The term "American Indian and Alaska Native" (AI/AN) is used to refer to indigenous peoples of the United States. It is encompassed by the broader term "Native American," which also includes indigenous peoples of Canada (known as Aboriginal Canadians, Native Canadians, or First Nations), Mexico, and Central and South America. "Alaska Native" is used to refer jointly to Eskimos (Inuit), Indians, and Aleuts living in that state. (The Inuit are also native to Canada.) "Native American" is widely accepted as the "correct" term for the indigenous peoples that were residing in North America when Europeans first arrived on the continent, and for their descendants. Although the terms Native American and AI/AN imply a certain degree of cultural homogeneity, the indigenous peoples of North America do not form a monolithic ethnic or cultural group, despite their sharing broadly similar experiences. There are hundreds of Native American groups, each with distinctive traditions, customs, values, spiritual beliefs, lifestyles, and languages. In considering Native Americans generally, or AIs/ANs specifically, it is important to recognize their internal diversity.
DEMOGRAPHICS
Contemporary AI/AN populations live in urban areas and on reservations. In the United States an estimated 2.5 million persons were projected to identify themselves in the 2000 Census as American Indian or Alaska Native, nearly 0.9 percent of the total United States population. These persons, most of whom will indicate an affiliation with one of the more than five hundred federally designated tribal organizations, are predominantly located in the western United States (48%), the South (29%), and the Midwest (17%), with just 6 percent in the Northeast. This distribution of the AI/AN population reflects the consequences of the historical pattern of settlement of the United States and the displacement of American Indians to primarily western and southern parts of the country. Alaska Natives numbered some 106,000 persons in 1999, approximately 4.3 percent of the total AI/AN population. Of persons who identified themselves as AI/AN in the 1990 Census, 1.2 million (57%) resided in the 33 reservation states served by the Indian Health Service (IHS), an agency of the U.S. Department of Health and Human Services. The AI/AN population, however, has become increasingly urbanized; in 1990, close to 66 percent of AIs/ANs resided in urban areas, while just 20 percent lived on reservations. This was a marked increase from 1980, when 54 percent of AIs/ANs lived in urban areas, and from 1970, when 45 percent did so.
According to 1990 Census projections to November 1, 2000, the estimated median age for AIs/ANs was twenty-eight—a full eight years below that of the national population. The distribution of sex for AIs/ANs (51% female and 49% male) did not differ from that of the national population. The AI/AN population did have a greater prevalence of poverty (32% versus 13% nationally) and unemployment (16% versus 6% nationally), and a lower prevalence of high school graduates (65% versus 75% nationally) and college graduates (9% versus 20% nationally).
HISTORICAL, SOCIAL, AND POLITICAL CONTEXTS OF NATIVE-AMERICAN HEALTH
Since their initial contact with Europeans in the late fifteenth century, AI/AN populations have experienced catastrophic losses of life, land, political autonomy, and social cohesion. Illness was often the first, and most ravaging, effect of colonization felt by indigenous peoples. Infectious diseases such as smallpox, measles, and influenza were introduced by Europeans and reached epidemic proportions among Native Americans, who had never been exposed to these diseases and had no immunity to them. As colonization and westward expansion continued, Native Americans were subject to war, genocide, removal from tribal lands, relocation, and forced labor. These factors all contributed to the decimation of 50 to 90 percent of the indigenous populations by the end of the nineteenth century.
The experience of forcible relocation onto reservations under the Bureau of Indian Affairs' assimilation program, and similar programs of Canadian churches and other institutions, designed to "civilize" AIs/ANs in the late nineteenth century, brought drastic changes to the social organization and living conditions of Native Americans. These changes led to an increase in health problems, including diseases such as tuberculosis, venereal disease, and alcoholism. The transfer in 1954 of responsibility for Indian health from the Bureau of Indian Affairs to the IHS heralded not only an administrative change but also the emergence of a new medical ideology by which the poor health status of Native Americans was no longer attributed to "savage ignorance," but to a lack of sufficient medical knowledge. The IHS did in fact bring many infectious diseases under control; however, chronic diseases emerged to take their place. Further, social pathologies began to have an increasing impact on the AI/AN population in the latter half of the twentieth century.
In the 1950s and 1960s, the federal government again pursued a policy of "assimilation," by which AIs/ANs were encouraged to relocate from reservations to urban areas. At the same time, though, the IHS was establishing itself as a highly centralized, largely reservation-based (and thus rural), health care service. In the 1970s the IHS reversed this trend with an increasingly decentralized service—concomitant with encouragement of tribes to directly operate or contract their own health services. Today there are problems not only with the ongoing provision of adequate health services in rural areas, but the AIs/ANs living in urban areas also have difficulty gaining care from the IHS, which devotes just 2 percent of its budget to urban programs.
NATIVE AMERICANS' HEALTH IN THE TWENTY-FIRST CENTURY
As North America enters the twenty-first century, Native Americans carry a disproportionate burden of ill health relative to the general population. Life expectancy for AIs/ANs is 71 years, in contrast to 75 years for the United States population. While the infant mortality rate does not differ between AIs/ANs and the national population, infant mortality due to sudden infant death syndrome and accidents is greater by factors of two and three, respectively, for the AI/AN population. AI/AN children between ages one and four have a 70 percent higher mortality rate than the general population, while those aged five to fourteen have a 40 percent higher rate. Mortality due to accidents and homicide is greater by a factor of two for both age groups, in contrast to the national population. For AI/AN adults, relative to the national population, age-adjusted mortality rates are lower for heart disease and cancer, the two most common causes of death, but nearly three times higher for death due to accidental injuries and diabetes, four times higher for death due to liver disease, and 50 percent higher for death due to pneumonia, influenza, suicide, and homicide. Mortality data contrasting urban and rural dwelling AIs/ANs indicate a pattern favoring urban AIs/ANs in terms of lower infant mortality rates and lower cause-specific mortality rates.
Relative to the national population, AIs/ANs are distinguished by a high prevalence and incidence of chronic disease (e.g., diabetes, obesity, and gallbladder disease) as well as infectious disease (e.g., tuberculosis, meningitis, gastroenteritis, pneumonia, and sexually transmitted diseases). Age-adjusted prevalence rates of diagnosed diabetes (11%) and obesity (30%) are three and two times higher, respectively, for AIs/ANs than for non-Hispanic whites. High rates of disease and disease-specific mortality in AIs/ANs correspond to a high prevalence of behavioral risk factors (e.g., poor diet, physical inactivity, and smoking). These are expressed concomitant with high rates of social pathologies (e.g., alcohol or substance abuse, homicide, suicide, violence) and unintentional injuries (e.g., vehicle injuries, fires, burns, and drowning), and the morbidity and mortality associated with them. Thus, disease indicators and social indicators converge in their correspondence to ill health in AIs/ANs.
An understanding of individual-level risk factors is important for disease prevention and control, but such knowledge is of limited use without consideration of risk conditions. Health and health-related behavior interact with and emerge from social, political, and economic contexts. Unfortunately, however, some approaches to health promotion in AI/AN populations have tended to focus on changing behavior to the exclusion of environmental factors and have had limited success in Native American populations. Social pathologies and unintentional injuries in AIs/ANs have also been attributed largely to individual-level factors, though an understanding of the historical context of oppression and subjugation and its extension to the current context of economic disadvantage, unemployment, and undereducation is essential to adequately address these problems.
The health of AI/AN populations cannot be understood separately from their history of oppression and their continuing experience of marginalization. The adequate provision of health services and medical knowledge to AI/AN populations, while an important need and goal, is insufficient on its own to remove health disparities. So, too, is a well-intentioned emphasis by nonindigenous health practitioners and researchers on "cultural sensitivity" in community-based intervention and in clinical treatment and prevention settings unlikely, on its own, to yield substantial improvements in the health of AI/AN populations. The unequal distribution of wealth, power, and opportunity are the fundamental determinants of the health status of Native Americans. Only by addressing the social structure and the economic, political, and sociocultural forces that create this inequality can the health status of Native Americans be improved.
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