Envisioning health equity for American Indian/Alaska Natives: a unique HIT opportunity.

The Indian Health Service provides care to remote and under-resourced communities in the United States. American Indian/Alaska Native patients have some of the highest morbidity and mortality among any ethnic group in the United States. Starting in the 1980s, the IHS implemented the Resource and Patient Management System health information technology (HIT) platform to improve efficiency and quality to address these disparities. The IHS is currently assessing the Resource and Patient Management System to ensure that changing health information needs are met. HIT assessments have traditionally focused on cost, reimbursement opportunities, infrastructure, required or desired functionality, and the ability to meet provider needs. Little information exists on frameworks that assess HIT legacy systems to determine solutions for an integrated rural healthcare system whose end goal is health equity. This search for a next-generation HIT solution for a historically underserved population presents a unique opportunity to envision and redefine HIT that supports health equity as its core mission.

The public health foundation of health services for American Indians & Alaska Natives.

The integration of public health practices with federal health care for American Indians and Alaska Natives (AI/ANs) largely derives from three major factors: the sovereign nature of AI/AN tribes, the sociocultural characteristics exhibited by the tribes, and that AI/ANs are distinct populations residing in defined geographic areas. The earliest services consisted of smallpox vaccination to a few AI/AN groups, a purely public health endeavor. Later, emphasis on public health was codified in the Snyder Act of 1921, which provided for, among other things, conservation of the health of AI/AN persons. Attention to the community was greatly expanded with the 1955 transfer of the Indian Health Service from the US Department of the Interior to the Public Health Service and has continued with the assumption of program operations by many tribes themselves. We trace developments in integration of community and public health practices in the provision of federal health care services for AI/AN persons and discuss recent trends.

American Indian health policy: historical trends and contemporary issues.

The United States has a trust responsibility to provide services to American Indians and Alaska Native (AI/AN) persons. However, a long-standing history of underfunding of the Indian Health Service (IHS) has led to significant challenges in providing services. Twentieth century laws, including the Snyder Act, Transfer Act, Indian Self-Determination and Education Assistance Act, and Indian Health Care Improvement Act (IHCIA) have had an effect on the way health services are provided. IHCIA was reauthorized as part of the Patient Protection and Affordable Care Act (ACA). Several provisions in ACA allow for potential improvements in access to services for AI/AN populations and are described herein. Although policy developments have been promising, IHS underfunding must be resolved to ensure improved AI/AN health.

History, law, and policy as a foundation for health care delivery for American Indian and Alaska native children.

Most American Indian and Alaska Native Children (AIAN) receive health care that is based on the unique historical legacy of tribal treaty obligations and a trust relationship of sovereign nation to sovereign nation. From colonial America to the early 21st century, the wellbeing of AIAN children has been impacted as federal laws were crafted for the health, education and wellbeing of its AIAN citizens. Important public laws are addressed in this article, highlighting the development of the Indian Health Service (IHS), a federal agency designed to provide comprehensive clinical and public health services to citizens of federally recognized tribes. The context during which various acts were made into law are described to note the times during which the policy making process took place. Policies internal and external to the IHS are summarized, widening the lens spanning the past 200 years and into the future of these first nations' youngest members.

Forty years in partnership: the American Academy of Pediatrics and the Indian Health Service.

Fifty years ago, American Indian and Alaska Native children faced an overwhelming burden of disease, especially infectious diseases such as pneumonia, meningitis, tuberculosis, hepatitis A and B, and gastrointestinal disease. Death rates of American Indian/Alaska Native infants between 1 month and 1 year were much higher than in the US population as a whole, largely because of these infectious diseases. The health care of American Indian/Alaska Native patients was transferred to the Department of Health, Education, and Welfare in 1955 and placed under the administration of an agency soon to be known as the Indian Health Service. The few early pediatricians in the Indian Health Service recognized the severity of the challenges facing American Indian/Alaska Native children and asked for help. The American Academy of Pediatrics responded by creating the Committee on Indian Health in 1965. In 1986 the Committee on Native American Child Health replaced the Committee on Indian Health. Through the involved activity of these committees, the American Academy of Pediatrics participated in and influenced Indian Health Service policies and services and, combined with improved transportation, sanitation, and access to vaccines and direct services, led to vast improvements in the health of American Indian/Alaska Native children. In 1965, American Indian/Alaska Native postneonatal mortality was more than 3 times that of the general population of the United States. It is still more than twice as high as in other races but has decreased 89% since 1965. Infectious diseases, which caused almost one fourth of all American Indian/Alaska Native child deaths in 1965, now cause <1%. The Indian Health Service and tribal health programs, authorized by the Indian Self-Determination and Education Assistance Act of 1976 (Pub L. 93-638), continue to seek American Academy of Pediatrics review and assistance through the Committee on Native American Child Health to find and implement interventions for emerging child health problems related to pervasive poverty of many American Indian/Alaska Native communities. Acute infectious diseases that once were responsible for excess morbidity and mortality now are replaced by excess rates resulting from harmful behaviors, substance use, obesity, and injuries (unintentional and intentional). Through strong working partnerships such as that of the American Academy of Pediatrics and the Indian Health Service, progress hopefully will occur to address this "new morbidity." In this article we document the history of the Indian Health Service and the American Academy of Pediatrics committees that have worked with it and present certain statistics related to American Indian/Alaska Native child health that show the severity of the health-status disparities challenging American Indian/Alaska Native children and youth.

The health care experiments at Many Farms: the Navajo, tuberculosis, and the limits of modern medicine, 1952-1962.

In January 1952 a team of medical researchers from Cornell Medical College learned that tuberculosis raged untreated on the Navajo Reservation in Arizona. These researchers, led by Walsh McDermott, recognized a valuable opportunity for medical research, and they began a ten-year project to evaluate the efficacy of new antibiotics and test the power of modern medicine to improve the health conditions of an impoverished rural society. The history of this endeavor exposes a series of tensions at the heart of medical research and practice. Researchers exploited the opportunities made possible by the ill-health of a marginalized population, but did so with the cooperation and gratitude of the Navajo. They introduced new antibiotics that liberated patients from hospitals, but erected an intrusive system of outpatient surveillance. They provided innovative health-care services, but failed to reduce the dominant causes of morbidity and mortality. As every act of treatment became an experiment, they risked undermining the trust on which research and clinical care depended.

The U.S. Public Health Service Commissioned Corps: a need for engineers.

In 1798, President John Adams signed the bill creating the Marine Hospital Service to medically care for U.S. merchant seamen. That agency is known today as the U.S. Public Health Service (PHS). In 1918, the PHS Commissioned Corps commissioned sanitary engineers in the Reserve Corps, and in 1930, President Herbert Hoover signed the Parker Act authorizing sanitary engineers to be part of the regular Commissioned Corps. During the world war years, PHS engineers were detailed to improve sanitation for military bases in the United States and abroad. In the 1960s, most PHS engineers served in the Indian Health Service, upgrading sanitation facilities for American Indians and Alaskan Natives. During the 1970s, PHS engineers were involved in providing an integrated and coordinated attack on environmental issues. Today, PHS engineers are involved with many aspects of public health protection and have been detailed around the world to provide emergency assistance in the wake of disasters.

The IHS dental program--a historical perspective.

The federal government provides health services for American Indians and Alaska Natives based on treaties with tribes, legislation, and executive orders. These services began in the late 1700s, when they were the responsibility of the Department of War. This responsibility was later transferred to the Bureau of Indian Affairs and in 1955 the Indian Health Service was established within the United States Public Health Service. This paper describes the development and mission of the Indian Health Service dental program. During the 1950s, Public Health Service officers were assigned to the dental program, dental assistant training centers were established, and clinical prevention programs were implemented. Increased dentist recruitment, the implementation of four-handed dentistry, and the development of an automated information system were the highlights of the 1960s. Considerable effort was placed on work force development during the 1970s, while expansions of both treatment and prevention services were the highlights of the 1980s. Unfortunately, decreases in administrative staffing and a decline in clinical services have been noted during the last decade. The main reasons for the decline were initiatives to reduce the size of federal government and inability to recruit and retain dentists in clinical positions. Also, many tribes have elected to manage their own programs and have requested and received their share of IHS administrative funds to use in their programs. Recent pay and budget legislation along with changes in program management should reverse this trend.

A political history of the Indian Health Service.

One of the few bright spots to emerge from the history of relations between American Indians and the federal government is the remarkable record of the Indian Health Service (IHS). The IHS has raised the health status of Indians to approximate that of most other Americans, a striking achievement in the light of the poverty and stark living conditions experienced by this population. The gains occurred in spite of chronically low funding and can be attributed to the combination of vision, stubbornness, and political savvy of the agency's physician directors and the support of a handful of tribal leaders and powerful allies in the Congress and the White House. Despite the agency's imperfections and the sizeable health problems that still exist among American Indians and Alaskan Natives, the IHS is an example of one federal program that has worked.

The history and politics of US health care policy for American Indians and Alaskan Natives.

This paper traces the development of the US federal government's program to provide personal and public health services to American Indians and Alaska Natives since the 1940s. Minimal services had been provided since the mid 19th century through the Bureau of Indian Affairs of the Department of the Interior. As a result of attempts by western congressmen to weaken and destroy the bureau during the 1940s, responsibility for health services was placed with the US Public Health Service. The transfer thus created the only US national health program for civilians, providing virtually the full range of personal and public health services to a defined population at relatively low cost. Policy changes since the 1970s have led to an emphasis on self-determination that did not exist during the 1950s and 1960s. Programs administered by tribal governments tend to be more expensive than those provided by the Indian Health Service, but appropriations have not risen to meet the rising costs, nor are the appropriated funds distributed equitably among Indian Health Service regions. The result is likely to be an unequal deterioration in accessibility and quality of care.

Interactions between public health nurses and clients on American Indian reservations during the 1930s.

This essay examines the encounters between clients and public health nurses hired by the Office of Indian Affairs to work on American Indian reservations during the 1930s. It relies on two different types of sources. The first are the accounts of the nurses, including letters, memoirs, and above all their monthly and annual reports to Washington. The second are oral histories conducted by the authors with elderly residents of two Sioux reservations in South Dakota during August 1993. One of the key missions of the public health nurses was to inculcate Euro-American beliefs. They assumed that American Indians would follow a linear progression from understanding the 'rules of health' to the eradication of all traditional practices. That model left no room for ambiguity or syncretism. The Sioux viewed the nurses as resources to be used strategically and selectively. Those who accepted the nurses' services did so because the services addressed specific needs the Sioux themselves defined as important. Most disregarded the health education programme insofar as it assumed the superiority of Euro-American values.