk of those stocked were
in fact surplus farm products rather than nutritionally balanced selec-
tions. Other regular items were refined sugar, coffee, lard, peanut
butter, and sweet syrups. The USDA milk supply, as one particular,
has created special problems for Indians, who are among the several
non-European races who have a low lactose tolerance. The inability to
absorb milk leads to diarrhea, abdominal bloating, and irritability.
Under the commodity program, Indian populations normally did
not receive nourishing foods such as fresh meat, milk, raw vegetables






65


and fruits, but foods with long storage life and high carbohydrate and
fat content, such as rice, beans, potatoes and corn meal. Meat, fruits,
vegetables and milk were distributed in cans. The lack of transporta-
tion often interfered with obtaining commodity foods. Programs
designed for special high-risk groups were not adequately geared to
their unique needs. Eligibility of the elderly, for example, for participa-
tion in their special program, began at age 60 in disregard for the
average Indian's shorter life span. Moreover, little if any provision
was made for home delivery, where most aged Indians are. Those
elderly people who could get to nutrition centers designed for them
confronted a staff lacking knowledge about their special nutritional
needs and their severe dental problems.
Eligibility requirements were equally unrealistic in the Women,
Children and Infants' Food program. Certification is required. It is
also insufficiently funded, provides a great deal of non-nutritious foods,
and lacks the means for dealing with emergency feeding situations
involving infants.
Success of the School Lunch Program and the Head Start Program
was limited from the beginning by the fact that for many of the
children receiving it, the breakfast or noon meal represented the only
one eaten all day. Again, the staff was neither trained in nutritional
matters, nor in appropriate methods of serving small children and
giving them the kinds of foods they could manage.
FOOD STAMP PROGRAM
The Food Stamp program was designed to overcome many of the
shortcomings of surplus feeding. But, as will be seen, the food stamp
program proved to be equally inadequate, with its own set of flaws.
It is especially unworkable for the American Indian, because it re-
quires advance planning and saving, both of which are not typical
Indian traits. Indians also have difficulty in completing the long,
complex application and eligibility forms. Often they do not possess
the documents necessary to eligibility. For those who cannot adjust
to the stamp system or who cannot prove eligibility, there is no al-
ternative, since USDA has ruled that a commodity program and a
stamp program cannot operate at the same time in the same com-
munity. For those who do ultimately qualify, there is the ever-present
transportation problem. The same Indian who cannot get to the com-
modity warehouse cannot get to the food stamp headquarters and
cannot get to the retail outlet where food is sold.
Because food prices at an isolated trading post are higher than those
at retail outlets elsewhere, a given ration of stamps does not buy as
much for the Indian consumer as it does for one in the general popu-
lation. Food stamp allotments are based on the estimated cost of
an "economy" diet, defined by USDA as one for limited, short-term,
emergency use only. Such a diet may or may not be nutritious. The
stamp program, like the commodity program, fails to provide ac-
companyming nutrition education, so that the consumer can derive
maximum health benefit from his food purchase.
A further hardship is placed on Indians who live on trust land. This
fact often renders them ineligible for the food stamp program even
though their actual incomes are at poverty level. A further complica-
tion in the application process comes with confrontation with local






66


governments where the problems discussed earlier again come to the
surface. Under the law, local governments are charged with ad-
ministering the food stamp program; even though they receive federal
financial assistance for this purpose, local governments often must
supplement from their own budgets, operate with limited staff, and
handle an overwhelming load of recordkeeping. The resentment and
frustration they feel often is vented on the Indians who are obliged
to deal with them.
There are weaknesses in the stamp program, and there are still
other weaknesses in the commodity program. Neither of them, alone,
is adequate to the task of nourishing American Indians. Skilled use of
the best of both has never been attempted. Instead, in mid-1973, the
commodity program was terminated, leaving the decade-old stamp
program as the only federal food-supply source for the Indian popula-
tion. Use of stamps was to be "nationally implemented," according to
the USDA, within a year, except where it proves "impossible or
impracticable." This is the exact situation in many Indian areas, where
applicants encounter a series of barriers much like those they have
always faced in attempting to avail themselves of federal services.
The federally-controlled environment in which Indians live has
never at any time been conducive to the practice of good nutrition.
Rather, the environment discourages such practice in every particular:
Non-existent or bad roads isolate much of the population from food
supplies available only at great distances away. Monopolistic trading
post suppliers overcharge the Indian customers who are able to reach
them, and sell food of questionable quality and poor nutritional value.
In many Indian homes, there is overcrowding, no running water,
inadequate or inappropriate cooking facilities, no electricity, no bath-
room, no refrigerator-and no breadwinner.

RECOMMENDATIONS
1. The Task Force recommends that the American Indian be
allowed to share with the general population the privileges of feeding
his own family rather than having a federal agency do it for him.
2. The Task Force recommends that American Indians themselves
conceive and administer their own plan to feed and nourish their
people.
3. The Task Force recommends as a minimum a drastic upgrading
in offered programs. It strongly recommends the creation of a new,
innovative system which eliminates the weaknesses and combines
the best features of all previous and existing programs.
REFERENCES
Moore, William M. and Silverberg, Marjorie M. and Read, Merrill S.: Nutrition,
Growth and Development of North American Indian Children. DHEW Publica-
tion No. (NIH) 72-26.
National Council on Hunger and Malnutrition and the Southern Regional
Council: Hunger USA Revised, a Report by the Citizens' Board of Inquiry Into
Hunger and Malnutrition in the United States. No date.
The Ages of Hunger: A Report on the Operation of Federal Food Programs,
Phoenix, Ariz., June 1972.
White House Conference on Food, Nutrition and Health, Washington, D.C.,
May, 1969.
Walker, Hazelle N.: Statement Before the Health Task Force, American Indian
Policy Commission, Phoenix, Ariz., April 20,1976.






67

USDA, Food and Nutrition Service: Donated Foods Distributed by Outlet,
Quantity and Cost, Washington, D.C., August 22, 1973.
Yuetter, Clayton: Statement Before the Subcommittee on Agricultural Re-
search and General Legislation Committee on Agriculture and Forestry, U.S.
Senate, March 27, 1974.
Ratified American Indian Treaties that Include Payments in Food.
Governing Council of The American Public Health Association: Education for
Health in the School Community Setting, a Position Paper. April 1, 1975 (New
Orleans).
Federal Trade Commission: Six Proposed Complaints Against McGee Traders,
Inc., Washington, D.C., Feb. 20, 1974.
Federal Digest: Nutrition Program for the Elderly, Title VII, DHEW Social
and Rehabilitation Service. Vol. 37, Number 126, August 19, 1972.
United States Department of Agriculture, Food and Nutrition Service, Famnily
Distribution Program: Quantity and Estimated Cost of Food Recommended for
Distribution, Washington, D.C., October 1, 1973.
USDA, Food and Nutrition Service: Food Stamp Certification, Washington,
D.C., August 27, 1971.
Federal Register: USDA Food and Nutrition Service: Food Stamp Program,
January 31, 1974.
Senate Bill 2871, January 21, 1974.
Lipner, Jay C.: Guide to the Food Stamp Program, Providence, Rhode Island,
January 1974.
Code of Federal Regulations, Agriculture, Parts 210 to 699, containing a codi-
fication of documents of general applicability and future effect as of January 1,
1973, with ancillaries, revised, January 1, 1973.
McCarty, Margaret, and Stang, Alice: Statement Before the Health Task
Force, AIPRC, Albuquerque, New Mexico, May 5, 1976.









Chapter 9


MENTAL HEALTH
It is no exaggeration to suggest that all the topics covered in this
report have a causal relationship to the mental health of American
Indians. Indians have lost their lands anditheir economic base, and
their culture has been seriously undermined. They have been taught
that they are inferior and that their most precious values were false.
Epidemics and other upheavals have disrupted family and community
systems. Aggravating these conditions are almost two centuries of
autocratic, uncoordinated federal control, substandard living condi-
tions, insufficient diets, poor physical health, meager employment
opportunities, and inappropriate education.
But perhaps the principal reason for the emotional distress of many
Indians is the gap between their culture and the dominant white cul-
ture, and the strain of fruitless past efforts to close that gap. This helps
to explain the accumulated resentment and frustration which Indians
feel. Indians and non-Indians alike are beginning to see the futility of
assimilation attempts. In the words of Carl Gorman, a Navajo, "the
Anglo culture is very different from the Navajo, and the Anglo ap-
proach will not always work. We have to acknowledge to ourselves
that our philosophy is different than that of the white man."
Manifestations of emotional disturbance among Indians were first
reported in 1928 by the Meriam investigators who described "exces-
sive use of alcohol, high accident rates, child abandonment, and poor
social and school adjustments." In 1955, a Public Health Service
report revealed that no facilities for psychiatric care were available
to Indians beyond institutionalization in asylums, newly named
"mental hospitals." The few medical social workers serving Indians
were not sufficient enough in number to meet "minimum require-
ments," according to the report. The function of these workers, more-
over, was limited to dealing with tuberculosis patients, mothers and
children with problems of physical health, and the aged, handicapped
or abandoned.
The Public Health Service investigation focused on general health;
mental health was given only cursory attention. No psychiatrists
were included in the study's clinical teams which examined sample
reservation populations. Some NIMH staff subsequently visited the
area, but "because of the shortage of time, it was not possible to col-
lect and develop quantitative data," the report stated. Two pages in
a report total of 327 were devoted to preliminary findings: excessive
alcohol consumption, high accident and violent-act rates, child aban-
donment, and desertion. "There appears to be especially intense
frustration," the psychiatrists said. They recommended an epidemio-
logical study of Indian mental health problems and, at least in theory,
showed themselves to be culture-sensitive to the unique Indian
setting."
(68)





69


They suggested that Indians' traditional concepts toward mental
illness be taken into account in treating them; that local culture-
conflict circumstances creating tension be relieved; that staff working
with Indians be oriented to Indian values and standards; that staff
avoid imposing foreign standards upon the Indians; that personnel
working in non-health federal agencies serving Indians be similarly
oriented and cautious; that institutional commitment be eliminated,
and that when it became necessary, "humanitarian and legal consid-
erations" be made. These recommendations, made in the mid-fifties,
are still valid today, but, as will be seen, they are far from being
implemented.
By the 1960's, the stigma attached to emotional illness had become
much less, and physicians were becoming more enlightened regarding
mental illness. The specialty of psychiatry was becoming increasingly
popular. Terms had been defined; methods of treatment were devised;
drugs for the specific "cure" of certain kinds of mentally disturbed
patients were being manufactured in great quantity. But, as with
general medical care, therapy for American Indians was lagging
behind. However, psychiatric morbidity among the Indian population
was being documented for the first time. The statistics were startling:
The alcoholism death rate of Indians ranges from 4.3 to 5.5
times higher than the United States all-race rate.
Two-thirds of these alcohol-related deaths are the result of
cirrhosis of the liver; 30% result from alcoholism itself; the
remainder are due to alcoholic psychoses.
The arrest rate for alcohol-related offenses is twelve times
that of non-Indians.
Alcoholics frequently die in jails as the result of delirium
tremens, internal bleeding, head injuries, pneumonia or suicide.
The American Indian population has a suicide rate about
twice the national average. These rates are highest in the young-
to-middle years, while rates for all races are highest in older
adults.
The Indian homicide rate is almost three times the national
average.
The high accident rate is closely correlated to use of alcohol.
Broken families, divorce, juvenile delinquency, illegitimacy,
child neglect and abuse have become common in a population
where they had rarely existed before.
Alarmed by these figures, Indian Health Service met in 1964 with
Indian leaders, mental health professionals and federal officials to
discuss solutions to the growing mental health problems of Indian
people. All agreed that Indian Health Service should begin to provide
mental health services, but there were differences over the definition
of mental health; over whether and to what extent Indians should
be involved; and whether service should begin, urgent as needs might
be, without first collecting basic epidemiologic information.
When Indian Health Service received a $100,000 Congressional
appropriation in the following year, it was decided to begin a pilot
program devoted to planning and data-gathering at the Pine Ridge
Reservation. Over the next ten years, mental health facilities of limited
scope were established for the eight regional areas in which Indian
Health Service was already providing general health care. With a few





70


exceptions, no mental health programs (or general health care), even
today, are reaching the balance of the Indian population, about 50%,
which lives off reservations in either urban areas or in tribal settings
never federally-recognized.
Indian Health Service mental health programs are distinctly
separate, administratively, financially and geographically, from the
Indian Health Service facilities for general health care, with resulting
advantages and disadvantages. Heading up each area mental health
program is a chief who reports to an area director. Two of these chiefs
are psychiatrists; three are social workers; three are public health
nurses. National headquarters for this modest mental health program
is in Albuquerque, New Mexico. It provides clinical, research, training
consultative and administrative resources to all twelve area programs.
At this early stage, each of the areas is able to provide only a fraction
of needed services because of severe understaffing and, as mentioned
earlier, they are reaching in most cases only those Indians who live
on recognized reservations. A comprehensive needs-assessment has
never been made, with the result that services are being delivered on
a random basis, with limited resources and funds.
Hospital care for those who require it is adequate in only two areas,
where there are separate wings for psychiatrically disturbed patients.
In other places, these patients are placed in any available bed, generally
with unsatisfactory results. This method adds to the hospital staff's
workload, complicating nursing routines, and confronts the staff with
a situation it is not trained to handle. Tension arises between Indian
Health Service general staff and mental health staff. The situation is
tolerable for short term crises such as detoxification or depression, but
is totally unsuitable for violent, manic, or chronic cases. The alter-
native currently being used is contracting for private, state or local
hospitalization. These facilities, however, are normally used only by
non-Indians, and discriminatory attitudes on the part of staff are both
explicit and implicit. In addition, this alternative necessitates separa-
tion from family and supportive counseling from mental health staff;
there are often great distances and expenses involved, and follow up
care is difficult once the patient returns home.
Direct psychiatric therapy for patients in acute crisis or with
chronic emotional problems is provided on a severely limited basis.
Psychiatrists are in short supply and their skills are needed in broad
programs of prevention, support, and education in the community as
a whole. Social workers and psychiatric nurses are also scarce. Few
area programs have sufficient skill or staff to train interested Indians
to take on some of the community work.
The paraprofessional mental health worker, whose parallel in general
health care is the community health medic or aide, carries a large
portion of the workload of a mental health clinic. Without him, the
program could not work at all. He is trained briefly at Desert Willow
Training Center in Arizona. He then returns to his community to
counsel, handle crises, provide transportation, do administrative and
liaison work, and any other problems which confront him. The needs
are such that all areas could make good use of many more such workers.
There is a need for training programs locally situated with locally
applicable curricula.
Indians themselves have managed alcoholism treatment programs
from the beginning, because they were funded as demonstration








projects by sources other than Indian Health Service. When it is
requested, Indian Health Service mental health personnel support
these programs with counseling, and they provide acute detoxification
resources when possible. If funding is terminated, however, and if it
should become necessary for Indian Health Service to take over these
vital programs, its money and manpower would have to be diverted
from the other mental health services it now offers.
In the Portland area, a model suicide prevention program has been
established for high-risk Indians who receive supportive, coordinated
care from Indian Health Service mental health staff, Indian volunteer
counselor attendants, community health representatives, social
workers, and VISTA volunteers. But there is a need for knowledge
about the specific patterns in Indian culture which result in suicide
behavior, since these vary greatly from tribe to tribe, and there is a
need for education of non-Indian other-agency employees to an
awareness of suicide vulnerability and warning signals.
Improvements in the total environment are crucial if the mental
health of the Indian population is ever to get better. Culturally-
inappropirate education, unemployment, and overdependency on the
federal government to supply life's necessities have created among the
Indian people a passive, hopeless attitude. Deprived of control ovei
their own destinies, Indians develop feelings of helplessness and
unworthiness; many become depressed. According to Dr. H. C.
Townsley, Chief of IHS Mental Health Programs, the alcoholism,
violent behavior and fatal accidents occurring so often in Indian com-
munities are outlets for this depression.
Psychiatrists who work with emotionally-disturbed Indians are
more and more coming to believe that the traditional methods prac-
ticed by Indian medicine men can be especially helpful in coping with
these problems. Medicine men are regarded by many as the natural
healers in Indian communities, and they also can provide manpower for
understaffed IHS personnel.
"Medicine men excel in the prevention and treatment of mental
and psychosomatic illness," says Dr. Townsley. "The mental health
staff of IHS have learned to join forces with them whenever possible.
Consultation with traditional healers help IHS doctors better under-
stand the needs of their patients." Townsley refers patients to medi-
cine men who are traditionally-oriented and who are suffering from
depression. He feels that they can be better treated in a medicine-man
ceremony than by western-style, symptomatic-based therapy.
Dr. Robert Bergman, a non-Indian psychiatrist who formerly
headed IHS' mental health program, said after working with medicine
men for several years that he came "to realize that we have more in
common than we first thought."
A training program for medicine men was established in the Navajo
Nation in the late sixties with funding from NIMH. Indian medicine
men draw salaries for their teaching, and students earn a small hourly
allowance for their study time. Today, medicine men are a vital link
in IHS' mental health programs helping Indian patients cope with
emotional disturbances. It is hoped that an experimental medicine
man program can be developed to determine whether healing cere-
monies could have an impact on Indian alcoholism, a major
problem on most reservations.






72


There is still some resistance among both Indians and non-Indians
to the use of Indian medicine men. And there is even resistance to an
integrated use of both traditional and Anglo methods, as is done in
the Navajo program. But there is little doubt that traditional Indian
therapy can be an effective mental health tool in Indian communities.
The medicine man, in providing a structure for the development,
support and affirmation of cultural identity, can hopefully revive
Indian pride in their tradition and heritage.
"Traditional healers have been treating people for thousands of
years," writes psychiatrist Claudewell Thomas in an NIMH publica-
tion, "and they come from a tradition considerably older than medical
practice. Whether they become a natural resource for mental health
workers depends on whether we pay attention to their existence."
Or as Jerome Frank phrases it in the same publication: "Cultural
differences lead people to look at the world in differing ways. Cultural
differences lead people to define health and illness differently, and
consequently to require different methods of treatment to cure their
illnesses."
American Indians themselves want to heal their people, using their
own religious and cultural resources. But they need access to federal
resources, appropriate to them and chosen by them, until this is
accomplished.
RECOMMENDATIONS
1. Services aimed specifically at families and children are generally
provided in a piecemeal fashion, when what are needed are therapeutic
and residential treatment centers, together with family therapy
workshops staffed by specially trained professionals. Family and clan
are strong traditional elements in Indian culture, and half the Indian
population is under twenty, with most of that half under the age of
fourteen.
2. A model dormitory project in one area has been a successful alter-
native to the traditional Bureau of Indian Affairs boarding school
system, which is generally insensitive to emotionally disturbed
children and is not sufficiently staffed to cope with them. In the
Bureau of Indian Affairs boarding school in Window Rock, Arizona,
when the mental health facility provided additional staff trained to
work with children, the results were impressive. Successful use of
Bureau of Indian Affairs schools for severe cases, as an alternative
to distant reform schools, has also been used in areas when it is feasible.
There is need for a special treatment program aimed at troubled
Indian youth and their families.
3. There are many in the Indian population who are retarded, handi-
capped, partially or totally deaf or blind, with special problems of
adaptation and survival. In addition to surgical restoration when
appropriate, these sensory-deprived Indians, and their families, need
special counseling and support in coping with their unique problems.
Specially-trained staff is needed to carry out such programs.
4. Mental health staff sees as one of its important functions consulta-
tion with personnel in other federal agencies providing services other
than health to Indians. Mental health staff indicates a readiness for
consultation and training, but constant personnel turnover in these
other agencies is a continual obstacle, and the little guidance which
mental health staff can provide is usually limited to a single contact






73

involving a single case. We recommend a program of interagency
consultation, coordination, and training.
5. Integration of traditional Indian medicine with non-Indian psy-
chotherapeutic methods is being tried in a special Navajo project
funded by NIMH. In other areas, however, this approach has met with
limited success because of resistance on the part of both Indians and
non-Indians, and because not all tribes have a reserve of medicine
men. But there is little doubt that traditional Indian therapy is an
effective mental health tool in the Indian culture. We recommend
that medicine men be added to the staff of each Area Mental Health
Program.












Chapter 10


TRADITIONAL INDIAN MEDICINE
Often discussed, "traditional" Indian medicine is perhaps the least
understood aspect of all the phenomena relating to Indian health.
Volumes have been written about Indian healers and "medicine men,"
in every case, or at least nearly every case, by non-Indians with vary-
ing degrees of insight and understanding. Attitudes of non-Indians
have varied from contempt and rejection to vague, poorly defined,
imperfect comprehension of the forces and concepts involved in tradi-
tional Indian care and healing.
Many non-Indians coming into contact for the first time with Indian
healers were impressed with the skill and success of Indian practi-
tioners. Others were less impressed, especially with failure of the
medicine man; and some even thought that medicine men were overtly
fraudulent. Present experience suggests that traditional Indian medi-
cine is at its lowest ebb and enjoys practically no esteem by non-
Indians, certainly among academic medical leaders. This decline in
the reputation of traditional medicine arises not only from the de-
terioration of traditional Indian life but from a concomitant movement
acting strongly in the opposite direction: scientism.
The basing of American medicine on scientific and experimental
observation has provided enormous success and advancement in a
variety of fields. This movement has been emphasized at the expense
of other approaches to truth, which have suffered as a result of the
emphasis on scientism. As part of the general confusion regarding
traditional Indian medicine, even the terms used to describe tradi-
tional Indian medicine are not entirely satisfactory.
The term "traditional" ordinarily refers to practices and beliefs
antedating and little influenced by "non-Indian" medical beliefs and
practices. The usual image produced in people's minds of the "medi-
cine man is a kind of religious, spiritual, counselor-healer who de-
pends upon superstitions, incantations, and prayers for supernatural
success. The term "shaman," referring to a priest who uses prayer and
divine intervention for curing illness, tends to have a rather dis-
reputable connotation. The public has not generally recognized that
the success of "scientific" medicine does not negate the inherent value
and success of traditional medicine.
Like so many aspects of Indian life, "traditional Indian medicine"
suffers from unwarranted generalizations. It is not commonly ap-
preciated that in pre-white times, Indians possessed considerable
knowledge of hygiene and practiced many daily beneficial health
habits. Use of certain resins from evergreen trees for dental hygiene,
and the mastication and partial digestion of certain foods which are
then fed to babies are examples of simple health measures practiced
by Indian people.
(74)






75


Certain questions arise relative to traditional Indian medicine and
its place in present Indian health. What is traditional medicine? Does
it have a role in Indian health? Is it a positive or negative force for
improved health in Indian communities? What is the extent of present
traditional Indian medicine being practiced? Should it be encouraged
or discouraged; or allowed to disappear by attrition along with so many
other cultural attributes of Indians? Are there ways that traditional
medicine and modern medicine can complement each other?
The nearly universal characteristic of a medicine man is one who
either possesses a special "power" or one who controls a special
"power" derived from some other source. More recent studies such as
that by Basso for the Western Apache are increasing our understand-
ing of the resources and important distinctions between medicine men.
Basso describes the great variety of "powers" that exist for the Apache
and supports the view that the "power" that medicine men possess
can be used secretly and to do harm.
There is also an heirarchy of power, from mild to strong, in com-
parative terms approaching that which is holy or sacred; hence, the
very close association with religion.
Basso also points out that the Apache are very clear about what
"power" can do, but cannot define it precisely and even feel that it
may defy definition.
There seems to be a general idea that the medicine man is practicing
a form of psychiatry. This is often discussed in a somewhat grudging
tone as if it were perhaps permissible to allow Indian patients suf-
fering from emotional stress or conversion disorders to visit a medi-
cine man so long as he did not interfere with modern techniques.
Perhaps this arises in part from the stated Navajo version of disease
being a result of disharmony between a person and some part of the
universe. Even so, the general tendency to confine Indian healing to
the area of mental health is much too narrow and confining and al-
together misses the point that Indian medicine makes no distinction
between physical and mental illness. This latter view has the advan-
tage of being a synthetic and holistic approach. Perhaps a great deal of
Indian medicine derives its appeal from this more comprehensive con-
cept of disturbed function. The value of litany and ritual symbolism
in medicine needs no further elaboration in this discussion. It is worth
pointing out, however, that although this topic is discussed a good
deal, it is certainly suppressed in scientific methodology. Indeed,
when discussing those vestiges of ritual present in scientific medicine,
professors ordinarily do so in terms of derision. It is little wonder
that the greatest complaint against physicians is that of coldness and
impersonal manner-just the opposite of the prolonged and elaborate
healing rituals conducted by medicine men. The very duration of the
traditional practice makes it "impractical" in the hustle and bustle of
everyday American life.
In the late eighteenth and early nineteenth centuries, the impact of
Indian medicine was very great, not only upon American medicine,
but also in Europe where many books were written about Indian
medicine and practices. It is likely that, had not science and technology
supervened, a great school of American Indian medicine would have
been developed. The story of Catholic priests learning of the use of
cinchona bark to treat malaria from Peruvian Indians is the best known
example of the effective use of Indian herbal medicines. This dramatic
78-188-76---6






76

use of an Indian remedy was a great stimulus in the attraction of
physicians to Indian remedies. Clearly, Indian healing was superior
to the purges, sweating and excessive bleeding commonly used by non-
Indian healers at the time of the discovery of America.
It was common for specialization to occur also, either as a result of
training or of a vision quest. For example, the great-great-grandfather
of one of the task force members was especially skilled in the treatment
of spider and insect bites. Thus, there are several different kinds of
medicine men.
One of the striking features of Indian healing is the similarity of
many of the circumstances associated with healing throughout tribes.
Some of these similarities include a requirement for gravity and serious-
ness on the part of the healer. In nearly all instances, this arises not
only from years of study but from danger and retribution directed
toward the healer, if he puts his skills to work for the disadvantage of a
person. Thus, the great Man Mamanti died suddenly a short time
after using his power to put Kicking Bird to death, in this instance
with knowledge of his own doom, since the worst abuse of special
healing power was to put someone to death.
Cupping and suction also seem to be nearly universal methods of
healing, and not confined only to the Americas. This universality is a
curious phenomenon. It is still a common practice among the Kiowa.
In this practice the healer (either a man or woman) listens to a history
and makes a brief examination over the affected part.
Among this tribe, the healer often examines the patient through a
black silk kerchief which permits the healer to visualize the abnormal-
ity. A series of superficial lacerations are then made in the skin over
the affected part, and suction applied through a hollowed-out buffalo
horn. Suction for some minutes is maintained by inserting resin or
clay (chewing gum is now the preferred material) into the hole in the
horn. This may be repeated a few times in the same area in which
several milliliters of blood are removed. In earlier days, it was not
uncommon for small "stones" to be removed by suction. Relief is
usually immediate. There are many testimonials to the effectiveness of
cupping and suction in the treatment of cases of pneumonia given up
as hopeless by physicians. Some form of recompense or payment to
the healer is also a universal requirement, except in the case of a near
relative.
In areas where peyote is used as part of the Native American
Church, it is commonly used as a medication also. In Oklahoma, it is
often used as a remedy-for influenza-like illnesses. This use is entirely
separate from any religious or hallucinogenic properties of the plant.
Ackerknecht has provided by far the greatest insights into tradi-
tional aboriginal ("primitive") medicine and its place in society. This
author is clearly distinguished from the phenomenal scholarship
exhibited, coupled with unusual perceptions relating to health and
practitioners. From his works, it is possible to formulate certain
axioms relating to "traditional" medicine. These may be summarized
as follows:
1. "Primitive" medicine was/is successful. Although no current
comparisons are available, there is abundant evidence that "primitive"
systems were at least as successful as "modern" techniques. In some
areas, such as treatment of snakebite and management of deliveries,
"primitive" medicine was decidedly superior to "modern" medicine.






77


It appears that the tremendous technological advances of the past
have produced such outstanding successes that a new vista of care
has opened for which there is no "primitive" counterpart (for example,
repair of heart defects). It is not reasonable to expect that "primitive"
medicine can deal satisfactorily with new situations of this sort just as
Indian medicine men could not satisfactorily deal with all the new and
strange diseases introduced by the white man. What is most significant
is that the activities of "traditional" Indian medicine be adapted to
the changing character of illnesses. It is short sighted to expect that
Indian medicine men would not have a crucial role to play in patients
undergoing open heart surgery, for example. There is reason to believe
that medicine men would be quite successful in counter-balancing the
stressful aspects of dramatic and fearful surgery. Such a program
would involve considerable interchange between the surgeon and the
medicine man.
5. Primitive medicine is much more a function of society than it is
of biology. That is, what is defined as disease is determined by the
society and not by the fact that a biological dysfunction is present.
Actually, there is probably more of societal determinism occurring in
modem medicine than is generally appreciated. However, Ackerknecht
discusses this topic in terms of the very real contribution of Indian
medicine to the preservation of the integrity of Indian society. The
idea that diseases were generated by violation of rules of society served
as a strong force in keeping persons within the limits of the rules
prescribed by society.
In brief, Ackerknecht makes the point that primitive medicine rep-
resents an approach to life derived from cultural characteristics of
given groups, and serving a much broader purpose than does modern
medicine. Primitive medicine men and modern physicians are not dif-
ferent stages of development along the same track, but are actually
alien to each other. We may infer further that based on these obser-
vations, it simply makes no sense to compare "traditional" and
"modern" medicine. One will be fundamentally different from the
other. It is characteristic of modern America that this difference will
be interpreted as inferiority, a judgment which undoubtedly springs
from some emotional or personality need of the dominant society.
6. In a great many primitive cultures, there is often an aspect of
magic even in the application of an herb. The "spirit" of the herb
fights against the "spirit" causing the disease. It is not uncommon to
rub an herb over an affected part in addition to its internal use.
Shamanism
The term "shaman" is not a very satisfactory one. This problem
of insufficient terminology to discuss the important aboriginal dis-
tinctions is nowhere so obvious as in attempting to describe medical
conditions. The term "shaman" is from Russian and refers to a
Siberian man of power capable of divining and prophesying, and is to
be clearly distinguished from medicine men, in the sense that the
shaman was and is a very special kind of medicine man, often using
ventriloquism as part of his procedures.
Loeb differentiates between the shaman as a person voluntarily
"possessed" through whom a spirit speaks and who also carries out
exorcism; and the seer, a "non-possessed" man with whom the spirit
speaks and does not exorcise or prophesy. Loeb found that the seer






78


historically antedated the shaman. He also found that some societies
possessed both types of men of power, and that, of course, the two
classes were not always mutually exclusive.
Another characteristic of the shaman was the passing through of
what can only be interpreted as a profound mental disturbance (by
contemporary standards) as part of preparation for shamanism with
an apparent "cure" occurring as a person became a shaman. This
seems to have a great deal of similarity, although perhaps consciously
stylized to a more intense form, to the vision guest which was often
associated with "abnormal." Behavior such as alternating sadness and
rage as well as actual flagellation equivalents. The pre-shamanistic
psychosis has been described among the Eskimo medicine men. At
any rate, the term "shaman" is a very special and exact one, which
is much too loosely applied to medicine men in general.
Ackerknecht points out that there is no primitive distinction be-
tween natural and supernatural. This distinction appears to be an
interpretation (artifact?) of modern man. Ackerknecht also points out
that perceptions of real and non-real, natural and supernatural are
simply ways of dealing with the world that are mediated by the cul-
ture under consideration. He quotes Kroeber: "What high cultures
stigmatize as purely personal, non-real and non-social, abnormal and
pathological, lower cultures treat as objective, socially useful, and
conducive to special ability." He goes on to point out that concepts
of causality engendered by such dichotomous cultures will obviously
be quite different, perhaps even opposites. The only criteria for nor-
mality of behavior must be whether a given cultural trait is func-
tionally useful for the preservation and well being of the group. There
is general consensus that American Indians were succeeding quite well
before the advent of the white man. One may conclude, then, that
their practices, including medical practices, must be viewed as suc-
cessful and normal for the given group.
Although Ackerknecht's discussions are invaluable in providing
truer understanding of "traditional" medical concepts and practices,
his work has never been "popularized" in the sense of being widely
read outside the academic community. His work also is that of an
observer, not a participant. It remained for Castaneda to correct these
two deficiencies. In his series of monographs, he has for the first time
made available to a wide audience invaluable experiences relating to
Indian medicine men. Castaneda's accounts are of intensive periods
of apprenticeship to a Yaqui medicine man. Castaneda correctly re-
gards the Yaqui, Don Juan, as a "man of power." Don Juan is not
described specifically as a man who treated disease as such, yet there
can be no mistaking the identity of his "power" as identical to that
of medicine men, varying only in minor ways. Don Juan clearly under-
stands human life and personal and interpersonal relationships in spe-
cial ways. This understanding does not differ from that of medicine
men.
It is clear that the powers of Don Juan die in the realm dismissed
disdainfully by scientists as fraud, "witchcraft," or "magic." There is
no question that this is true. The real question is not whether Don
Juan's powers are "magic" (i.e., "supernatural") or not, but whether
they are one, real, and two, useful. It seems to us that these two criteria
are what are paramount. It really is irrelevant that these phenomena
are not explainable in terms of present scientific concepts. There is no






79


reason why science with its limited ability can really answer questions
of ultimate causality.
Perhaps the greatest service performed by Castaneda is "structural
analysis." He describes Don Juan's power and his own experiences,
and he develops a vocabulary for describing the phenomena. He deals
with the reality of the phenomena by affirming their reality and the
fact that this reality cannot be grasped in terms of usual experience;
hence, his useful term, "non-ordinary reality."
Whether or not Castaneda's descriptions and traditional medicine
re-open Berkeley's thesis that reality and being depend only upon the
perception of the beholder, is beyond the scope of the present discus-
sion. One cannot study the subject without a strong suspicion that
Samuel Johnson, by kicking a stone, was not even relating to Berkeley.
It will be interesting to see whether or not appropriate persons will
carry the precepts of "traditional medicine" and the way of knowledge
described by Castaneda forward in time to prevent the complete dis-
solution of this uinque and rewarding approach to health.
Ev valuation of current Indian attitudes towards traditional medicine
Constrained by the inadequate time available to carry out studies,
the task force was unable to collect a statistically valid sample of
Indian opinion. However, considerable experience by task force
members and interviews with Indian people during site visits permit
certain conclusions to be made.
The most striking feature of Indian people relating to traditional
Indian medicine is a universal reluctance to discuss it. This appears to
be true in all parts of the country. Attneave has suggested that fear
has been conditioned into many Indians as a result of experience with
negative teachings by missionaries. There seems to be no reason to
doubt this. Indians also undoubtedly have perceived strong negative
attitudes against traditional healing by white physicians. Some of the
attitudes expressed by Indians are reflected in that of a young Apache
woman who believed traditional medicine should not be discussed nor
should attempts at training programs be made because of the special
"sacred" nature of Indian medicine.
Members of the Pine Ridge Health Board, when asked about tradi-
tional medicine on their reservation, replied that there really weren't
any real medicine men left and expressed little enthusiasm for pro-
grams designed to train medicine men. This was surprising in view of
the strong tradition of Yuwipi healing ceremonies in the state.
However, we did receive testimony that the Blackfeet Tribal
Health Department assumes an advocacy role in linking those identi-
fied in the community as medicine people and tribal members seeking
the services of such people. In assuming this advocacy role, the health
department is also beginning to provide an edcuation for the young
people who may not be historically exposed to traditional medicine so
that there are two health delivery systems available. Included in
plans for the proposed Blackfeet Indian Hospital is the use of the old
facility for various ancillary projects, which include "Traditional
Tribal Healers and Medication."
Dillon Platero, Director of the Rough Rock Demonstration School
of Navajo Nation, noted that the majority of the 115,000 Navajo
depend on traditional medicine for a portion of their health care and
that due to a declining economy, it has become difficult for any but a





80


very few men to undertake the lengthy training necessary to become a
medicine man. As a result, a vital force in the maintenance of the
mental health of this group is in danger of extinction.
Training of medicine men
Significant progress towards preservation of Indian traditional
medicine occurred with the establishment of the Navajo School for
Medicine Men, an account of which is given by Bergman. This school
was conceived by Navajos during the operation of the demonstration
school at Rough Rock beginning in 1965. A modified apprentice
system was utilized with each medicine man having two apprentices.
Significantly, the medicine men received a modest salary and the
students a small subsistence allowance. Thus, a critical limiting factor
(the lengthy apprenticeship during which time students bring their
families and have no income) impedingethe training of medicine men
was at least partially ameliorated: the provision of faculty salary and
student financial support.
The actual training, after some difficulty in obtaining funds, began
in 1969 with twelve trainees under a grant from the National Institute
of Mental Health. The initial training consisted of learning the shorter
sings with a plan to proceed to longer sings.
The report by Bergman is of interest from two other standpoints.
First, the medicine men when visiting the Gallup Indian Center had
a number of criticisms of care, and made recommendations for im-
provement, including the building of a hogan on the grounds. They
pointed out that the physicians could visit the patients at any time
during the medicine man's treatment program. Second, the inter-
change between Dr. Bergman and the medicine men proved to be
very beneficial. One of the medicine men was gratified to learn that a
non-Indian was wise enough to use hypnosis.
These trainees have now graduated and are working on the reser-
vation. There has continued to be some problems with funding. The
usual government bureaucracy, characteristically, is poorly equipped
to deal with training of medicine men.
The real significance of this school for medicine men is in its demon-
stration that a "modern" method of support for training can produce
medicine men without interfering in the value of the process itself.
This should make it possible to expand the program to other tribes.
Cooperation between Indian and non-Indian healers
The antithetical properties between Indian and non-Indian healing
makes misunderstanding most natural. It is not surprising that non-
Indians cannot comprehend the values of Indian medicine. This
diversity of cultural backgrounds seriously interferes with coopera-
tive programs of mutual support. There are a few instances of coop-
eration between Indian and non-Indians. There are no data to suggest
that cooperation is becoming more common. It does appear, however,
that recent graduates of medical schools are more receptive to the
values of Indian medicine. Driver mentions a white physician who
regularly referred patients to a medicine man before surgery. Shaw
relates an experience in which a medicine man was brought to a
tuberculosis hospital to perform a ceremony so that patients would not
leave. It is of interest that part of his ceremony was transmitted to
individual rooms over an intercom system! Since these early reports,
there have been more instances of cooperation, especially with the





81


Indian Health Service. It is not unusual for medicine men to practice
in the hospital setting.
However, it must not be assumed that cooperation between medi-
cine men and Indian Health Service physicians (even psychiatrists,
whom one might anticipate would be more understanding of medicine
men) is all it should be. Attneave, in a survey conducted for the
Indian Health Service, found little cooperation. She relates instances
of aversion of Indian Health Service physicians to medicine men.
One physician felt it would be unethical for him to refer a patient
to a medicine man for consultation. Attneave believes that the situa-
tion with regard to cooperation is as yet too unstable to be susceptible
to a policy statement by the Indian Health Service, but that each
service unit should be free to work out arrangements that best suit
the local situation. An example of a service unit's receptivity to a
dual medical system-"modern" and "traditional"-is found in the
Blackfeet Tribal Health Department, which reported that hospital
administrators had indicated a willingness to pay for a medicine
person's services under contract care if the hospital patient needed
such services.
It would appear, however, that personnel entering the Indian
Health Service should be screened for attitudes relating to medicine
men. Additionally, orientation programs for Indian Health Service
personnel would surely be valuable as a first step in bridging the gulf
between physicians and medicine men.
The dichotomy between physicians and medicine was discussed
at the Eleventh Annual meeting of the Professional Association of
the U.S. Public Health Service in New Orleans in 1976 by Dr. William
Niedermeier, who is a staff physician at the Indian Health Service
Hospital in Shiprock, New Mexico. Dr. Niedermeier related cases of
appendicitis in which lives were seriously jeopardized by delays in
treatment caused by taking children to medicine men.
The most significant fact relating to the cases presented by Nieder-
meier is not that the medicine man interfered with good medical
judgment but that in each instance the family took the child to a
medicine man after a diagnosis had been made. There could be no
better demonstration of which form of therapy is preferred by the
families. It is quite likely that Indians in many instances would
prefer to die harmoniously than be subject to the sterile, alienated,
barbaric practices of physicians, even if the physicians' techniques
prove to be life-saving.
There is no question but that many situations exist which traditional
medicine cannot deal with effectively; and certainly there are situa-
tions in which a three-day delay would result in death. Knowing the
evolutionary nature of Indian medicine, it is clear that case confer-
ences between physicians and medicine men would result in modifications
preserving that which is valuable in both modes of practice. However,
before progress can be achieved, it will be necessary to recognize that
there is more to the function of the medicine man than ceremony as
suggested by Niedermeier. This concept is precisely a major part of
the program.
This discussion is not to imply that Dr. Niedermeier has an incom-
plete understanding of medicine men; indeed, he may be very under-
standing. The description above is taken from a newspaper, U.S.
Medicine, for June 15, 1976, which contains an article entitled "Indian





82


Medicine Men Hinder M.D.'s" This is a report of a paper given by
Dr. Niedermeier, and as such it may not completely or accurately
reflect his own attitudes or understanding. Nevertheless, the title
and article clearly reflect an anti-Indian bias that is not justified by
the cases cited. That is, the hypothesis that the children's lives were
not saved by the medicine men was not disproved by the data presented.
Kane and Kane emphasize that to the Navajo, the Indian Health
Service physicians occupy the lowest level of a ll healers. They point
out further than many Navajos do not recognize many physician
treatment modalities as treatment at all. Delay in care and malpractice,
they say, is not caused only by the Indian medicine man. These
authors relate barriers to adequate medical care in which physicians
were responsible. It is of interest that the authors found the solution
to these problems caused by physicians to be as elusive as the prob-
lems related by Niedermeier with medicine men.
It is not possible to understand the basis for Indian-non-Indian
cooperation without a study of "The People's Health" by Adair and
Deuschle. This is an account of an encounter by the Cornell Medical
School and the Navajo tribe in the 1950's and is an important analysis
of the problems encountered by an innovating group in a foreign cul-
ture. These authors summarize some of the Navajo concepts of health
and disease and compare these with the more simplistic non-Indian
views. They make an important observation, not often enough ad-
mitted, that Navajo culture has been in a continuous state of change
and adaptation even before the advent of white society, and that plans
for innovation must take this fact into account. It is important to
recognize also that innovation is going to meet with a great deal of
resistance before the subject group accepts the innovator's precepts.
Additionally, a period of testing and evaluation must be undergone
during which alternative explanations for health phenomena may be
embraced.
Adair and Deuschle also point out the serious prejudice possessed
by physicians on the reservation prior to the 1950's.
Cooperation between traditional medicine men and physicians
was not a new concept, having been recommended by Leighton in
the early 1940's. Adair and Deuschle pointed out that the Navajo
beliefs should not prove to be insurmountable, but would have to be
taken into account if any health program were to really succeed.
These authors outline the requirements for successful cooperation
between innovators and the subjects that should serve as a model
for the Indian Health Service. These requirements are as follows:
1. Members of the donor society must have a comprehensive knowl-
edge of the culture of the society for whom change is planned.
2. Those who are planning change must be totally aware of their
own culture including its biases.
3. The innovations must meet a need felt by the recipient society.
4. The cultures of both the donor and recipient society must be
understood to be undergoing constant change.
5. Change occurs from the interaction between two societies in
contact. This requires knowledge of beliefs and attitudes held by each
in regard to the other.
6. There must be an understanding of the role that the accultured
plays in transmitting new ideas to the recipient society, especially the
more conservative members.






83

7. The political and prestige structure must be understood and its
leadership identified and cooperated with.
8. Communications between the two cultures must be facilitated as
well as between components of both societies.
Many Indians indeed have come to understand that there are areas
in which "scientific" medicine produces superior results and areas in
which traditional medicine provides insights and answers to problems
which scientists cannot address themselves. For example, ultimate
causality of many chronic and relapsing illnesses is better understood
in the context of traditional medicine rather than non-Indian terms.
White doctors are usually deficient in bestowing future protection
against disease, and indeed in general are little interested in this
aspect of medicine.
The system of healing utilized by American Indians has been much
more comprehensive, extensive and holistic than generally appreciated.
There has been a misplaced preoccupation with psychiatric aspects of
healing.
There is a striking universality of healing practices among Indian
tribes and between Indians and non-Indians. This includes such
characteristics as seriousness of benevolent intentions; establishment
of diagnosis; a concept of causality; a relatively long period of prepara-
tion; reward to the healer involving a payment of a fee. In most areas,
the Indian concept is considerably more comprehensive and holistic
than that possessed by European-American "scientific" medicine.
There is at least one demonstration project on the Navajo reservation
that illustrates the value of cooperation between Indian and non-
Indian healers. The limits of benefits of this type of cooperation are
not known and have not been explored, and are probably much more
profound and important than ever suspected.
The variety of Indian opinion in this subject area, as in so many
others, suggests that it may be impossible to secure a general Indian
consensus. For this reason alone, the Navajo program is important
as a demonstration project. It not only serves to preserve medicine
men but provides a very important educational service for Indians
and non-Indians alike by making the concepts of Navajo medicine
more popularly understood.















Part Four


THE DELIVERY SYSTEM
Chapter 11
INDIAN HEALTH SERVICE-ITS ROLE AS THE PRIMARY PROVIDER OF
HEALTH CARE TO AMERICAN INDIANS
Recent emphasis on Indian health coincided with the transfer of
the Division of Indian Health to Health, Education, and Welfare
in 1955. Since that time, although the level of Indian health has
improved along with that of the rest of the country, it is still much
below the national average. The exact role of the Indian Health
Service with respect to other federal and state health care programs
remains unclear. Theoretically, Indian Health Service programs
are supplementary or "residual" to other federal and state programs.
According to this theory, Indians have dual entitlements: one, as
citizens of the United States; and two, by virtue of treaty rights.
Thus, in theory, Indians should fully utilize all federal and state
programs and get additional benefits from Indian Health Service
which are not available to non-Indians. Following this logic, Indians
should be receiving better health care than the rest of the United
States population. Although this might not automatically result in a
better level of health than for the rest of the population, one would
expect the difference between Indians and non-Indians to be less
than it is.
Congress views Indian Health Service as a supplementary service
and, therefore, provides for limited funding; but states and counties
view Indian Health Service as the primary provider of health care
for Indians. This results in per capital expenditure for Indian health
at more than 25% below the per capital expenditure for health care
for the average United States population. The prime sufferers in
this process are the Indian people.
In order to correct this situation and its misunderstanding, the
United States Congress directed Indian Health Service to perform
four major functions under the Transfer Act of 1955. They were:
a. Provide training and technical assistance.
b. Coordinate available health resources through federal,
state and local programs for the benefit of Indian people.
c. Serve as principal federal advocate for Indian Health.
d. Provide comprehensive health services, including hospital
and ambulatory medical care, preventive and rehabilitative,
and environmental services.
Progress, by and large, has been less than satisfactory, partly due
to limited funding and partly due to ineffective management.
Indian Health Service has usually been so overwhelmed by the
crisis orientation of its activities that it has not been able to adequately
(85)






86


review the overall objectives of its program and its strategy. It
does not have a completely efficient planning, management and evalu-
ation system. As a result, the delivery of its services remains deficient.
Indian Health Service has always been funded on a categorical
basis, and it in turn funds the area offices on categorical basis. This
concept does not take into account local and regional differences and
leaves little flexibility in terms of addressing local priorities and prob-
lems. This funding method, combined with the fact that Indian Health
Service has fixed funding limits, forces it to abruptly curtail or stop
providing a given service simply because it runs out of money. After
that time, even if a person is entitled to the service, he may not
receive it because funds are no longer available. This results in an
excessive backlog of services and unmet needs. While people go with-
out services, there is little evidence that Indian Health Service has
made any effort to mobilize the resources of other federal and state
agencies for the benefit of Indian people. In addition, Indian Health
Service Service Units are not authorized to do third-party billing for
those patients who are eligible for other federal assistance.
Even after 22 years of existence, Indian Health Service has not
been able to provide health facilities to Indians at many inaccessible
locations. In many states people have to travel 60 miles; in parts of
California almost 900 miles; and in Alaska almost 1500 miles to the
nearest Indian Health Service facility. In addition, only half of the
health facilities meet even the minimum standards of the Joint
Commission on Accreditation of Hospitals.
Discrimination against Indians continues to be prevalent, and
enforcement of the civil rights of Indians is minimal. The tri-agency
agreement between the Office of Civil Rights, the Social and Rehabili-
tation Services, and the Indian Health Service pertaining to Medicaid-
Medicare continues to be ineffective and unimplemented. During the
Task Force on Health hearings at Indian Health Service, it was
determined that the Office of Civil Rights has handled only 7 cases of
denial of civil rights to Indians during the past 2,2 years. On the other
hand, the Task Force was told of several instances of implicit discrim-
ination. In spite of these contradictions, neither the Indian Health
Service nor the Social and Rehabilitation Services nor the Office of
Civil Rights has ever taken positive action to determine the exact
extent of the problem. Distribution of copies of the memorandum of
agreement seems to be the extent to which Indian Health Service has
gone in informing Indian people of their civil rights, while practically
nothing has been done by the Office of Civil Rights or the Social and
Rehabilitation Services. In addition, no effective program has been
conducted to inform state, county, and local officials about their re-
sponsibilities to Indian people.
Lack of federal initiative is evident in the area of Medicaid and
Medicare eligibility. Neither the Indian Health Service nor any other
federal agency has any idea of the number of Medicaid-Medicare
eligible Indians, or how many are actually receiving these benefits.
It can be reasonably concluded that most federal programs, unless
they are specifically earmarked for Indians, have had very little
influence on the lives of Indian people; and since Indian programs are
presumed to be supplementary in nature, they never have adequate
funding to deal with the problems effectively. Therefore, it is felt that
unless some fundamental changes take place, the level of Indian






87


health is not likely to improve. The succeeding pages of this report
discuss the issues and recommendations which will bring about the
desired change and thereby improve the level of Indian health.
Research
Biomedical and Systems research has not been among the man-
dated functions of IHS. Thus, even though there is some exciting
activity taking place in these fields, it has not been possible to ade-
quately review the research activities of IHS because of time limita-
tions. However, in the course of its study, the Task Force inevitably
developed information relating to research.
The two most conspicuous areas of formal research are the activities
associated with the Health Program Systems Center (Hipsic) and the
collaborative programs with the National Institute of Metabolic and
Digestive Diseases at the Phoenix Indian Medical Center. These
activities have led to several exciting discoveries. Among these are
the applications of satellite technology to communications, com-
puterized storage and retrieval of patient data, simplified management
of infant dehydration, medical management of gall stones, and very
significant discoveries relating to the occurrence of various diseases
among and between various Indian groups.
Recommendations
1. Preventive health care.-Every effort must be made to prevent
people from getting sick, by addressing the causes of their health
problems. These are discussed in terms of better environmental con-
ditions, better nutrition, safety and accident prevention, health edu-
cation, and preventive measures and psychological counseling.
2. Curative health care.-Once a person gets sick, it is felt that a
specific basic package of services must be provided; and that the
current method of funding be drastically revised.
3. Service delivery system.-The Indian Health Service delivery
system should be strengthened by establishing clear cut areas of
responsibility and authority. The Community Health Practitioner
program should be made the basis for the health care delivery system.
4. Support services.-Many support services need to be developed
and strengthened. These are discussed in terms of Indian self-determi-
nation, transportation and accessibility, social services, training,
Indian preference, and role of traditional medicine.
5. The Task Force strongly recommends enlargement of research
activities of IHS. It is clear that answers to certain questions may be
answered only by research within IHS. A research mission would be
one of the functions of IHS if National Health Insurance greatly alters
the delivery system.












Chapter 12


INDIAN HEALTH SERVICE-CLINICAL WORKLOAD AND UTILIZATION
OF SERVICES
An evaluation of IHS operations can only be made against the back-
ground of total clinical responsibilities. As a description of the kinds of
clinical problems is considered elsewhere, this section will deal with
clinical workloads and costs burdening IHS.
An estimate of the total Indian population for the various IHS
areas between 1965 and 1972 is given in table 1. Nearly one-half the
population is accounted for by the Oklahoma and Navajo areas. The
smallest number of patients are in the USET area. There has been a
steady increase in the total number of Indians served, basically result-
ing from population growth.
The number of hospital admissions and utilization rate are shown in
table 2. The number of admissions doubled between 1955 and 1974,
rising from 50,143 to 103,853. These data include both IHS and con-
tract hospitalizations. This increase represented an increase in rate of
utilization from 150/1000 to 212/1000 population.
The utilization rate is portrayed graphically in figure 1. During this
time, the overall utilization rate increased by 41%. Since 1965 the
utilization rate of IHS hospitals has changed little as has that for
contract hospitalizations. Data in tables 1 and 2 suggest that, if each
admission represented a separate patient (which it does not), then
nearly one-fourth of the people served by IHS were hospitalized. This
would appear to be an unusually high proportion of people requiring
hospitalization. The number of admissions to hospitals doubled be-
tween 1955 and 1974. The most striking increase occurred in admis-
sions under contracts.
Admissions and births in IHS hospitals are shown for each area in
table 3. The only significant change occurred in the Tucson program
area, which has experienced a steady decline in the number of admis-
sions. The explanation for this is not apparent, but if it has resulted
from special outpatient programs, as seems likely, then it represents
the impact that can be expected on hospitalizations if these programs
were excepted in other areas.
There are no striking changes in the number of births which would
permit one to draw conclusions, except for a drop in births for 1974,
1975 and 1976 (projected) for the Tucson program area. Again, the
significance of this change is not readily apparent.
The average daily patient load (ADPL) for each area is shown in
table 4. The usual variation between areas is expected.
The outpatient load for IHS is shown in table 5. There has been a
steady increase in outpatient visits from 1955 to 1974. The number of
visits in 1974 is over five times that of 1955.
(88)











89



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90

TABLE 2.-HOSPITAL UTILIZATION RATE INDIAN AND ALASKA NATIVES


[Fiscal years 1955-74 does not include births]
Total Indian Health Service Contract
Utilization Utilization Utilization
Number of rate per 1,000 Number of rate per 1,000 Number of rate per 1,000
admissions population admissions population admissions population

Fiscal year:
1974 --------------- 103,853 212.4 73,402 150.2 30,451 62.3
1973 --------------- 102,350 213.5 75,245 157.0 27,105 56.5
1972...--------------- 102,472 218.2 76,054 161.9 26,418 56.3
1971 --------------- 94,945 206.6 70,729 153.9 24,216 52.7
1970 --------------- 92,710 205.7 67,877 150.6 24, 833 55.1
1969----- 94,490 213.9 69,560 157.5 24,930 56.4
1968--- ----- 92,186 213.0 68,086 157.3 24,100 55.7
1967 ....---------------... 89,556 211.3 65,456 154.4 24,100 56.9
1966. --------------- 91,799 221.3 67,049 161.6 24,750 59.7
1965.---.-.-.--- 91,744 226.1 67, 744 166.9 24,000 59.1
1964 ..---- ----------- 89,934 226.7 65, 934 166.1 24,000 60.5
1963. --------------- 87,549 225.7 64,749 166.9 22,800 58.8
1962 --------------- 81,476 214.4 59,976 157.8 21,500 56.6
1961.-.---...--.--------- 74,313 195.5 54,313 142.9 20,000 52.6
1960 --------------- 76,754 201.9 56,874 149.6 19,880 52.3
1959...------------.--- 73,268 198.0 54,568 147.5 18,700 50.5
1958. --------------- 71,859 199.1 55,649 154.2 16,210 44.9
1957.-.----.....---------- 66,455 188.8 53,160 151.0 13,295 27.8
1956...--------------- 57,975 169.0 46,218 134.7 11,757 34.3
1955-.-.--- ----- 50,143 150.2 42,762 128.1 7,381 22.1


TABLE 3.-IHS HOSPITAL WORKLOAD STATISTICS BY AREA
IFiscal years, 1975,1974 and 1973]

1976 1975 1974 1973

ADMISSIONS (8 MO)
Total all areas -- ------- --50,745 74,594 73,402 75,245
Aberdeen area ...----------- ---- ---- ----.8,564 12, 906 11,930 13,820
Bemidji area ----------------------------------- 1,037 1,529 1,537 1,692
Albuquerque area-------------------- 2,040 3,486 3,560 3,443
Alaska area----.... -- -------------------- 6,414 9,675 10,518 10,667
Billings area ------- ----------------------------2,114 3,035 2,870 3,240
Navajo area---------------- 12,918 18,097 18,113 18, 286
Oklahoma City area ------------------------------ 6,726 9,886 9,349 9, 384
Phoenix area ------------------------------------ 9,003 13,206 12,808 11,842
Tucson program area----------------675 912 1,088 1,305
USET....-- --------------1,254 1,862 1,629 1,566
B IRTHS
Total all areas----------------------- ------- 6,680 9,768 9,690 9,844
Aberdeen area. --------------- 691 1,085 965 1,124
Bemidji area------------------- --- --------------- 81 125 140 141
Albuquerque area.---- --------- 106 187 320 296
Alaska area--- ---- --- ----764 1,072 1,116 1,065
Billings area... ------------------------------------ 247 338 366 369
Navajo area..------- ---------.--. 2,442 3, 514 3,315 3, 292
Oklahoma City area---..----- --------------. 1,276 1,889 1,747 1,831
Phoenix area -- ---------------------------------898 1,280 1, 384 1,411
Tucson program area----------------------- 56 100 140 134
USET----.-------- ...----------------------------- ......119 178 197 181







Rt


TABLE 4

1976 1975 1974 1973

ADPL (8 MO)
Total all areas....----------- -----.. 1,307.3 1,329.8 1,376.2 1,498.7
Aberdeen area.----------------------------------.. 174.8 173.9 166.8 207.0
Bemidji area.----------------------------------- 18.1 17.9 18.0 18.1
Albuquerque area --------.-------- ----. 65.0 62.8 72.0 77.3
Alaska area- .- ---------------- 228.5 241.7 269.7 286. 6
Billings area..------------------------------------. 43.1 39.0 41.3 50.1
Navajo area..- ---------- ------- --- 335.4 330.3 340.8 375. 4
Oklahoma City area-----------.------------------- 149.5 158.2 150.6 169.5
Phoenix area-.-- -------------- 246.7 253.4 265.3 260.9
Tucson program area--- ------------ -- 21.8 21.8 21.7 25.9
USET-.-..-.... ..-------------------- 24.4 30.8 30.0 27.7


TABLE 5.--NUMBER OF OUTPATIENT MEDICAL VISITS I TO PHS INDIAN HOSPITALS AND FIELD HEALTH CLINICS
[Fiscal years 1955-74]

Total Hospitals Field clinics

Fiscal year:
1974---......----. ---------------...------------------ 2,361,654 1,366,564 995,0919
1973.----------..----. -------.-----..-----.. ----..------- 2,329,160 1,330,660 998,500
1972.......-------------------------------------------- 2,235,881 1,275,726 960,155
1971.......--- --.- ----------------------------------- 2, 195,240 1,202,030 993,210
1970.- -------------------------------------------- 1,786,920 1,060,820 718,100
1969 --- ----------------------------------- 1,661,500 982,300 679,200
1968.....---------------.----------------------------- 1,575,440 926,640 648,800
1967-------------------------------------------------1, 494,600 849,800 644,800
1966 .....-----.- ------------------------------------- 1, 467,000 788,500 578 500
1965 -- --------------------------..-------------------1, 325,400 757,700 567, 700
1964.-------------------------------------------------- 1,295,000 742,400 552,600
1963------------- ---------------------------- 1,271,400 721,700 659,700
1962 -------------------------------------------- 1,142,300 673,200 469, 100
1961 -------------------------------------------------- 1,022,600 628,700 393,900
1960-.. --------------------------------------------.--. 989,500 585,100 404,400
1959 ---------------------------------------------- 957,900 546,900 411,000
1958 ---- -------------------------------------- 900,000 533,440 366,560
1957.. ---------------------------------------------- 650,000 510,000 140,000
1956' --------------------------------------------- 540,860 415,860 125,000
19553 ------------ ------------------------------- 455,000 355,000 100,000

Excludes visits for dental services.
Decreased because of underreporting of grouped services.
Estimate.

























78-188-76-----7










TABLE 6.-INDIAN HEALTH SERVICE OBLIGATIONS, BY ACTIVITY
IFiscal years 1966-72 (In millions of dollars)]


Direct Contract
patient Field patient
medical health medical
care services care Administration

Fiscal year:
1955--..-...----------------------------------- 15.1 3.2 5.0 1.3
1956..---------------..------.. ----------------- 20.5 4.6 7.7 2.1
1957---------.............------------------------------ 22.6 5.9 7.9 2.1
1958..----------------------- --------------- 25.0 6.9 7.7 1.1
1959..............--------------------------..------------ 25.8 7.1 8.0 1.3
1960 ----------------------------------- --- 27.6 8.0 8.6 1.3
1961 -------------------------------------- 30.8 8.9 8.7 1.4
1962 --------------------------------------- 32.3 9.3 9.7 1.4
1963....--------------------------..------------ 34.7 10.0 10.2 1.5
1964--------------------------------- 36.0 10.7 11.0 1.7
1965 -------------------------------------- 37.6 11.6 11.7 1.8
1966------------ -------------------------- 39.7 13.0 12.6 1.9
1967.--------------------------------------- 44.0 15.6 14.0 1.8
1968.--------------------------------------- 47.5 19.1 15.5 1.7
1969........--------------------------------------... 51.3 22.8 17.7 1.9
1970 -------------------------------------- 57.8 27.0 19.9 2.
1971.-------------------------------------- 67.2 32.4 23.6 2.3
1972-------------------------------------- 78.8 44.4 29.5 2.4


TABLE 7.-NUMBER OF DENTAL SERVICES PROVIDED
[Fiscal years 1955-73]

Percent
Services increase
provided over 1955

Year:
1974..... --------------------------------------------------------927,701 415.4
1973 -------------------------------------------.....------------- 863,057 379.5
1972...-- --------------------------------------------------------- 844,724 369.3
1971 -------------------------------------------------------- 776,168 331.2
1970....------------ ------------------------------------- ---- 646,580 259.2
1969...------------....------------.------------------------------- 634,479 252.5
1968---........--.- ----------------------------------------------.. 613,084 240.6
1967-----.----------- --- ------.----------------------------------- 545,509 203.1
1966 -------------------------------------------------------- 502,710 179.3
1965 .-.-----...------------.----..--------------------------------495,006 175.0
1964------...........------ -- ---- ..-------------...------------------------------- 462,981 157.2
1963.------------------------------------------------------------- 398,452 121.4
1962.-- -----------------------------------------------.. ------ ---- 364,988 102.8
1961........-- ----------------------------------...........-------------------- 348,776 93.8
1960.....----.- ---------------------.-------------.----- ---------- 307 248 70.7
1959--...------...------ -.------------------------------------- --- 283,206 57.3
1958...........---------------------------------... .-----------------------... 282,372 56.9
1957..-----------------..-----------------.----------------------- 249,048 38.4
1956..--------.----------. -------------------- -------------------- 219,353 21.9
1955-----------.-----------..----------------------------------- 180,000 ..........----