Health challenges in American Indians-Alaska Natives Essay

The American Indians and the Alaska locals have since quite a while ago encountered a lower wellbeing status than white Americans. The gathering is additionally portrayed by a lower future and an unbalanced weight of disease, maybe connected with lower training, lopsided destitution, and across the board discrimination in the transference of care administrations (Mervi, 2020). These are the wide personal satisfaction encounters established in financial hardship and destitute social conditions—the malady of the circulatory system and harmful neoplasm. Wounds and diabetes are the main sources of higher death rates in the gathering contrasted with different Americans. The American Indians and the Alaska locals keep on becoming extinct at a higher degree because of ceaseless sicknesses, liver maladies, for example, cirrhosis, attacks, deliberate self-hurts, and incessant lower respiratory contaminations.Health challenges in American Indians-Alaska Natives Essay

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The American Indians and the Alaska native should be encouraged to approve healthier lifestyles, including diminishing the alcohol intake and use of tobacco ("Disparities," 2013). The policymakers have a significant role to play, including an increasing allocation to the IHS, which has been underfunded for long periods and further making positive moves towards alleviating the greater disparities in the delivery of the healthcare services. Determining the means to end the inequalities in the delivery of services is critical for behavioral change and alleviates the significant disparities in economic and social status among Americans and further enables the IA and the AN to access better health care services (Ystanes & Strønen, 2017). The state government should consider supporting adequate health awareness initiatives among the people to enable them to adopt appropriate cultures such as exercising and eating healthier diets, which will lower mortality rates associated with diabetes mellitus.Health challenges in American Indians-Alaska Natives Essay

Positive trends and context

Despite the history of oppression of these native peoples — and negative images that often pervade American popular culture — Native Americans have much to celebrate beyond their historically important traditions and cultures, which provide a vital link to the country’s history and pre-history for all citizens.

According to the Census Bureau, American Indian- and Alaska Native-owned businesses generated $34.4 billion in gross receipts in 2007, a 28% increase from 2002. These businesses numbered 236,967, up 17.7% from 2002. The Economic Policy Institute notes that “Native Americans have increased their income and wealth through new and innovative economic development activities. For instance, tribes have increased their control over their natural resources and food systems, they have become players in the country’s energy sector, and they have begun trading with Asia.” Further, a 2013 report from the National Congress of American Indians notes:

Over the last 30 years, Indian Country has experienced significant economic growth as measured by average individual and tribal incomes. The growth is substantial. Although poverty for tribal citizens on reservation and trust land is more than two-and-a-half times higher than for the total population, poverty declined from 2000 to the 2006-2010 period by almost three percentage points on reservations, while increasing for the entire nation…. Meanwhile, tribal citizens have witnessed progress in addressing some of the most basic infrastructure disparities since 2000. In Alaska, 38 percent of tribal households in Native Village Statistical Areas lacked complete plumbing, 33 percent had an incomplete kitchen, and 34 percent were overcrowded in 2000. By the 2006-2010 period estimate, incomplete plumbing dropped by a third to 25 percent, complete kitchens increased by 13 percentage points, and the number of homes lacking a telephone was cut nearly in half.Health challenges in American Indians-Alaska Natives Essay

More than 156,000 Native American veterans had served in the United States military, as of 2010. Despite stereotypical images of gloom and decay, the population has been growing in recent years — there was a 1.1 million-person increase in the nation’s American Indian and Alaska Native population between the 2000 Census and 2010 Census, and the “population of this group increased by 26.7% during this period compared with the overall population growth of 9.7%.” It is also a relatively young population, with a median age of 29, compared to 37.2 for the general population.

In terms of preserving the cultural diversity of the United States, Native Americans have maintained non-English languages in the home at higher rates (28% among those age 5 or older, versus 21% across the population as a whole), with that percentage rising to 73% on the Navajo Nation Reservation and Off-Reservation Trust Land, in Arizona-New Mexico-Utah.

However, beyond these trends — and many others that seldom get mass attention from the non-native press and the public — there are a variety of profound political and moral challenges confronting native peoples and U.S. public officials.Health challenges in American Indians-Alaska Natives Essay

Overview of health outcomes

Native Americans suffer disproportionately from a variety of mental and physical health problems, which may largely stem from the social marginalization and high poverty rates that they experience. A 2008 study by the Urban Indian Health Board in Seattle found that urban American Indian/Alaska Native youths were three times more likely to engage in suicidal behaviors compared to whites and were twice as likely to use illegal drugs. A 2014 systematic review published in PLoS One found that rates of obesity, diabetes and heart disease were consistently higher in American Indian/Alaska Native populations compared to whites. Obesity, poor nutrition and related health problems have their own unique, complex history and explanations on tribal lands. Basic access to supermarkets, for example, continues to be a big problem.

While health researchers have paid less attention to Native Hawaiians, it appears that this population experiences similar patterns of elevated morbidity. A 2009 study by University of Hawaii researchers found that Native Hawaiians and other Pacific Islanders are among the highest risk demographic groups for heart disease in the United States.

Research limitations

Most studies of Native American health have focused on documenting problems among the population. When it comes to evaluating policies and programs that may improve Native American health, the research is lacking in many areas. The research deficit is more general for indigenous peoples globally. For example, a 2012 systematic review by researchers at Australia’s Queen Elizabeth Hospital looked at the effectiveness of tobacco cessation programs for indigenous people throughout the world, and it found only four studies on the topic, none of which identified effective interventions. There has been more research on Native American health promotion for other health outcomes — for example, a 2009 review in the American Journal of Health Promotion found 64 studies looking at interventions designed to increase levels of physical activity among American Indians and Alaska Natives. That article notes, however, that considering the high prevalence of disease such as diabetes among Native Americans, there were disproportionately few studies looking at physical activity among indigenous peoples, with a particular lack of research on urban American Indians.Health challenges in American Indians-Alaska Natives Essay

Wider health and safety context

Beyond the historical legacy of marginalization and socioeconomic factors, there are deep structural problems with the current justice system and basic public safety on tribal lands, severely affecting public health outcomes of all kinds across tribal populations. These systems are in urgent need of attention, according to a 2013 report to the President and Congress by the Indian Law and Order Commission (comprised of designated representatives of the executive and legislative branches). The report, “A Roadmap for Making Native America Safer,” is the product of multi-year hearings and fact-gathering missions across Indian country. It states that governance and justice systems must be reformed, as the “extraordinary waste of governmental resources resulting from the so-called Indian country ‘jurisdictional maze’ can be shocking, as is the cost in human lives.” The report’s authors conclude that the current reliance on federal and state justice systems is simply not working:

Ultimately, the imposition of a non-Indian criminal justice institution in Indian country extracts a terrible price: limited law enforcement; delayed prosecutions, too few prosecutions and other prosecution inefficiencies; trials in distant courthouses; justice system and players unfamiliar with or hostile to Indians and Tribes; and the exploitation of system failures by criminals, more criminal activity and further endangerment of everyone living in and near Tribal communities. When Congress and the Administration ask why the crime rate is so high in Indian country, they need look no further than the archaic system in place, in which Federal and State authority displaces Tribal authority and often makes Tribal law enforcement meaningless.Health challenges in American Indians-Alaska Natives Essay

The studies below characterize public health problems that Native American communities face and evaluate interventions meant to improve health and well-being:

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“Association of Contextual Factors with Drug Use and Binge Drinking among White, Native American and Mixed-Race Adolescents in the General Population”
Chen, Hsing-Jung; Balan, Sundari; Price, Rumi Kato. Journal of Youth and Adolescence, November 2012, Vol. 41, Issue 11, pp 1426-1441. doi: 10.1007/s10964-012-9789-0.

Abstract: “Large-scale surveys have shown elevated risk for many indicators of substance abuse among Native American and mixed-race adolescents compared to other minority groups in the United States. This study examined underlying contextual factors associated with substance abuse among a nationally representative sample of white, Native American and mixed-race adolescents 12-17 years of age, using combined datasets from the National Survey on Drug Use and Health (NSDUH 2006-2009, N = 46,675, 48.77 % female). Native American adolescents displayed the highest rate of past-month binge drinking and past-year illicit drug use (14.06 and 30.91 %, respectively). Results of a logistic regression that included seven predictors of social bonding, individual views of substance use and delinquent-peer affiliations showed that friendships with delinquent peers and negative views of substance use were associated significantly with both substance abuse outcomes among white and mixed-race adolescents and, to a lesser extent, Native American adolescents. The association of parental disapproval with binge drinking was stronger for white than for Native American adolescents. Greater attention to specific measures reflecting racial groups’ contextual and historical differences may be needed to delineate mechanisms that discourage substance abuse among at-risk minority adolescent populations.Health challenges in American Indians-Alaska Natives Essay

Socioculturally distinctive groups exhibit differing behaviors associated with disease and health. Members of a group typically share beliefs about etiologies of diseases and what actions to take in response, or "explanatory models."1 Accordingly, use of medical facilities must be considered in context.2 The decision to seek treatment not only reflects cultural, gender, and individual beliefs about etiology, but also is influenced by the meaning of seeking help. Decisions to use conventional medical, mental health, or substance abuse services also may be influenced by the general availability of such services, perceived barriers to treatment, actual access to resources and equity in services, or coercion. Individuals usually choose among several treatment options and evaluate the importance of various monetary and nonmonetary costs of treatment. Furthermore, a patient may not make an individual choice, but may follow family or community preferences, including use of alternative therapies offered by traditional healers.Health challenges in American Indians-Alaska Natives Essay

HISTORICAL FACTORS
In contrast to other ethnic minority groups now encompassed within the United States, American Indians and Alaska Natives are descendants of aboriginal peoples who had been in North America for several thousands of years prior to European contact. Archaeologists, physical anthropologists, linguists, and ethnohistorians continue to accumulate knowledge about dates and paths of migrations, which are presumed to stretch from the northeastern portions of Asia, across the Bering Straits, and into the "New World" of the Western Hemisphere.

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Suggested Citation:"19 Health Status of American Indian and Alaska Native Women." Institute of Medicine. 1994. Women and Health Research: Ethical and Legal Issues of Including Women in Clinical Studies: Volume 2: Workshop and Commissioned Papers. Washington, DC: The National Academies Press. doi: 10.17226/2343.×
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Status as the "First Americans" is a matter of considerable pride, and, as indigenous peoples, American Indians and Alaska Natives point to the sophistication and complexity of their societies at the time of European contact. Although some were nomadic hunters and gatherers living in groups of 30 to 100, others were members of more numerous tribal groups of sedentary agriculturalists who tilled fields of domesticated plant foods and had political structures that forged alliances between settlements. Still others were organized into larger and more socially complex groups, with massive ceremonial structures, elaborate artistic motifs, and extensive trade relationships with groups at distances of up to a thousand miles.Health challenges in American Indians-Alaska Natives Essay

EARLY IMPACT OF DISEASE AND A LEGACY OF DISTRUST
All aboriginal societies had healers who aided the sick, and in such a context distinctions between religious practices and health practices, as understood by most white Americans, are a largely artificial dichotomy. However, these traditional ministrations had little effect on the variety of diseases introduced by Europeans. "Old World" diseases included "smallpox, measles, the bubonic plague, cholera, typhoid, pleurisy, scarlet fever, malaria, yellow fever, diphtheria, mumps, and whooping cough, and probably typhus and syphilis." Epidemics were recurrent, and accompanying them were ''direct and indirect effects of wars (and genocide), enslavements, removals, and relocations, and the destruction of 'ways of life' and subsistence patterns. . . ."3 For example, smallpox had a profound impact on mortality in children under age five, fetal loss and infertility in women, and possibly infertility in men.Health challenges in American Indians-Alaska Natives Essay

Depopulation from morbidity and mortality also led to general social disorganization and breakdown in performance of social roles. An epidemic of measles that occurred within the last quarter-century in a South American aboriginal group with no immunity provides a glimpse of deteriorating conditions that occurred in the wake of smallpox (and other) epidemics from the seventeenth to the nineteenth century. Caring for children, obtaining food, tending the sick, and attention to sanitary conditions were sufficiently disrupted to increase morbidity and mortality.4 Previously healthy women and men were so demoralized that many turned their backs, assumed a fetal position in their sleeping hammocks, and awaited death.

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Native people recognized that diseases followed encroachment of Europeans, and most believed that epidemics were spread deliberately. For example, major smallpox epidemics occurred during the mid-nineteenth centuries, when "missionary barrels" containing clothing and blankets formerly used by persons infected by smallpox ("fomites") were sent to needy and unsuspecting remnants of displaced tribes. Between 1829 and 1833 outbreaks of malaria decimated coastal native settlements from Vancouver southward to California and

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Suggested Citation:"19 Health Status of American Indian and Alaska Native Women." Institute of Medicine. 1994. Women and Health Research: Ethical and Legal Issues of Including Women in Clinical Studies: Volume 2: Workshop and Commissioned Papers. Washington, DC: The National Academies Press. doi: 10.17226/2343.×
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also those located in the Columbia River basin.5 Other historical factors have promoted mistrust. For example, forced assimilation is a highly sensitive issue. Between 1969 and 1974, 25 to 35 percent of American Indian children were placed in institutions, foster care, or adoptive homes. In 1969, it was reported that 85 percent of Indian children in foster placements were in non-Indian homes. Passage of P.L. 95-608 in 1978 (the Indian Child Welfare Act) now requires placement of children with Indian families through tribal authorities.6

Placement in off-reservation boarding schools began in 1879.7 Both male and female children attended these schools, usually beginning at puberty. Boys were taught to be farmers, girls, to be domestic servants. Use of native languages was discouraged, even during recreation and leisure; all pupils wore uniforms. Garments worn by girls were especially designed to deemphasize feminine characteristics and to protect chastity. No personal adornments were permitted, specifically native crafts and hairstyles. Although young people rebelled against regimentation, these experiences permanently marked their perspectives on Indian-white relations. These affronts to Indian identity are still serious issues. serious issues.Health challenges in American Indians-Alaska Natives Essay

RESERVATION LIVING CONDITIONS
More than two decades ago a landmark five-year demonstration project disclosed the impact of a comprehensive system of primary care services on a previously underserved remote American Indian community.8 Located near the center of the Navajo Reservation (about 23,000 square miles), Many Farms had a population of about 2,000 persons, most of whom spoke no English. Typically, matrilineal extended families of about 15 persons ("outfits"), comprising an older woman and her husband, their daughters and sons-in-law, and grandchildren, resided in a harsh environment in isolated, poorly ventilated, one-room wood and mud dwellings with dirt floors ("hogans"). About 20 percent of income came from "welfare" sources, and there was a commodities distribution program. Shepherding, odd jobs, weaving, and silver working were major sources of earnings, which for households were $586.00 per year ($147.00 per person) in the early 1960s. Indigenous curers, or medicine men, received respect and much traditional culture was preserved.Health challenges in American Indians-Alaska Natives Essay

Tuberculosis and other respiratory disorders were common. Rashes and fly-borne infectious diseases, such as enteric diseases and trachoma, were promoted by the lack of latrines and ubiquity of domesticated animals. Trauma and severe burns, typical in rural areas, were frequent. Chronic diseases included congestive heart failure, gall bladder disease, and arthritis.8 Both the birthrate (4 percent increase per annum, or 45.8 per 1,000) and infant mortality rate (55 percent of deaths occurred in the first year of life) were high, and the median age was 15 years. Thus, Navajos at Many Farms three decades ago exhibited a

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Suggested Citation:"19 Health Status of American Indian and Alaska Native Women." Institute of Medicine. 1994. Women and Health Research: Ethical and Legal Issues of Including Women in Clinical Studies: Volume 2: Workshop and Commissioned Papers. Washington, DC: The National Academies Press. doi: 10.17226/2343.×
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demographic profile now associated with Third World nations. The closest hospital was 55 miles away, one-half of births occurred at home, and hemorrhagic complication of pregnancy was one of the major health problems of women ages 15 to 44. A handful of public health nurses gave smallpox immunizations in school clinics and otherwise cared for about 10,000 persons dispersed over 4,000 to 5,000 square miles.Health challenges in American Indians-Alaska Natives Essay

Primary care physicians were introduced in 1956. Major acute microbial diseases observed during the five-year experiment were pneumonia, diarrhea, otitis media, measles, and impetigo. Only reduction of tuberculosis transmission, decreased incidence of otitis media, and increased referral for hospitalization were attributable to the experiment. The pneumonia-diarrhea complex (cause of about two-thirds of infant deaths) and trachoma (transmitted from child to child by unwashed hands, towels, and utensils) remained serious health problems.8 Thus, it appears that Navajos at Many Farms needed the services of sanitarians and public health nurses before they could reach a juncture at which they could develop diseases usually considered to require medical treatment.Health challenges in American Indians-Alaska Natives Essay

CONTEMPORARY HEALTH PROBLEMS AND ASSESSMENT OF NEEDS
The 1980 and 1990 Censuses indicate that American Indians and Alaska Natives comprise roughly 1 percent of the U.S. population (about 1.75 million persons).9 They are heterogeneous in tribal origin, preservation of traditions, and extent of urbanization.10,11,12 Indians became citizens in 1924. In 1953, in an effort to decrease unemployment and encourage immersion into the American mainstream, the Bureau of Indian Affairs, a federal agency, began the Urban Relocation Program to resettle Indians from geographically dispersed remote reservations. Target cities included Boston, Chicago, Cleveland, Dallas, Minneapolis/St. Paul, New York, and San Francisco, but job training and employment did not always materialize and many had to rely on public assistance. As a result of relocation, however, less than 50 percent of Indian people now reside on independently governed reservations (often in widely separated areas), and there are about 300 autonomous groups in the United States.10,13 In Alaska, 22 ethnic groups are dispersed in 250 villages, and some reside in or near major cities and towns.Health challenges in American Indians-Alaska Natives Essay

It would be exceedingly difficult to conduct a national survey of health status of American Indians and Alaska Natives. Appropriate authorities from each tribal entity, or "reservation," included in the sample would need to grant permission.15 To learn about Indian people living in towns or cities, where numbers are comparatively small, an adequate health survey would require local oversampling. Even if these obstacles were overcome, definitions of group

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Suggested Citation:"19 Health Status of American Indian and Alaska Native Women." Institute of Medicine. 1994. Women and Health Research: Ethical and Legal Issues of Including Women in Clinical Studies: Volume 2: Workshop and Commissioned Papers. Washington, DC: The National Academies Press. doi: 10.17226/2343.×
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membership would arise. Like ''minorities" or "ethnic groups," there is disagreement about criteria for inclusion. The Bureau of Indian Affairs counts individuals who meet legal definitions for registration on tribal rolls, usually quantified by fraction of "blood," with one-fourth to one-eighth minimum as typical. In other instances, persons elect to be known as "Indian" for individual or social reasons, such as intermarriage. For purposes of the United States census, self-identification as American Indian/Alaska Native is adequate.12,16 For survey purposes, however, even the concept of ''household" might not correspond to usage of this term for other minorities. As a consequence, information about Indian health and mental health status is fragmented and uneven in quality.Health challenges in American Indians-Alaska Natives Essay

Native Americans are not included in the National Health and Nutrition Survey (NHANES) conducted by the National Center for Health Statistics, Centers for Disease Control.18 Most systematic data collection that exists is drawn from patients served by the Indian Health Service (IHS),19 which potentially serves about 1.1 million people.9 Both baseline data and routine monitoring systems are needed to meet federally established health objectives, especially for Healthy People 2000.18 Gaps and limitations have been recognized, and collaboration has begun among the IHS, other federal agencies, and tribal authorities. The Indian Self-Determination and Education Assistance Act of 1975 (P.L. 93-638) established mechanisms that give federally recognized tribes the freedom and power to plan and implement health, educational, and social services.

The predominant health problems among American Indians and Alaska Natives now stem from behavioral risk factors directly related to injuries and chronic diseases.20,21Since 1959, the Sanitation Facilities Construction Program of the IHS has improved housing as well as established safe water supplies and adequate waste disposal facilities.22 As might be expected, there are still unmet needs for a variety of interventions and health services for Native Americans both on and off of reservations.19 Common problems for adults include lack of prenatal care, need for access to substance abuse or diabetes treatment, and excess deaths from cigarette smoking and alcohol abuse.23 Problems for adolescents include lack of access to substance abuse or other mental health treatment; deaths from suicide are especially disturbing.24,25,26

Cigarette Smoking
Although cigarette smoking among Native Americans has received comparatively little attention, rates are higher than for whites. In 1989, poor school achievement was linked to cigarette use among 31 percent of Indian youth.24 A study of 119 youths on reservations in Washington found 72 percent of those under age 12 used smokeless tobacco at least once a week.Health challenges in American Indians-Alaska Natives Essay

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Suggested Citation:"19 Health Status of American Indian and Alaska Native Women." Institute of Medicine. 1994. Women and Health Research: Ethical and Legal Issues of Including Women in Clinical Studies: Volume 2: Workshop and Commissioned Papers. Washington, DC: The National Academies Press. doi: 10.17226/2343.×
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of current use of smokeless tobacco use in adults found rates were highest for Plains Indian men, 15 to 20 percent, in contrast to about 5 percent of white men, increasing the risk of oral cavity cancer. Rates for Indian women ranged between 0 and 2 percent.21

There is considerable variation according to geographic region. In California in 1989, 40 percent of all deaths of both sexes were attributable to cigarette smoking, in contrast to 17.8 percent and 12.4 percent of white men and women, respectively.19 In four regions in 1985 to 1988, current cigarette smoking among Native Americans ranged from 14 to 58 percent of women and 18 to 48 percent of men, in contrast to about 25 percent of both white men and women. Highest rates were found in the Plains region, and a separate study of four Indian communities in Montana during 1987–1989 found current smoking rates of 54.5 percent for women and 50.7 percent for men.Health challenges in American Indians-Alaska Natives Essay

Smoking cessation programs for Indian women are important, since infant mortality attributed to maternal smoking includes both respiratory disease and sudden infant death syndrome (SIDS).28 Lung cancer mortality rates for Indian women in IHS regional units appear to co-vary with rates of tobacco smoking. Tobacco use also contributes to cardiovascular disease, malignant neoplasms, and cerebrovascular diseases. For cancer mortality, lung cancer is the leading cause of death for women in six out of twelve IHS areas, and exceeds the risk for women in the U.S. general population in four areas. Reduction of tobacco smoking prevalence by 20 percent among American Indians is an objective of Healthy People 2000.29

Obesity
Among ethnic groups in the United States, overweight and obesity occur most frequently in American Indians.30 In 1987, the estimated rates of overweight for adult U.S. males and females were 24.1 percent and 25.0 percent, respectively. Rates for American Indian men, 33.7 percent, and women, 40.3 percent, were considerably higher. Among Indian children and adolescents, 24.5 percent of boys and 25 percent of girls were overweight and 11.1 percent of boys and 7.3 percent of girls were obese. For children four years old and under, 11.2 percent were obese (compared to 8.1 percent of U.S. preschool children), with the highest rate for one-year-olds.

An ethnographic study of daily dietary intake of 107 Navajo women found 63 percent to be 20 percent overweight.31 Subjects had a mean age of 47 years, had attended school for a mean of six years, and most resided about six miles from a food store. Diets were high in saturated fat and refined carbohydrates and low in fiber and vitamin A. Women who were younger and better educated, planted home gardens, read newspapers, had better housing, lived nearer food stores, and had spent more time off of the reservation had better diets.Health challenges in American Indians-Alaska Natives Essay

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Suggested Citation:"19 Health Status of American Indian and Alaska Native Women." Institute of Medicine. 1994. Women and Health Research: Ethical and Legal Issues of Including Women in Clinical Studies: Volume 2: Workshop and Commissioned Papers. Washington, DC: The National Academies Press. doi: 10.17226/2343.×
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Household income correlated significantly with dietary intake.

Another ethnographic study compared diets of obese and nonobese Hualapai women in Arizona.32 Obese women weighed 20 percent or more than desirable weight for height. Subjects were matched for age and percentage of Hualapai ancestry, and were similar in education, income, household composition, marital status, and employment history. Consumption of fat, fiber, and protein did not differ between obese and nonobese women, but obese women consumed more carbohydrates in the form of sweetened soft drinks and alcoholic beverages.Health challenges in American Indians-Alaska Natives Essay

High prevalence of obesity in American Indians is related to hypertension, diabetes, coronary artery disease, poor survival rates for breast cancer, increased rates of gallstones, and poor pregnancy outcome.33 Prevalence of obesity has surged within the last half-century,30 and some portion is attributable to the nutritional content of commodity foods distributed to American Indians through feeding programs.33 Other factors include increased employment among women, the availability of refined carbohydrates from convenience stores and fast food restaurants, and sedentary lifestyle.32,33 Among Indians, dietary changes may interact with genetic factors,34 conserving body fat to protect against food shortages.Health challenges in American Indians-Alaska Natives Essay

Diabetes
Diet and physical activity are important throughout the life cycle. Information available about the prevalence of diabetes mellitus (Type 2 diabetes) among Native Americans shows links with obesity, hypertension, anemia, and nutrient deficiencies.35,36,37 One-third of outpatient visits to the IHS in 1989 were related to diabetes.38 A recent study of 415 Navajos with Type 2 diabetes39 found a ratio of females to males of 1.35 to 1, although clinical findings were remarkably similar for women and men. Both weight reduction and increased exercise are involved in treatment of this chronic disease, although many Indian people are found noncompliant with their treatment regimens.

Major studies have focused on the complex interconnection among diet, obesity, diabetes, and pregnancy in Southwestern Indians, especially the Pima tribe. Both genetic and environmental factors are implicated.40,41 Longitudinal studies have shown that Pima adults currently weigh more than at the turn of the century, and that young adults weigh more than their elders. Higher body mass index predicts risk for Type 2 diabetes, which is familial and associated with lower metabolism, and affects about one-half of the Pima people. However, gestational diabetes mellitus is widespread among Native American women and can lead to higher birthweight babies as well as to Type 2 diabetes in mothers.Health challenges in American Indians-Alaska Natives Essay

In a regional study of behavioral risk factors, about 25 to 35 percent of Native American women (and 25 to 30 percent of Native American men) were found to be overweight (body mass index higher than 27.3 in women and 27.8

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Suggested Citation:"19 Health Status of American Indian and Alaska Native Women." Institute of Medicine. 1994. Women and Health Research: Ethical and Legal Issues of Including Women in Clinical Studies: Volume 2: Workshop and Commissioned Papers. Washington, DC: The National Academies Press. doi: 10.17226/2343.×
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in men), in contrast to about 16 to 20 percent of white women and 16 to 23 percent of white men.21 Sedentary lifestyle (less than three 20-minute sessions of leisure time physical activity per week) was reported by about 40 to 65 percent of Native American women and 44 to 60 percent of Native American men, and 50 to 60 percent of white men and women.21 In 1989, one study reported that poor health status was linked to overweight and to poor body image among 65 percent of Indian youth.Health challenges in American Indians-Alaska Natives Essay

A follow-up study of 1,012 diabetic male and female Native Americans in Oklahoma examined mortality rates and causes of death.43 The cohort consisted of 379 men and 633 women diagnosed with non-insulin-dependent diabetes mellitus at baseline during the period 1972–1980. Follow-up was conducted between 1986 and 1989. At that time, 45 percent (452 persons) were deceased, of whom 59 percent were female. Death certificates were obtained and ICD-9 codes analyzed. Major causes of death recorded for the 257 women were circulatory diseases (67 percent), diabetes (26 percent), malignant neoplasms (12 percent), digestive disease (10 percent), and renal disease (6 percent). There was a linear pattern of increased death rates at younger ages, and the ratio of observed to expected deaths for Indian women versus other Oklahoma women was 4.09.

Reproductive Health
Sexually transmitted diseases are associated with complications of pregnancy. One study tested 968 pregnant Navajo women for Mycoplasma hominis and Chlamydia trachomatis and pregnancy outcome.44 Half of the women (50 percent) had M. hominis and 22 percent, C. trachomatis . Complications of pregnancy included 21 percent with preclampsia, 12 percent with postpartum fever or endometritis, and 8 percent with premature rupture of membranes. Sociocultural assessments rated women for "traditionality" (measured by participation in traditional religion, having undergone a Navaho puberty ceremony, or planning a "Blessing Way" ceremony for the baby). M. hominis combined with a traditional lifestyle strongly predicted postpartum fever, endometritis, and premature rupture of membranes. It was concluded that ''traditionality" could reflect absence of modern conveniences and sanitation or indicate a state of psychological stress associated with the impact of "cultural change.''

Another study found rates of C. trachomatis among 183 pregnant Indian women to be about 25 percent.45 Since perinatal infection can cause inclusion conjunctivitis and pneumonia in newborns, prenatal screening of mothers is encouraged. Further, in this population, Trichomonas tended to be associated with C. trachomatis infection. Health challenges in American Indians-Alaska Natives Essay
Suggested Citation:"19 Health Status of American Indian and Alaska Native Women." Institute of Medicine. 1994. Women and Health Research: Ethical and Legal Issues of Including Women in Clinical Studies: Volume 2: Workshop and Commissioned Papers. Washington, DC: The National Academies Press. doi: 10.17226/2343.×
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American Indian women appear lower than for Hispanics and non-Hispanic white women.46

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There is limited information about HIV infection and AIDS prevalence in Indian women.47 In 1991, 14 percent of 292 American Indian adult and adolescent AIDS cases known to the CDC were female.48 Risk factors include intravenous drug use, multiple sex partners, early sexual activity, and alcohol use. Perinatally transmitted AIDS affected eight children under age five.49 In a sample of 481 Indian women in Idaho, Oregon, and Washington,48 6.4 percent were at high risk from intravenous drug use, and 30 percent were in the middle group of persons who had sexual intercourse with two or more partners in the previous year. The greatest proportion of high and middle risk women were ages 12 to 29, and 18 to 49, respectively. Middle risk subjects had begun sexual activity at earlier ages and were younger at first pregnancy. They also reported having sexual partners who resided both on and off reservations, which could facilitate transmission of HIV infection from urban to rural areas, and encourage spread of HIV into small communities.Health challenges in American Indians-Alaska Natives Essay

The IHS conducted an HIV seroprevalence survey for the period July 1, 1989, to June 30, 1991.49 Sources were 37,681 blood specimens obtained from persons being evaluated for STD, entering drug and alcohol treatment programs, or receiving prenatal care in the first or third trimester. One per 3,500 initial prenatal patients and one per 1,000 third trimester/perinatal patients were HIV-1 positive. The rate of HIV- 1 infection among patients evaluated for STD was one per 220 males and one per 1,400 females. It was estimated that about 2,300 (range 1,030 to 3,615) men and about 400 (range 180 to 640) women were infected with HIV. During 1990, about 35 infants would have been born to mothers infected with HIV, and, of these, approximately 11 infants would have been infected perinatally.

Fetal alcohol syndrome (FAS) and Fetal Alcohol Effects (FAE) have an impact on Native American infants. May found the lowest FAS rates (1.3 per 1,000) occurred for Navajo women.50 A much higher rate occurred among Plains Indian women (10.3 per 1,000), and 25 percent of all Plains women with one FAS child also gave birth to others.50 These findings have prompted local-level studies in other regions.Health challenges in American Indians-Alaska Natives Essay

A behavioral risk factor study was conducted at Warm Springs in Oregon in 1990 among persons over age 18.22 Of the 234 women surveyed in this study, a pattern of binge drinking was most typical. Among these women, 60 percent reported blackouts, 42 percent had been arrested for driving under the influence of alcohol, 39 percent had received detoxification treatment, and 25 percent had been enrolled in alcohol treatment at least once. In addition, 31 percent had consumed alcohol during their last pregnancy. From a survey of 429 children who had been younger than age 5 on September 1, 1991, 121 were referred for screening for FAS/FAE because of suspected prenatal alcohol exposure, birthweight less than 3,000 grams, or developmental delay. From this sample,

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Suggested Citation:"19 Health Status of American Indian and Alaska Native Women." Institute of Medicine. 1994. Women and Health Research: Ethical and Legal Issues of Including Women in Clinical Studies: Volume 2: Workshop and Commissioned Papers. Washington, DC: The National Academies Press. doi: 10.17226/2343.×
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23 were found to meet two criteria, and 19 were evaluated. A total of eight children, four with FAS and four with FAE, were identified. All mothers were over age 30 and had consumed alcohol during pregnancy (there was no assessment of cigarette smoking, inhalant use, or cocaine use). One mother had two children with FAS. A total of seven of the eight children were in foster placement when assessed. Another comprehensive program targeted 48 high-risk Navajo women, of whom 81 percent participated.51 This program provided alcohol detoxification and family planning services and was hospital based and family oriented, characteristics that seem to have encouraged participation.Health challenges in American Indians-Alaska Natives Essay

During the 1970s, sterilization procedures were performed on poor minority women (black, Hispanic, and Native American).52 A General Accounting Office (GAO) investigation has examined allegations of genocide by the Bureau of Indian Affairs and the IHS. In a sample of four out of 12 IHS service areas, 3,406 Native American women were found to have been sterilized during 1973–1976. Of these women, 88.1 percent (3,001) were ages 15 to 44.

The IHS now uses protocols to protect patients' rights for both sterilizations,53 and for the depot contraceptive Norplant.53,54,55 Sterilization procedures must be voluntary and accompanied by thorough counseling about risks, benefits, and details of the procedure, as well as information about alternative methods of contraception. Only tubal ligation and vasectomy are acceptable, and hysterectomy is prohibited for purposes of sterilization. Sterilization is prohibited for patients under age 21, patients incapable of giving informed consent (i.e., mentally incompetent), or patients institutionalized in a correctional or mental health facility. Informed consent must be documented, and rules of the Department of Health and Human Services must be followed. These rules require that consent be obtained 30 days prior to the procedure routinely, or after 72 hours has elapsed in the case of emergency abdominal surgery. Consent for sterilization cannot be obtained when a woman is in labor, seeking to obtain an abortion, or under the influence of alcohol or any other mind-altering substance. Care providers are encouraged to seek informed consent during the second trimester of pregnancy to avoid exceeding a 180 day limitation for any specific informed consent signature.Health challenges in American Indians-Alaska Natives Essay

Norplant, which now has been used by half a million women in nearly 50 countries, has been available to the IHS since January 1991. A Norplant implant costs $365, which is cost effective for long-term contraception. Generally, Norplant candidates are advised that five years is an optimal time period. Interestingly, Norplant is efficacious because it reduces the amount of cervical mucus and increases its viscosity, creating a barrier preventing migration of sperm through the cervix into the uterus. It inhibits growth of the endometrium and in some patients it suppresses ovulation. The mucus barrier is believed to potentially decrease risk of pelvic infectious disease (PID). High priority patients are women with medical conditions for whom pregnancy might endanger health, women who have recently had an abortion, sexually active teenagers with one

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Suggested Citation:"19 Health Status of American Indian and Alaska Native Women." Institute of Medicine. 1994. Women and Health Research: Ethical and Legal Issues of Including Women in Clinical Studies: Volume 2: Workshop and Commissioned Papers. Washington, DC: The National Academies Press. doi: 10.17226/2343.×
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or more children, sexually active teenagers (with parental consent) who have plans for career or college education, and women in their twenties who are not ready to contemplate permanent sterilization. Its use is contraindicated in women who are pregnant, have undiagnosed abdominal-uterine bleeding, known or possible breast cancer, thrombo-embolic disease, or liver disease. Other contraindications include migraine headaches, severe obesity, or moderate to severe acne. Norplant is inadvisable for women over age 30, since its use may obscure onset of occult endometrial neoplasia. Any woman planning to have children within four years is advised to seek another contraceptive method.Health challenges in American Indians-Alaska Natives Essay

Infant Mortality
Infant mortality rates for American Indians are difficult to calculate. Accurate rates depend on identification as American Indian on both birth and death certificates. Several studies have shown that high rates (about 20 percent in some areas) of misclassification occur when births and deaths occur outside of IHS facilities.9

Primary causes of neonatal (first 28 days of life) death are congenital anomalies, respiratory distress syndrome, disorders related to short gestation and low birthweight (less than 2500 grams), SIDS, effects of maternal complications of pregnancy, and infections specific to the perinatal period.9 Primary causes of infant (29 to 365 days of life) mortality are SIDS, congenital anomalies, respiratory distress syndrome, disorders related to short gestation and low birthweight, and pneumonia and influenza.9 It has been estimated that SIDS accounts for 40 percent of postneonatal deaths and 25 percent of infant mortality in Native Americans.56

Infant mortality and neonatal death rates vary across the IHS service areas, with lowest rates in the southwestern states and highest in the northern plains and northwest states.9,57 Infant mortality and neonatal death rates in the Southwest were higher in the past, having improved in recent years, and reflect concerted efforts on the part of the IHS to improve outreach efforts to pregnant women.9,58,59 Special services are provided to young primigravida women,60 since in 1987, 19 percent of all low-birthweight Indian infants were born to mothers under age 20.9 Health challenges in American Indians-Alaska Natives Essay

Cancer, Cardiovascular Disease, and Tuberculosis
A meta-analysis of cancer incidence rates in American Indians versus the general population61 found reduced incidence of cancer at most sites. Decreased incidence was noted for colon, breast, and uterine cancer. However, increased rates of cervical cancer were observed.

Another meta-analysis of cancer incidence in Indian people62 found women to have elevated rates of cancers of the gallbladder, cervix, and kidney, but

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Suggested Citation:"19 Health Status of American Indian and Alaska Native Women." Institute of Medicine. 1994. Women and Health Research: Ethical and Legal Issues of Including Women in Clinical Studies: Volume 2: Workshop and Commissioned Papers. Washington, DC: The National Academies Press. doi: 10.17226/2343.×
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decreased rates for cancers of the colon, breast, and uterus, and for lymphomas. Rates of lung cancer and leukemias were similar. Risk for kidney cancer is associated with obesity, cigarette smoking, and occupational exposures. As noted, obesity occurs for more than half of Indian women, and cigarette smoking by Indian women in some regions is more common than among women in the general population. Gallbladder cancer is associated with benign gallbladder disease as well as obesity and parity, and is more prevalent among Indian than white women. The overall lower cancer mortality rate may be influenced by more immediate causes of excess deaths, such as diabetes, accidents, or infectious diseases.Health challenges in American Indians-Alaska Natives Essay

Respiratory diseases that most severely affect Indian mortality are pneumonia, cancer of the lung, chronic obstructive pulmonary disease (COPD), and tuberculosis.63 For the period 1980–1986, tuberculosis rates for Indian men and women were 2.2 and 1.7 per 100,000 versus 0.9 and 0.4 for the general U.S. population. Pneumonia rates for Indian people were slightly higher, 24.0 for men and 16.1 for women per 100,000, versus 19.1 for men and 17.6 for women per 100,000 for the general U.S. population. Lung cancer rates for Indian males (19.9 per 100,000) and females (8.8 per 100,000) were considerably lower for the general U.S. population (70.6 and 28.8 per 100,000, respectively). From 1980 to 1986, no emphysema deaths were reported for Indian women or men. Overall, Indians had lower COPD rates (115 per 100,000).

In 1990, the incidence of tuberculosis in American Indians was 18.9 per 100,000.48 Rates had decreased since 1975, when the incidence rate was 48.0 per 100,000, but rates began to rise again in 1989. In 1990, 39.4 percent of cases (N = 146) were female, with 74 percent pulmonary and 26 percent extrapulmonary. The number of cases reported for women dropped from 154 in 1989 to 146 in 1990. These rates are not indicative of tuberculosis secondary to AIDS. The goal for Healthy People 2000 is to reduce the incidence rate to 5 per 100,000. Adequate screening, contact tracing, and treatment efforts by the IHS are being mobilized to attain this objective. Rising rates of cardiovascular disease among Native Americans are the focus of the "Strong Heart Study."64 Risk factor levels were examined for Indian people living in central Arizona, southwestern Oklahoma, and North and South Dakota. The study focuses on persons ages 35 to 74 and includes a mortality survey to estimate death rates from cardiovascular disease, a morbidity study to estimate incidence of initial and recurrent myocardial infarctions and CVAs, and clinical examinations to estimate the prevalence of risk factors. About 1,500 persons at each site are included in the study. Among the three sites 1,209 females and 1,165 males were enrolled in a 35- to 44-year-old cohort, and 2,175 females and 2,096 males were enrolled in a 45- to 74-year-old cohort.Health challenges in American Indians-Alaska Natives Essay

Prevalence of myocardial infarction, as diagnosed by electrocardiogram, was highest in North and South Dakota Sioux, lower in Indians residing in Oklahoma,

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Suggested Citation:"19 Health Status of American Indian and Alaska Native Women." Institute of Medicine. 1994. Women and Health Research: Ethical and Legal Issues of Including Women in Clinical Studies: Volume 2: Workshop and Commissioned Papers. Washington, DC: The National Academies Press. doi: 10.17226/2343.×
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and lowest among Pima in Arizona. Contributory factors varied among the three locations. Cholesterol levels were lowest among the Pima, who also had the lowest rate of tobacco smokers. Hypertension was high in Oklahoma tribes and the Pima. All groups had high rates of diabetes and of obesity, but rates were highest among the Pima. Interestingly, more than 90 percent of Pima reported "full-blooded" heritage, in contrast to 73 percent of the Oklahoma tribes and less than half of the Sioux Health challenges in American Indians-Alaska Natives Essay
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