Caring & Curing by mcherald



    From the


                                      In 1955, the Transfer Act established the Indian Health
                                      Service (IHS) as part of the United States Public Health
                                      Service (USPHS) in the former Department of Health,
                                      Education, and Welfare, currently known as the Depart-
                                      ment of Health and Human Services. One of the initial
                                      orders of business for the first Director of the IHS was to
                                      describe the health status of American Indians and Alaska
                                      Natives (AI/AN). A report entitled “Health Services for
                                      American Indians” was prepared by the Surgeon General of
                                      the USPHS and submitted to Congress on February 11,
                                      1957. This report became known as the “1957 IHS Gold
                                      Book.” The Gold Book is recognized as a founding
                                      historical marker outlining the challenges that faced the
                                      newly formed IHS.

                                       I am proud of the accomplishments made by the IHS since
1955. As we commemorate our 50th anniversary, I am pleased to present to you this progress
update. Such progress would not have been possible without the vision of great leaders and the
dedication of the IHS staff and Tribal partners.

Our goal at the IHS is to ensure that comprehensive, culturally acceptable personal and public
health services are available and accessible to AI/AN people. Since 1955, the IHS, in consulta-
tion with Tribes, Urban Indian programs, and Indian organizations, has been working diligently
and effectively towards this goal.

This Executive Summary is a preview of the updated version of the IHS Gold Book
that describes the health status of AI/ANs after the first 50 years of the IHS.                     3
      Table of

Message From the Director ................................................ 1

The Birth of the Indian Health Service ............................... 7

Federal Indian Policy ....................................................... 13

Indian People .................................................................. 17

Health of American Indians and Alaska Natives ................. 19

The Indian Health Service Program .................................. 23

The Future ..................................................................... 28

                                                                    The Birth
                                                                    of the
                                                                    Indian Health

Historical Summary of Indian Health:                            During the late 1700s, European immigrants brought
                                                                smallpox, plague, tuberculosis, and other infectious diseases to
The Story of a Public Health Mission                            the continent. Lacking immunity from foreign contagions,
                                                                American Indians were vulnerable to these maladies. Thus,
American Indians and Alaska Natives (AI/AN) share a             illness spread rapidly and decimated many Tribal groups.
complex, sometimes turbulent, history with the European
settlers and other immigrants who came to this country.
                                                                Federal health care for Indian people began with tentative steps
Many AI/AN ancestors lost their lives to achieve Tribal
                                                                and gradually evolved throughout the 19th and first half of the
recognition and Indian rights. Through their struggle, the
                                                                20th centuries. In the early 1800s, while the administration
often-embittered relationship between the settlers/immigrants
                                                                of Indian affairs was based in the Department of War, Indians
and AI/ANs has evolved into one of structure, substance, and
                                                                living near military forts were provided such episodic care as
direction. The initial treaties of 1784,
                                                                                         military physicians might offer. The
in which the Federal Government
                                                                                         fact that the vaccination of Indians was
acknowledged certain responsibilities
                                                                                         an important public health measure
toward the indigenous people, began
                                                                                         provided an added incentive to render
the formalization of
                                                                                         this care to Indians. In 1832, Con-
AI/AN rights. The Government’s
                                                                                         gress directed $12,000 for small pox
obligations were subsequently recon-
                                                                                         immunizations for Indians. Four years
firmed and defined by Supreme Court
                                                                                         later, the Federal Government began a
decisions, congressional legislation,
                                                                                         program that provided health services
Executive Orders, and other Federal
                                                                                         and physicians to the Ottawa and
policies. The relationship between
                                                                                         Chippewa Tribes. In subsequent
Tribal Governments and the Federal
                                                                                         decades, the Government gradually
Government is founded in the U.S.
                                                                                         assumed an increasing obligation to
Constitution, which recognizes that
                                                                                         provide health care, which usually
federally recognized Indian Tribes are
                                                                                         consisted of sending a physician and
sovereign nations with certain inherent
                                                                                         medications to Tribes. The responsibil-
rights. This distinguishes AI/ANs
from all other ethnic groups in the
United States.
ity for Indian medical services was transferred from military to   assigned to the BIA from the PHS, thus beginning participa-
civilian control when the Bureau of Indian Affairs (BIA) was       tion by the USPHS Commissioned Corps in Indian health
transferred from the War Department to the Department of the       programs.
Interior in 1849. The first separate funding for Indian health
($40,000) was identified in an appropriation act in 1911.
                                                                   The 1950s
The cession of most of the lands in the United States
by the Indians, codified in hundreds of treaties,                  In 1954, all functions of the Secretary of the Interior relating
forms the basis for the Government’s provision of                  to the conservation of the health of Indians were transferred to
health care to Indians. Many treaties identified                   the Surgeon General of the USPHS. On July 1, 1955, about
health services as part of the Government’s                        2,500 health program personnel of the BIA, along with
payment for Indian land. Indian treaties were                       48 hospitals, 18 health centers, 62 stations, 13 school
contracts between the Federal and Tribal Govern-                      infirmaries, and other locations, came under the jurisdiction

ments. Indian Tribes gave up their land in return                      of the newly created Indian Health Service (IHS).

for payments and/or services from the U.S.
                                                                         At the time of the transfer, conditions in Indian health
                                                                               facilities were marginal at best. Around 1956, the

Pre-Indian Health Service,                                                       Committee on Appropriations of the House of

                                                                                 Representatives, 84th Congress, directed the

1921-1955                                                                        USPHS to make a comprehensive survey of

                                                                       Indian health. The USPHS established a survey team,

In 1921, the Snyder Act (42 Stat.                                     and over the next year this team conducted an extensive

208), was passed by Congress to provide continuing author-             survey of Indian health, including in-depth studies of nine

ity for Federal Indian programs. The Snyder Act is                              reservations. The results were transmitted to

the basic authorization for Federal health                                                 Congress in 1957 as “Health Services for

services to U.S. Indian Tribes. It identified                                                 American Indians.” This report had a

the “relief of distress and conservation of                                                      gold cover and became commonly
health of Indians” as one of the Federal                                                          known as the “1957 IHS Gold
functions.                                                                                        Book.” The conclusions: 1) A
                                                                                                  substantial Federal Indian health
                                                                                                  program will be required; 2) all
The health status of Indians remained poor                                                     community health resources should be
during the following three decades. Several                                                   developed in cooperation with Indian
studies of Indian health, including those by the                                            communities and done on a reservation-
Institute for Government Research (1928), the                                        by-reservation basis; 3) Federal Indian health
Hoover Commission (1948), and the American Medical                 programs should be planned in each community and services
Association found high infant mortality and excessive deaths       made available to Indians under State and local programs; and
from infectious disease. Based on these studies, efforts were      4) efforts should be made to recognize the obligations and
made to transfer the Indian health program from the BIA to         responsibilities to Indian residents on a nondiscriminatory
the United States Public Health Service (USPHS) in the             basis from the State and local communities.
Department of Health, Education, and Welfare. It was also                                                                              8
during this time period that public health advisors were first
James R. Shaw, M.D., was assigned as a public health advisor        was started (Desert Willow, near Tucson, Arizona) to train
to the BIA in 1952. He became the first IHS Director with           Indian community members as community health representa-
the transfer in 1955 and served until 1962. He focused              tives (CHR). The CHR program was established in 1965 to
initial efforts on: 1) improving the quality of clinical care,      bridge the existing gap between patients in the community who
2) expanding prevention programs, and 3) bridging the gap           needed care and health clinics and hospitals to provide it. In
between the Tribal members who needed care and the health           1968, the CHR program became the first formal assumption
facilities to provide it. Dr. Shaw recognized the importance of     by an Indian Tribe of an IHS-supported program.
health statistics and built on the 1957 IHS Gold Book
baseline to measure progress. He established a professional
unit to provide reports on Indian health (e.g., morbidity           Dr. Rabeau believed strongly in the use of scientific data to sell
statistics and hospital and clinic data use). The first priority    programs. Health services research (the Health Programs
was to establish competent and high-quality medical care.           Systems Center (HPSC)) was established on the San Xavier
Extensive recruitment of health professionals; the remodeling       Reservation near Tucson in 1967. In
of health facilities; and the establishment of clinical laborato-   1971, HPSC became a component of a
ries, radiological services, and surgical teams were undertaken.    new organizational unit of the IHS, the
Funds were made available to buy services from private              Office of Research and Development
physicians and hospitals that provided the needed care for          (ORD). The basic mission of the ORD
Indian people. Preventive services including immunizations,         was to increase the efficiency and
prenatal and well-baby care, and environmental sanitation were      effectiveness of IHS service units and
provided. The passage of the 1959 Indian Sanitation                 to expand the participation of the
Facilities Act (Public Law 86-121) enabled the IHS to build         Indian community in managing its
facilities for the provision of safe water and sanitary waste       health affairs.
disposal. This program was critical in improving living
conditions and reducing water- and waste-borne communicable         The 1970s

                                                                    The decade of the 1970s was one of the
The 1960s                                                           most revolutionary in the history of
                                                                    Indian health services. President
With progress being made in establishing basic health services      Richard M. Nixon’s Indian Policy
during the 1950s, the IHS shifted its emphasis to health            Statement of July 8, 1970, had the
program management, health planning, health professional and        most significant effect on Federal-Indian relations since the
health occupations training for Indians, and health manage-         end of the treaty-making era. The President noted that
ment training for IHS administrators. Carruth J. Wagner,            Federal-Indian relations were based on the U.S. Constitution
M.D., the second director of the IHS, served from 1962 to           and on treaties between the U.S. Government and the
1965 and focused on building management skills and training         Governments of Indian Tribes – a Government-to-Govern-
personnel at all levels to lead the program. Medical and dental     ment relationship. He advanced the concept of Tribal “self-
residencies were established as well as training programs for       determination,” proposing that Federal programs provided to
nursing, nutrition, and environmental health.                       Tribes be “taken over” and managed by Tribal Governments.
                                                                    These new Federal policies led to landmark legislation to
                                                                    support self-determination and improve Indian health care.
Under the 1966-1969 leadership of Erwin S. (Stu) Rabeau,                                                                                 9
M.D., the third IHS director, an innovative training center
Emery A. Johnson, M.D., the fourth IHS director, served             Health committees formed by individual
from 1969 to 1981 and is known to have had superior and             Tribes or intertribal organizations
legendary political skills. He immediately recognized that the      evolved into more formal Area-wide
remarkable change in Federal Indian policies had tremendous         boards. In 1972, the Area Health
potential for improving Indian health services. He worked the       Boards formed the National Indian
political channels to expand health care programs, fostering        Health Board (NIHB). The NIHB and
Indian leadership to obtain funding for new programs.               the American Indian Health Care
                                                                    Association (AIHCA), formed by the
                                                                    Urban Indian Health programs, were
During this period, Congress established President Nixon’s          the first national Indian-controlled
Government-to-Government relationship policy in law through         organizations directed toward their own
the passage of the Indian Self-Determination and Education          health-care programs. Another strategy
                        Assistance Act (ISDEAA) (Public Law         to assist Indian participation and
                        93-638) in 1975. The law provided           acceptance was the promotion of
                        that any Indian Tribal Government           collaboration between “Western” (e.g.,
                        could, on request, take over the            IHS) and American Indian medicine.
                        operation of any BIA or IHS function.       Collaboration had begun earlier with
                                                                    Dr. Shaw, the founding director of the IHS, who considered
                          Congress also established two major       native healers to be important participants in improving their
                          national goals in the Indian Health       communities’ health.
                          Care Improvement Act (IHCIA)
                          enacted in 1976: 1) to ensure the
                          health status of Indian people is
                                                                    The 1980s
                          elevated to the highest possible level,
                          and 2) to achieve the maximum             The 1980s were marked by great increases in funding for
participation of Indian people in the Indian health programs.       Indian health programs, special emphasis on professional
Additional innovations included the establishment of a              excellence, construction of modern health facilities, and
scholarship program to support preparatory and graduate             movement towards greater Tribal involvement. In 1981,
education for AI/ANs, the construction of Indian health             Everett R. Rhoades, M.D. (Kiowa) (1981-1993), became the
facilities and sanitation systems for Indian homes and commu-       first American Indian Director of the IHS – a leadership
nities, and authority to receive reimbursement through              landmark for the Agency. His profound sense of service to
Medicare and Medicaid programs for care rendered to Indians         Indian people led him to leave a successful academic career to
eligible for services under these programs.                         lead the IHS.

In the legislation, Congress gave the IHS a clear mandate not       The IHS was elevated to Agency status within the
only to provide medical care but also to eliminate the existing     United States Public Health Service (USPHS) in 1988.
health disparities between Indian people and the general U.S.       It had formerly been a Bureau within the Health Resources
population. The IHS efforts were directed toward developing         and Services Administration under the Department of Health
an efficient and effective health-care delivery system while        and Human Services. For the first time, a formal consultation
promoting AI/AN participation in and management of their            process between the IHS and Tribes was begun in the “Tulsa
own health-care systems.                                                                                                             10
One” meeting in the mid-1980s. Tribal Governments were             The Current Status of the IHS
involved in establishing and designing allocation methodologies
to be used in annual appropriations.
                                                                   Providing services in the community has always been a
                                                                   hallmark of the IHS program. Charles W. Grim, D.D.S.,
Attention was focused on disparities in the level of funding for   M.H.S.A. (Cherokee) (2002-present), the current IHS
individual Tribal and community programs, and the concept of       Director, has advocated for and enhanced the two major and
equity in the allocation of resources was given major attention.   fundamental achievements of the present system of health
Further refinement of IHS mechanisms for measuring both            care for AI/ANs: 1) the development of comprehensive,
the “level of need funded” and a “resource requirement             community-oriented care, with the consolidation of preventive,
methodology” was useful not only in the formulation of the         curative, environmental, and local management within a single
IHS budget but also in its execution.                              national program; and 2) the transition from a directly
                                                                   operated Federal program to one under the control and
                                                                   direction of the local Indian community. Fundamental
The 1990s                                                          changes in Indian health services continue and are supported
                                                                   by Dr. Grim.
The 1990s were characterized by the continued evolution of
the self-determination process and the conversion of the IHS       Emphasis is on decentralized operations that are integrated
Director position from career public health officer to political   through 12 regions, identified as Area Offices, and IHS
appointee. Michael H. Trujillo, M.D. (Laguna), IHS Director        Headquarters, located in Rockville, Maryland. The basic
from 1994 to 2002 and the first political appointee, was           organizational element in the IHS health care program is the
known for his strong support of self-determination.                service unit, which serves the local community. It often is a
                                                                   hospital-based program with outlying clinics, but many service
With the passage of the ISDEAA in 1975, legislation was in         units are made up of one or more ambulatory-care facilities.
place to support the process for Tribes to contract or assume      The unique mission, goal, and emphasis on comprehensive
the responsibility for programs formerly managed by the IHS.       community-based care makes the IHS one of the most
As experience was gained in the 1980s, the process evolved         complex organizations of any type for delivering health care to
from “self-determination” into “self-governance.” In 1994,         the sovereign Indian Nations.
Congress passed legislation to extend Tribal self-governance on
a demonstration basis to allow Tribes to contract for the          Presently, 34 Urban programs, generally operated by local non-
programs, services, functions, and activities within the IHS       governmental and non-Tribal organizations, provide various
and BIA. The success of the demonstration period resulted in       clinical services as well as active outreach programs to assist
permanent authority in 2000.                                       urban Indians in gaining access to other programs. The Urban
                                                                   programs are partially supported through contracts with the
With the continued evolution of the process, the total Indian      IHS.
health system became identifiable by distinct sectors. These
sectors include those managed by the IHS, those managed by         The IHS Headquarters integrates the vast and myriad pro-
Tribes, and those categorized as Urban Indian health programs,     grams operating under very different circumstances across the
with the total system described as “I/T/U.” With the transfer      Nation into a coherent, unified program meeting the various
of IHS programs to Tribal entities, IHS Headquarters and           mandates set by Congress. Area Offices provide valuable
Area Offices decreased dramatically in size.                       support services on a regional basis to the service units within
                                                                   their jurisdiction.



Federal Paternalism
Since its beginning as an independent nation, the United
States has assumed responsibility for dealing with the
indigenous peoples of this country. Article 1, section 8,
clause 3 of the U.S. Constitution regulates commerce “with
foreign Nations and among the several States, and with
Indian Tribes.” Article II, section 2,
clause 2, the treaty clause, grants the
Federal Government the exclusive
authority to make treaties on behalf of          “The Government’s long-range goal for
the United States. These two clauses             our Indian citizens -- economic self-sufficiency,
establish the cornerstone of Federal             with access to good health services, good schools
Indian policy.                                   and good housing, and participation on a basis of
                                                 equality in the life of the country and community.”
The Federal Government has a special                                                   - 1957 IHS Gold Book
relationship with the Tribal Govern-
ments it has recognized. It considers
them “dependent” Nations within the United States and, in
turn, assumes a trust responsibility to these Indian Nations
based on treaties, court determinations, and Federal laws.
The Federal Government has provided services to Indians for
more than 200 years. The earliest Federal services provided
to Indians were based on treaties and were intended to
compensate Indians for the land cessions and other benefits
granted to the United States. This relationship continues to
carry immense legal and moral obligations.
Transfer of the Indian Health Service to                             organizations and public officials felt that health care could
the Public Health Service                                            better be served by the USPHS under the Department of
                                                                     Health, Education, and Welfare (HEW), now the Department
                                                                     of Health and Human Services (HHS).
In the early 1800s, the provision of Federal health services to
Indians was part of the U.S. Army’s responsibility to control        In 1954, Congress enacted the Transfer Act to move the
the spread of infectious diseases and, in particular, to protect     responsibility for Indian health care to HEW. In 1955, the
soldiers and other non-Indians living nearby. It was not until       Indian Health Service (IHS) became an agency within the
1832 that Congress first appropriated funds for health care to       USPHS. Since the Transfer Act, health care to AI/ANs has
                                    Indian people specifically for   improved significantly. In 1959, the Indian Sanitation
                                    the purpose of purchasing        Facilities Act enabled sanitation to become an integral part of
                                    quantities of the smallpox       the national IHS public health program. The provision of safe
                                    vaccine to immunize the          water and sanitation has dramatically contributed to improving
                                    Indians. While the responsi-     the health status of AI/ANs.
                                    bility for Indian health care
                                    began with the War Depart-
                                    ment, that responsibility was    1950s and 1960s: Termination of Fed-
                                    transferred to the newly         eral Trusteeship Over Indians
                                    created Department of the
                                    Interior in 1849.
                                                                     In the 1950s, the termination policy of the Federal Govern-
                                                                     ment was intended to assimilate Tribes into the broader society
                                    It was not until 1908 that       by the rapid termination of the Tribal/Federal Trust relation-
                                    the Bureau of Indian Affairs     ship, elimination of the reservations, and relocation of Indians
                                    (BIA) within the Depart-         to urban areas of the country. It was believed that if Indian
                                    ment of the Interior began       people were relocated from their reservations to urban and
                                    to develop health services for   non-reservation areas, they would assimilate into the general
                                    Indians. By 1910, Congress       society more rapidly, move away from their traditional ways of
                                    began appropriations for         living, ultimately become part of the larger culture and society,
health care services administered by the BIA. In 1921,               and be free from Government control and oversight. It was
Congress enacted the Snyder Act, authorizing funding for             also anticipated that Indian people would become more
Federal Indian health programs for the relief of distress,           economically successful and, thereby, be released from the
conservation of health, and employment of physicians for             poverty and unemployment that existed on many of the Indian
Indian Tribes as well as directing the BIA to administer             reservations.
programs “for the benefit, care, and assistance for the Indians
throughout the United States.”
                                                                     The result of the termination policy was the sale of Tribal
                                                                     lands, assumption of judicial authority by State governments
In 1926, commissioned corps officers of the United States            over the terminated Indian lands, and the right of States to tax
Public Health Service (USPHS) began to be assigned directly          those terminated Indian lands. It also devastated Tribal
to Indian health programs. During the period that responsibil-       communities and, in turn, Tribal customs, languages, and
ity for Indian health remained with the BIA, Indian advocacy         cultures. During the “termination period,” Congress enacted         14
legislation that terminated the Tribal/Federal Trust relationship   Evolution of Tribal Self-Determination:
with 109 Tribes and Bands. The effect was the termination of
Tribal sovereignty for these 109 Tribes and Bands. Fortu-
                                                                    Where We Are Today
nately, Congress has not terminated a Tribe since 1966.
                                                                    During the Administration of President Richard M. Nixon
                                                                    Indian self-determination progressed quickly. In 1970,
1960s and 1970s: Acculturation and                                  President Nixon’s Special Message to Congress called for “self-
Integration                                                         determination without termination.” In 1975, Congress
                                                                    enacted the Indian Self-Determination and Education
                                                                    Assistance Act (ISDEAA), Public Law (P.L.) 93-638. This
Acculturation and integration of Indians into the larger U.S.
                                                                    Act heralded a new era in Indian policy, which Tribes promptly
culture and society were always goals of the U.S. Government
                                                                    embraced. During this period, Congress passed legislation to
since it was believed that the most appropriate way to improve
                                                                    restore individual Tribes that had been terminated.
their educational, social, and economic status would be if they
were to learn English and the skills of the larger culture of the
country. Unfortunately, this meant that Indians would lose          In 1976, Congress passed the Indian Health Care
their individual languages and cultural and Tribal identities.      Improvement Act, P.L. 94-437, which provided
                                                                    authority for specific directives, programs, and
                                                                    activities. With the passage of these key statutes,
Government boarding schools were established in the mid-19th                                                                            without termination”
                                                                    Tribes began to contract under the ISDEAA
century with the specific agenda of stripping Indians of their
                                                                    programs authorized by the Indian Health Care                                - President Richard Nixon
languages and cultures as a way to assimilate them into the                                                                                  Special Message on Indian Affairs
                                                                    Improvement Act.
larger society and culture of the country. Throughout the
mid-19th and the 20th centuries, Congress, Tribes, Indian
advocacy groups, governmental studies, social policy makers,        In 1994, Congress passed legislation to extend Tribal self-
and scholars debated over the appropriate manner to diminish,       governance on a demonstration basis to allow Tribes to
destroy, or conserve Indian culture.                                contract for the programs, services, functions, and activities at
                                                                    the BIA and the IHS. The demonstration program was so
                                                                    successful that Congress passed legislation in 2000 to make
By the 1960s, Indians began to advocate for their own civil
                                                                    self-governance a permanent authority for the IHS and the
rights and self-determination. By the early 1970s, the period
of “relocation” ended. The social and political movements of
the 1960s and 1970s were not missed by AI/ANs. It was
during this period that the era of “self-determination” as a        A key factor in the success of the policy of Indian self-
Federal policy began to emerge. Self-determination meant            determination is that it authorizes Tribes to plan and deliver
that Tribes could determine their own destiny and manage their      services appropriate to their diverse demographic, economic,
own Federal programs in a manner that was appropriate to            and institutional needs. There are 562 federally recognized
their individual Tribal communities. During this era, Indian        Tribes, and more than 50 percent of the IHS budget is
activist groups and Tribal and Urban Indian leaders questioned      contracted to Tribes though the ISDEAA.
and challenged Federal policies towards AI/ANs while asserting
their rights under hundreds of treaties that promised rights,
benefits, and services based on their relinquishment of millions
of acres of Indian lands and other benefits to the United                                                                                                                        15

American Indians and Alaska Natives (AI/AN) are represented         1959 with its population of Alaska Natives, and overall
by 562 federally recognized Tribes that are culturally diverse      population growth contributed to this four-fold increase among
and strong. The Tribes have different population characteris-       AI/ANs. The AI/AN population served by the IHS also grew
tics and a multitude of native languages.                           tremendously during this time period.

Populations of AI/ANs: U.S. Census, IHS Service, IHS User           The proportion of AI/ANs living in urban locations also
   3,000,000                                                        changed. In 1950, the estimated number of AI/ANs living in
                                                                    urban settings was 55,909 (16 percent). As of the 2000
   2,500,000                                                        Census, the estimate was approximately 1,497,402
                                                                    (60 percent), a three-fold increase.
                             US Census AI/AN
                                                                    In 1950, American Indians experienced overcrowding and a
                                                                    lack of plumbing, electricity, and adequate sanitation facilities.
                                                                    Some 67 percent of American Indians lived in overcrowded
                                                   IHS AI/AN User
                                                                    dwellings. As of 2000, 14.8 percent of AI/ANs were living in
                                       IHS AI/AN Service            overcrowded dwellings. While a vast improvement, this figure
                                                                    is still 2.5 times higher than the overall U.S. population.

                                                                    More than 265,000 Indian homes have been provided with
               1950   1960   1970     1980      1990       2000

                                                                    sanitation facilities since 1959, when the Indian Sanitation
In 1955, the Bureau of Indian Affairs (BIA) estimated the           Facilities Act (Public Law 86-121) authorized the construc-
American Indian population in the continental United States         tion of essential sanitation facilities. However, some 40,000
(excluding Alaska) to be 472,000 persons. The 2000 Census           Indian homes still lack either a safe water supply or sewage
counted almost 2.5 million AI/ANs. More accurate popula-            disposal, or both.
tion enumeration methodologies, the addition of Alaska in

According to the 1950 Census, the median income for              In terms of the educational attainment of American Indians,
American Indians was $725. This equates to $5,011 in 1999        the median school years completed in 1950 was 7.1 years. By
dollars. The median income of AI/ANs in the United States        2000, 70.9 percent of AI/ANs had received a high school
in 1999 was $30,599. Poverty still disproportionately affects    diploma (including equivalency) or some college, an associate’s
the AI/AN population, with some 25.7 percent living with an      degree, a bachelor’s degree, or a graduate/professional degree.
income below the poverty level.

                                                Median Household Income 1950 and
                                                      2000, in 1999 Dollars.





                                                       1950               1999

                                                                       of American

Elevating Health Status                                            disparities have emerged; diabetes among Indians is at crisis
                                                                   proportions, as an example. The IHS mission is not yet fully
The Indian Health Service (IHS) has attained a remarkable
record of achievement in improving the health of Indian
people. This is one of the few bright spots to emerge from the     1950s
history of relations between American Indians and the Federal
Government. The IHS has raised the health status of the
American Indian and Alaska Native (AI/AN) population               In the first decades of the IHS, emphasis was placed on
dramatically over the past 50 years, a striking achievement in     children’s health and the control of communicable diseases.
the light of the poverty and stark living conditions experienced   Priority problems among American Indians included complica-
by this population.                                                tions of childbirth, vaccine-preventable diseases, malnutrition,
                                                                   basic sanitation, treatment of dysentery, acute care for injuries,
                                                                   and tuberculosis (TB). In 1956, fully half of all hospital beds
Starting as an emerging Government health care system caring       in IHS and contract hospitals were occupied by TB patients.
for America’s poorest, rural, and most vulnerable populations,     Heart disease was the leading cause of death, with a rate per
the IHS was not anticipated by many to become successful.          100,000 population of 170 deaths, half of which were due to
Such an accomplishment is due to a succession of dedicated         coronary artery disease. Unintentional injury was the second
IHS leaders, a strongly committed workforce, the support of        leading cause of death, with half of these deaths due to motor
Tribes and Congress, and an unwavering devotion of all to a        vehicles. Enteric diseases were very common due to the
singular mission — to raise the physical, mental, social, and      80 percent of AI/AN homes that lacked indoor plumbing
spiritual health of AI/AN people to the highest level. Despite     and a safe water supply.
imperfections and the lingering health problems that exist
among Indian people, the IHS is an example of a Federal
program that has worked.                                           21st Century

Despite many successes to tell, the story is incomplete. The       As the IHS advances in the 21st century, immunization rates
needs of Indian people have changed enormously in the past         are high, infant mortality rates are low, TB has been largely
half century. Progress in eliminating health disparities has       controlled, and most communities are experiencing access to a
slowed, particularly in the last 15 years. New health gaps and
            The 10 Leading Causes of Death
                in the AI/AN Population
            1951-1952	                    1996-1998
 1.	   Heart disease            1.    Heart disease
 2.	   Accidents                2.    Cancer
 3.	   Influenza and pneumonia  3.    Accidents
 4.	   Tuberculosis             4.    Diabetes
 5.	   Certain diseases         5.    Chronic liver

       of early infancy               disease

 6.	   Cancer                   6.    Stroke
 7.	   Intestinal disease       7.    Pneumonia and

       (dysentery, enteritis)         influenza

 8.	   Stroke                   8.    Suicide
 9.	   Congenital               9.    Chronic obstructive
       malformations                  pulmonary disease
10.    Homicide	               10.    Homicide

safe water supply. The immunization rate among AI/AN                this significant increase has made it the fourth leading cause of
children was 83 percent in 2001. The rate of new TB cases in        death among AI/ANs. Complications of diabetes, such as
the IHS in 2001 was 13.2 per 100,000 population. By                 heart disease, kidney failure, vision loss, and amputations have
2000, infant mortality was reduced to 9.0 deaths per 1,000          increased enormously since 1955. While the IHS has become
live births, almost one-tenth of the AI infant-mortality rate of    a world leader in treating diabetes, the challenge for the future
1955. The number of AI/AN homes with indoor plumbing                will be working at the local level to change eating and exercise
increased over four-fold from 1950 to 2004.                         behaviors and ultimately reducing the prevalence of this
                                                                    devastating and costly disease.

The average life expectancy of AI/ANs has increased by
10 years since 1955, leading to a rapid increase in the number      Fifty years ago, cancer was a rare disease among AI/ANs.
of elders and an increasing need for facilities to care for them.   Cancer death rates have steadily increased since that time,
Several factors have contributed to a shift in the pattern of       although they are still lower than the U.S. rate for all races.
disease for AI/ANs, most notably the control of infectious          The increase is due to many factors, including increased
diseases; access to abundant fast foods and foods high in sugar     smoking, sedentary lifestyle, changes in diet, fewer pregnan-
and fat; commercial tobacco products; and the overall transi-       cies, an aging population, and, possibly, an increase in exposure
tion to a more Western lifestyle. Chronic diseases now account      to environmental pollution.
for 6 of the top 10 leading causes of death, with an epidemic of
obesity and diabetes affecting every community.
                                                                    From 1954 to 1998, the total injury rate among AI/ANs
                                                                    decreased approximately 36 percent. Important strides are
At the time the IHS was established, diabetes was not among         being made in the area of injury prevention, but injuries still
the 10 leading causes of death. In the last 50 years, there has     account for 41 percent of the years of potential life lost, and
been a four-fold increase in the death rate due to diabetes, and    unintentional injuries are the leading cause of death for           20
              AI/AN Unintentional Injury Deaths                     disparities are significant and vexing, and range across a
                                 1954           1996-1998
          spectrum of emotional pain and physical suffering. Alcoholism
                                                                    rates are over seven times the national average, suicide rates are
Total injury deaths             136.0           52.4                almost double, and homicide rates are one-and-a-half times the
Motor vehicle related deaths     68.9           51.2                national average for all races.
Deaths due to other injuries     67.1           36.4   rate per
                                                       population   The guarded hope rests in the fact that Tribes and Tribal
                                                                    communities have, in the past 20 years, increasingly chosen to
                                                                    take responsibility for behav-
AI/ANs under age 44. Community-based injury-prevention
                                                                    ioral health care delivery. The
work must continue to improve safety and reduce dangers that
                                                                    IHS Division of Behavioral
lead to illness and death among the AI/AN people.
                                                                    Health (DBH) was established
                                                                    in 1995 as a response to
Findings from IHS patient-based surveys indicate a higher           Tribal self-determination and
prevalence of oral diseases for American Indians. Most oral         a national movement that
diseases result from limited access to community and personal       viewed alcoholism/substance
preventive measures, such as fluoridated water and toothpaste,      abuse and mental health/social
as well as lack of oral hygiene. More recent surveys done IHS-      services as integrated, not
wide in 1984, 1991, and 1999 show a general decrease in the         separate. To that end, the
mean number of decayed, missing, and filled permanent teeth         original Alcoholism and
for children.                                                       Substance Abuse and the
                                                                    Mental Health and Social
                                                                    Services program branches
Oral health has evolved from the days in 1913 when five             established in the mid-to late-
dentists were employed to by the Bureau of Indian Affairs to        1970s were combined in a
provide services to various reservations. Presently, a commu-       single division to improve
nity-oriented primary care model is used for dental services,       coordination and program-
with oral health organized into levels of care with special         ming. Today, the DBH
emphasis on community prevention programs. These advance-           supports the AI/ANs’ delivery
ments in the treatment and prevention of oral disease have          of behavioral health care by
improved the health and well-being of AI/ANs, with more work        providing national services
underway to bring the level of oral health up to par with other     and infrastructure. As care transitioned from the IHS to
U.S. populations.                                                   Tribal and Urban Indian health programs, the need to support
                                                                    Tribes in behavioral health care delivery became critical. The
The overall state of AI/AN behavioral health is one of great        primary areas of support include national programs and
need and guarded hope. The great need is seen in the external       programming, advocacy, education, traditional practice, and
demands upon individuals, families, and communities that are        health information systems. The DBH has become the
many and powerful. Long histories of subjugation and the            primary policy and legislative office and a national data
continued resulting challenges of changing cultures, poor           repository to support congressional funding of all BH services
economics, and lack of opportunities mean most of these             nationally.
demands are negative and destructive. Behavioral health                                                                                  21
Clearly, a need for the services provided by the IHS continues.
But in the face of the chronic diseases that now plague
AI/ANpeople, our approaches must expand and represent a
true partnership with individuals, families, and communities.
The recent past has shown that our progress in reducing the
overall mortality rate of AI/AN people has slowed down; it has
been a challenge to simply maintain access to critical services
by the continually growing AI/AN population. As a result, the
disparity between the health status of AI/ANs and the overall
U.S. population is actually widening at the present time.
Thus, we must continue to seek more efficient and effective
approaches to address these health problems as well as advocate
for the resources that are essential to close the disparity gap.

 As with all organizations, time will bring new challenges and
new ways for the Indian health system to serve. The story to
be told at the 100th anniversary will be different from the one
told in 1955 or today. One constant that will remain is the
resolve and deep commitment of the IHS and its stakeholders
to do all that is in our power to accomplish our vital mission.


Comparison of IHS: 1950s-Present                                of Indian Affairs (BIA) to the United States Public Health
                                                                Service (USPHS) within what is now the Department of
A milestone was reached in 1954 when Congress transferred       Health and Human Services. It is instructional to compare
the responsibility for American Indian and Alaska Native (AI/   and contrast some key attributes of the Indian health care
AN) health care from the Department of the Interior’s Bureau    system THEN and NOW.

                        Then – 1955                                                  Now – 2005
                                                  IHS Beneficiaries
In 1955, fewer than 500,000 Indians were identified in the      In 2005, the IHS provided personal health care services to
U.S. Census count. Of this number, the USPHS reported           more than 1.4 million AI/ANs, 442 percent more than in
serving 335,000 Indians primarily located in and around         1955. Additionally, more than 200,000 Indians not person-
reservation lands. The IHS services available outside of        ally receiving medical care from the IHS or Tribal programs
reservation areas were extremely limited or non-existent.       live in or near Indian communities that benefit from IHS
                                                                environmental, sanitation, and community public health
                                                                programs. Among urban areas, where more than 600,000
                                                                Indians reside, 34 Urban programs provide limited health care
                                                                services to approximately 100,000 urban Indians.

                        Then – 1955                                                      Now – 2005

In 1955, the USPHS administered Indian health services at         In 2005, the IHS appropriation was $3.77 billion, a 108-fold
an annual cost of $35 million, about $24 million of which was     increase in 50 years. Of the total 2005 funding,
for the lower 48 States and $11 million for Alaska. None of       $639 million (17 percent) was collected from Medicare,
the funding came from third-party collections. The IHS            Medicaid, and private insurance. Counting both appropria-
spending per person averaged about $71.                           tions and collections, the IHS spending per person is esti-
                                                                  mated at $2,100 for personal health care services plus $500
                                                                  for public health programs.

                                      1955 - $35 Million             2005 - $3.77 Billion

In 1956, the IHS employed about 2,900 employees: 350 at           In 2004, more than 15,000 full-time equivalents (FTE) were
Area Offices, 100 at Headquarters, and 2,450 at hospitals and     employed by the IHS (more than 1,000 assigned to Tribes).
other field locations. There was a wide variety of professional   The broad mix of medical and field health staff continues, but
and sub-professional groups, including physician, nurse, and      the percentage of the workforce in hospital settings is substan-
field health categories.                                          tially lower. There also is an unknown number (assumed to be
                                                                  in the thousands) of non-Federal health care staff working
                                                                  directly for Tribes.

                    Then – 1955                                                               Now – 2005
             A Program FOR Indians                                                       A Program BY Indians
Few Indians were represented in the professional and manage-      Now, AI/ANs predominate in the IHS workforce: 88 percent
ment ranks. Recruitment and staff turnover were chronic           of administrative FTEs, 94 percent of technical/clerical FTEs,
problems.                                                         and 50 percent of professional FTEs. Recruitment and
                                                                  turnover of health professionals are problems today as they
                      Indian                                      have been throughout the history of the program.
                                                                           Administrative              Technical/Clerical      Professional

                                                                   Non-                        Non-
                                                                  Indian                      Indian

                                                                                                                             Non-       Indian
                                                                  The Indian Health Care Improvement Act (P.L. 94-437),
                                                                  passed in 1976, created a scholarship program to support the
                                                                  development of AI/ANs as health professionals. Since its
                                                                  inception, more than 8,000 AI/AN students have been
                                                                  supported through the program.


In 1955, IHS facilities consisted of 48 hospitals, 18 health      In 2005, IHS and Tribal facilities consist of 48 hospitals,
centers, 62 stations, 150 locations, and 13 school infirmaries.   238 health centers, 6 school centers, 167 health stations, and
The Indian facilities were smaller than typical U.S. commu-       180 Alaska village clinics. Facilities are distributed more widely
nity hospitals and were widely distributed on and near reserva-   than in 1955, including some in urban settings, but the
tion lands. Hospitals and services provided in inpatient          geographic distribution continues to reflect historical Indian
settings predominated. Reports in 1957 characterized the state    lands. Although hospitals are retained in similar numbers, the
of facilities as “poor and outmoded.”                             revolutionary shift in patient care away from inpatient settings
                                                                  to ambulatory settings is not readily apparent in the numbers.
                                                                  Despite many improvements achieved by a continuous program
                                                                  to replace, expand, and modernize facilities, the age of IHS
                                                                  facilities and inadequate ambulatory care capacity continue to
                                                                  be problems.

                         Then – 1955                                                     Now – 2005

The IHS services for Indians included an array of curative and     To the extent resources permit, AI/ANs served by the IHS
preventive services ranging from hospital care to construction     receive a full range of preventive care, primary medical care
for safe water and waste disposal. Services in hospitals           (hospital and ambulatory care), community health programs,
predominated, and care was primary in nature. Substantial          alcoholism programs, and rehabilitative services. Secondary
staff efforts were focused on prevention activities, control of    medical care, specialized medical services, and other rehabilita-
communicable diseases, and field health activities such as         tive care are provided either by IHS staff or by non-IHS health
improvement in water supply, waste disposal, and other sanitary    providers under contract. The system approach is akin to rural
facilities on Indian reservations. Efforts to improve sanitation   medicine but with attributes that give it unique qualities and
in individual homes began.                                         flair – teamwork among doctors and other staff, unwavering
                                                                   commitment to community-based primary care, and accom-
                                                                   modation and respect for traditional Indian practices and
                                                                   beliefs. Extending beyond the medical model, IHS environ-
                                                                   mental and sanitation programs addressing conditions in
                                                                   Indian communities and homes have helped to lower
                                                                   dramatically the rates of communicable diseases, especially
                                                                   water- and waste-borne diseases.

                         Then – 1955                                                     Now – 2005

The IHS took from the BIA some structural legacies but             While the IHS has retained a layered structure of administra-
instituted new practices and approaches to management              tive support services in Area and program offices, an emphasis
brought by leadership that came from the USPHS. The first          on community-oriented primary care and attention to the
priority was to establish competent and high-quality medical       diversity among Indian communities have gradually produced a
care. Extensive recruitment of health professionals; the           more decentralized organization. The extent of decentraliza-
remodeling and renovation of health facilities; and the estab-     tion and Indian community control accelerated with the Tribal
lishment of clinical laboratories, radiological services, and      “self-determination” movement and laws. Paramount to the
surgical teams were undertaken. In the second phase, the IHS       success of the programs is the active involvement of the
emphasis shifted to health program management, comprehen-          community members themselves — not only by participating
sive health planning, health professional training for Indians,    in health programs and healthy living but also in directing and
and formal health-management training for IHS administra-          operating the programs. Tribal decisions to contract/compact
tors. In a phase leading to the present, efforts were undertaken   health care programs or to continue to have the IHS operate
to improve the efficiency and effectiveness of the service units   them are equal expressions of self-determination. Today,
and to expand the participation of Tribes and Indian communi-      approximately one-half of the IHS budget is allocated to fund
ties in managing their health affairs.                             tribally operated health programs.


                                                                     The Indian Health Service of Today
The Early Years
of the Indian Health Service                                         Although the character of remote reservation hospitals or
                                                                     health centers remains much the same, the Indian health care
                                                                     system of 2005 is far more complex than the one in 1955.
The heart of the Indian Health Service (IHS) has always been         Rural clinics are networked with large IHS medical and health
the small reservation hospital or health facility. Isolated and      centers that provide specialty care, such as surgery, coronary
self-sufficient, often grappling with problems that stretch          care units, and dialysis. Telemedicine connections bring sub-
available resources to the maximum, these small facilities have      specialist consultation to ice-bound villages in rural Alaska.
delivered primary care to generations of American Indians and        Patients are routinely transported to tertiary care hospitals and
Alaska Natives (AI/AN). The health facilities formed the hub         trauma centers by helicopter and airplane. Even small facilities
of a wheel – and in the center were the physicians, nurses,          are supported with an impressive array of modern medical
dentists, and pharmacists who delivered primary care. Radiat-        technology and information systems. A small army of commu-
ing out from this center were public health nurses, sanitarians,     nity health representatives, diabetes educators, health educa-
engineers, social workers, health educators, and other commu-        tors, dieticians, and outreach workers deliver health promotion
nity health workers. Whether serving a compact pueblo or the         messages and services to the community.
scattered clans of semi-nomadic hunters and shepherds, the
IHS health facility was typically the only source of modern
health care for a region. Most health services were managed          The modern IHS is quite decentralized, with fully half of the
locally, but extremely ill patients had to be transported to a       Indian health care system now being managed by Tribal health
more specialized city hospital for treatment. Transporting a         departments under self-determination compacts. The IHS
critically ill patient by pickup truck or by dogsled might prove     decisions are made in consultation with Tribal Leaders, and
to be a dangerous course of action. Traditional healers              many functions formerly performed by Area and Headquarters
practicing in their communities were viewed as a problem by          officials are now locally managed by the Tribes or Tribal health
many IHS providers. The Indian health care administration            boards. Tribal Leaders have developed a sophisticated under-
was paternalistic and highly centralized, with local service units   standing of health care and take an active role in advocating
reporting to Area Offices, which reported to Washington.             and planning for the health care needs of their own communi-
Decisions were made in Washington, with little input from            ties. Tribal communities expect and demand a high level of          28
Tribal Leaders.                                                      care.
Some things have not changed in 50 years: a sense of shared        It has become obvious to all of us in the Indian health system
mission, the willingness to provide care under difficult condi-    that addressing behavioral health and mental health issues in
tions, and the integration of public health principles into        our communities is crucial. The high level of mental illness
clinical practice. Also persistent are the chronic shortage of     and suicide rates among AI/AN youth is an indicator of the
human and financial resources and the challenges of providing      need to address a new set of very difficult behavioral health
care in the poorest and most remote corners of the country.        challenges. Not only is suicide the third leading cause of death
                                                                   for Indian youth ages 15-19, but the rates of suicide among
                                                                   Indian youth are the highest of any racial group in the Nation.
The Challenges of the Future – Progress                            We need to focus on screening and primary prevention in
                                                                   behavioral health.
Brings New Challenges
                                                                   The public health principles that have served the Indian health
As we begin the next 50 years of service, the IHS will face new
                                                                   system so well in the first 50 years will be even more important
challenges and exciting opportunities. The medical and public
                                                                   in the next 50 years. With the challenges of chronic diseases
health interventions that were effective in eliminating certain
                                                                   such as diabetes, obesity, cardiovascular disease, cancer, and
infectious diseases, improving maternal and child health, and
                                                                   injuries as well as the challenges of behavioral health, preven-
increasing access to clean water and sanitation are still needed
                                                                   tion is more important than ever. We must continue to
and very important to maintaining progress in decreasing the
                                                                   promote and develop community resources and involvement in
disparities in health status experienced by AI/ANs. But we are
                                                                   order to target health promotion efforts at the local level.
facing new challenges in dealing with chronic diseases that were
not major issues in past years as well other challenges that are
behavioral in nature and with which our traditional interven-      As Tribes continue to mature in their capacity to assume the
tions are not as effective. We are being challenged to focus on    management of health programs, the partnership between the
the health of communities rather than the medical needs of         IHS and Tribal health programs will be more critical than ever.
individuals.                                                       Our shared mission is vital to the health of AI/ANs across the
                                                                   Nation and in the generations to come.
A complex set of conditions, including longer life expectancy,
dramatic lifestyle changes, changes in dietary practices,
pollutants, and a variety of other environmental changes,
contribute to new challenges in managing chronic disease.
If we are to critically influence the future of our communities,
we not only must address the primary prevention of these
chronic diseases but also must look at improved chronic disease
management in our clinical care to patients.

                                    The information included in this summary is derived from the full publication
                                    that updates the 1957 IHS Gold Book, which is currently under preparation
                                    and is expected to be released in the coming year.
                                    Materials used to compile this summary include:
                                    •	 Indian Health Service file photos (circa 1950 through 2005).
                                    •	 Bergman, A.B. Milbank Quarterly. “A Political History of the Indian Health
                                      Service.” Malden, MA: Blackwell Publishers. 1999. Vol. 77(No. 4). pp 571-604.
                                    •	 Public Health Service, Office of the Surgeon General. Indian Health Service.
                                      Health Services for the American Indian (1957 IHS Gold Book). February 1957.

The mission of the IHS, in          •	 Rhoades, Everett R. American Indian Health: Innovations in Health Care, Promotion,
                                      and Policy. Baltimore, Maryland: Johns Hopkins University Press. 2000.
partnership with
                                    •	 U.S. Department of Commerce, Economics and Statistics Administration.
American Indian and                   U.S. Census Bureau. Census 2000 Brief. Structural and Occupancy Characteristics
Alaska Native people,                 of Housing: 2000. November 2003.
is to raise their physical,         •	 U.S. Department of Commerce, Economics and Statistics Administration.
mental, social, and                   U.S. Census Bureau. Census 2000 Brief. The American Indian and Alaska Native
                                      Population: 2000. February 2002.
spiritual health to the
                                    •	 U.S. Department of Commerce, Bureau of the Census. United States Census of
highest level.                        Population: 1950 (Vol. 4). Special Reports: Nonwhite Population by Race
                                      (P-E No. 3B). Washington DC: U.S. Government Printing Office. 1953.
                                    •	 U.S. Department of Health and Human Services, Indian Health Service.
The goal is to assure that            The Sanitation Facilities Construction Program of the Indian Health Service:

                                      Public Law 86-121 Annual Report for 2004.

comprehensive, culturally
acceptable personal and public      •	 U.S. Department of Health and Human Services, Indian Health Service.
                                      Trends in Indian Health, 2000-2001 Edition. Washington, D.C.:
health services are available and     U.S. Government Printing Office. February 2004.
accessible to American Indian
and Alaska Native people.

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