An Introduction to American Indian/Alaska Native Health Disparities
Dr. Joseph Burns, MD, a Native American CHD patient and clinician, and Dr. Alessandra Angelino, MD MPH, highlight health disparities in the American Indiana/Alaska Native community.
American Indian/Alaska Native (AI/AN) populations in the United States confront numerous health disparities. AI/AN populations experience higher rates of diabetes, heart disease, liver disease, tuberculosis, pneumonia, influenza, suicide, homicide, and traumatic accidents compared to non-AI/AN populations.
Significant disparities in the health of AI/AN infants and children are also evident. Mortality rates for AI/AN infants are roughly double that of non-AI/AN infants, and mortality rates of AI/AN children are nearly triple that of non-AI/AN children. In addition, there is a significant burden of early childhood disease including obesity and diabetes in AI/AN communities, at rates upwards of two times non-AI/AN children. These statistics are compounded by high poverty rates, lower education rates, and historical and intergenerational trauma unique to AI/AN communities.
Disparities in Heart Disease
Coronary artery disease affects AI/AN populations in disparate ways, largely driven by higher rates of diabetes. Further risk factors include high cholesterol, hypertension, renal disease, smoking, and exposure to toxic metals during all stages of life, from prenatal periods throughout childhood and into adulthood. For AI/AN children, the high prevalence of risk factors for cardiovascular disease, including obesity, insulin resistance, air pollution, toxic metal exposure, poor diet, and low levels of physical activity, predispose to early onset of exaggerated atherosclerotic disease. Unfortunately, there is a paucity of data regarding heart disease in the AI/AN population, and those that do exist focus on adults.
Settler Colonialism, Historical Trauma, and Adverse Childhood Experiences
These disparities have roots in settler colonialism and the associated traumas experienced by AI/AN individuals and communities over time. Settler colonialism is the process whereby a group of individuals forcibly subjugates another group of individuals, primarily through the seizure of land and the elimination of Indigenous practices and populations. This control of land is a means of deriving power and altering Indigenous relationships with the land, resources, and community. Since land is closely tied to Indigenous wellbeing, settler colonialism inherently predisposes AI/AN folks to health disparities.
Settler colonialism is further compounded by historical Trauma (HT), the cumulative, intergenerational traumas experienced by people of a shared identity. Individuals who have experienced HT often report feelings of anxiety, depression, anger, and avoidance related to historical losses and their impacts, impacting on health for those experiencing traumas as well as future generations. Further, those exposed to historical traumas and related stressors have been found to have epigenetic changes, passed from generation to generation and promote poor mental and physical health outcomes.
Settler colonialism and HT both have direct and indirect consequences on childhood outcomes, primarily through adverse childhood experiences (ACEs) including household dysfunction, childhood abuse, and exposure to parental mental health issues. Recent research has demonstrated that increased ACEs are associated with adverse health outcomes including smoking, depression, alcoholism, ischemic heart disease, cancer, and poor self-rated health.
Missing and Murdered Indigenous People Crisis
AI/AN individuals are also at risk for increased murder and experience of violence. The Missing and Murdered Indigenous Peoples (MMIP) crisis describes the mass disappearance, murder, and violence against Indigenous populations across the United States, Canada, and Australia. Though nearly 6000 cases of missing AI/AN people were reported in the United States, only 118 have been recorded in federal databases. Along the same lines, nearly 80% of AI/AN women have reported violence in their lifetime, and 30% of girls between 11 and 17 disclosed a history of sexual abuse. Despite this propensity of violence, there is a clear dearth of data reporting MMIP.
Land Rights and Access to Care
Considerable gaps exist in accessing care for AI/AN populations. Care delivery is closely tied to land allocation and federal recognition of tribes, and individuals typically receive care through the Indian Health Service (IHS), tribally operated clinics, or Urban Indian Health organizations. The population eligible for IHS care exceeds 2 million individuals, of which 31% are under age 15. Despite this large population and the inequities present, the IHS is chronically underfunded, limiting capacity for care. In addition to care in rural settings, AI/AN populations have access to Urban Indian Health Programs. These centers are important as 70% of the AI/AN population is located in urban centers. Currently 42 such centers are available to AI/AN individuals, though only 21 are full care centers. Additional barriers include higher rates of underinsurance relative to non-AI/AN populations, lack of transportation to care, and lack of understanding regarding Indigenous culture on part of care providers.
Community Engagement and Advocacy Opportunities
Healthcare providers, community members, and parent advocates have countless opportunities to alleviate these health disparities. Among these include working with tribal communities to clarify health priorities, increasing education surrounding Indigenous practices and culturally sensitive care, and increasing attention to the social determinants of health. Focusing on resilience and strengths of AI/AN individuals and communities is also a significant factor in improving the health of this population. Further, advocacy for community, state, and federal efforts to promote culturally relevant screening and research as well as promotion of IHS funding and the protection of the Indian Child Welfare Act (ICWA) all serve to protect this vulnerable population. Specifically with regard to reducing rates of heart disease in AI/AN populations, community-based and community-led programs focused on prevention in youth, including those promoting physical activity, traditional diets, and Indigenous wellness, have potential to eliminate disparities.
Dr. Joseph Burns is the current liaison to the American Academy of Pediatric Committee of Native American Child Health (CONACH), and recently founded the Collaborative of Pediatric American Indian Trainees (CoPAInT). As a Native American CHD patient and CHD clinician, Dr. Burns aims to tie together these interests to benefit future generations.
Dr. Alessandra Angelino is a pediatrics resident passionate about the health of American Indian and Alaska Native children. She is especially interested in adolescent health and the health of gender diverse youth, and continues to work with community organizations, tribal epidemiology centers, and the Indian Health Service to create guidelines, curricula, and policy that build upon community strengths. She has worked in Indigenous communities in Washington, North Carolina, and Australia, and hopes to continue engaging in clinical, policy, and advocacy work in AI/AN communities throughout and following her training.