PROGRESS
REPORT
COMMITTEE
ON
INDIAN
HEALTH
T
HE purpose of this statement is topro-vide a progress report concerning the
activities and accomplishments of the
Corn-mittee on Indian Health. The Committee
was established in late 1964 with the
following objectives defined by the Execu-live Board:
1. To encourage experienced
pediatri-cians to consider careers within the Indian
Health Service.
2. To conduct or sponsor studies of
spe-cial pediatric problems in Indian and
Alas-kan natives.
3. To provide leadership in the review
and development of methods and
proce-dures to improve the provision of pediatric
services to the Indian and Alaskan native population.
4. To stimulate continuing individual
and organizational interest in the Indian
Health Program by pediatricians,
particu-larly those in practice in areas with a large Indian population.
5. To establish a continuing liaison and
professional relationship between the Academy and pediatricians assigned to the
Indian Health Program.
COMMITTEE ACTIVITIES
Meetings
Since its inception, the Committee has
held formal meetings in Phoenix,
Anchor-age, Billings, Chicago, Washington,
Albu-querque, Tucson, and Oklahoma City.
Members of the Committee are physicians
who are informed and interested in Indian
health and who reside near Indian or
Alas-kan native populations. The Committee has
seen the problems of American Indians and
Alaskan natives firsthand during field trips
to reservations and other locations with
concentrations of Indian populations.
Shortly after its establishment, the
Corn-mittee saw the need to maintain continuing
liaison with other committees and agencies.
Therefore, a consultant from the National
Institute of Child Health and Human
De-velopment was named to the Committee,
and a liaison representative from the
Corn-mittee on School Health of the Academy
was added as a consultant.
Medical School Scholarship for American Indians
The Committee proposed to the
Associa-tion on American Indian Affairs, Inc., that a
scholarship for American Indians to study
medicine be established. The Association on
American Indian Affairs accepted this
pro-posal and has established the $3,000
Charles Eastman Scholarship for American
Indians entering the first year of medical
school. The Mead-Johnson Laboratories is
providing matching funds for the
scholar-ship. The Committee feels that this
devel-opment is an important step forward in
en-couraging the “First Americans” to provide
health manpower to their own people.
As a companion program to the Eastman
Scholarship, a summer program has been
established at the University of Oklahoma
to provide intensive training for American
Indian students desirous of pursuing health
careers. This program, entitled Project
Threshold, will provide intensive study and
preparation to better prepare students for
entering schools in the medical field. The
Committee was instrumental in the creation
of Project Threshold, which is also
receiv-ing financial assistance from the Association
on American Indian Affairs.
Pediatric Residency Training Programs
Two approved training programs at
In-dian Health Service Facilities were
estab-lished with the assistance of the Committee.
These are at the Indian Medical Center in
Phoenix, Arizona, and the Alaskan Native
Health Center in Anchorage, Alaska.
Regional Conferences Concerning Indian Health
Another accomplishment of the
Commit-tee is the establishment of conferences on
Indian health at selected universities in
areas where Indian populations are
cant. The first of these conferences was
con-ducted in September 1966 at the University
of Washington, Seattle; it was concerned
primarily with problems of Indians and
Alaskan natives in the Pacific Northwest
and Alaska. A positive outcome of this
meeting was the initiation of efforts which
led to the establishment of the pediatric
residency training program in Anchorage.
The second regional conference was held at
the University of Arizona, Tucson,
Novem-ber 1967, in collaboration with the
Depart-ment of Anthropology; it dealt primarily
with the relationship of Indian culture and
attitudes to health care of the Indian
popu-lation. The third conference was held in
May 1969 at the University of Oklahoma,
Norman. This conference was cosponsored
by the National Institute of Child Health
and Human Development and had as its
topic, “Nutrition, Growth, and
Develop-ment of North American Indian Children.”
The proceedings of these conferences will
be published.
These regional conferences, which are
devoted to major problems of health and
education of American Indian populations,
will be continued.
Recruitment of Physicians to the Indian Health Service
Prior to the establishment of the
Commit-tee, virtually no inquiries were received
about short-term assignment of volunteer
physicians to the Indian Health Service.
Approximately 125 inquiries were received
from physicians about volunteer
assign-ments by the end of the first year of the
Committee’s existence. About 15% of these
were from pediatricians. Interest in such
as-signments has continued to grow.
The Committee has conducted a survey
of all pediatricians who have served in the
Indian Health Service and is analyzing
rea-sons why these pediatricians have either
re-mained in or chosen to leave the Service.
This survey should provide valuable infor-mation for the expansion of pediatric pro-grams within the Indian Health Service.
A letter describing the opportunities for
young physicians in the Indian Health
Ser-vice has been sent to the dean of each
med-ical school and the director of each
ap-proved pediatric training program. The
Committee has also provided information to the dean of each medical school and the di-rectors of pediatric training programs about
COSTEP
(
Commissioned Officer StudentTraining Program
)
,
which allows students to serve for a 2- to 3-month period with theIndian Health Service. Information has also
been provided about the CORD Program
(
Commissioned Officer ResidencyDefer-ment
)
,
which allows physicians to be de-ferred from military service during the in-ternship and residency before beginning duty with the Indian Health Service.The Committee is impressed with the
excellent training experience available through the Commissioned Corps System of
the U. S. Public Health Service, and
espe-cially the Indian Health Service (in lieu of
2 years experience in one of the traditional
branches of the military service
)
; and, it believes that information on this System hasnot been widely disseminated to eligible
candidates. The Committee is attempting to
inform potential candidates about opportu-nities in the Indian Health Service.
Health and Educational Relationships
Health activities are the responsibility of
the Indian Health Service of the
Depart-ment of Health, Education, and Welfare;
but, matters relating to the education of
In-dians is in the purview of the Bureau of
In-dian Affairs
(
BIA), Department of theInte-nor. The Committee early declared and
reaffirmed the principle that the health and education of Indian children are
insepara-ble. It recognized the need to make
prog-ress in this area and the need for close
cooperation between the two agencies
con-cerned with health and education, and a
successful 2-day meeting to discuss
prob-lems of mutual interest was attended by
highly placed officials of both the Bureau of
Indian Affairs and the Indian Health
Ser-vice. This productive meeting has far
reach-ing potential. As follow-up to this initial
AMERICAN ACADEMY OF PEDIATRICS 659
Committee has been instrumental in
devel-oping guidelines for solving school health
problems, individual members have visited
various BIA boarding schools, and the
Committee continues to advise the BIA on
policies relating to school health in a
van-ety of ways.
Comprehensive Care
The Indian Health Service conducts the
only truly comprehensive health program in
the U. S. Public Health Service, and the
Committee invited the Surgeon General of
the U. S. Public Health Service to describe
the structure and experience of the Indian
Health Service to make it available to other
Federal health programs. At this meeting,
in 1966, the Indian Health Service Program
in comprehensive care was outlined as a
prototype program. Many of the activities now have been adopted by other Federal
agencies with health programs.
COLLABORATION WITH THE INDIAN
HEALTH SERVICE IN TRAINING
PROGRAMS
Project Head Start
Project Head Start has been initiated on
several Indian reservations and has proved
immensely helpful in providing a solution
to some of the pediatric problems among
this population group. The Committee has
met on several occasions with representa-tives of the Office of Economic Opportu-nity, the Indian Health Service, and the
American Academy of Pediatrics to advise
and monitor Head Start programs and the
consultation service to these programs.
Health Manpower
The Committee has encouraged the
Ser-vice to expand its program of training allied
health workers. Members of the Committee
have actively participated in these training
programs. The education and training ac-tivities include professional and auxiliary
training for Indian Health Service staff,
training of Indians under cooperative efforts with Indian tribes, and training
assis-tance to Government programs in the
inter-national field. Allied and auxiliary
person-nel training has been greatly expanded as a
means of supplementing the work of the
professional and of increasing involvement
of the Indian people. This training includes
training programs for community health
representatives and aides, practical nurses,
health record technicians, specialists in
en-vironmental health services, and
techni-cians for laboratory, radiology, and
den-tiul and other fields.
Pediatric Exchange Program
An exchange program between residents
in pediatrics at the Children’s Memorial
Hospital, University of Oklahoma Medical
Center, and medical officers at Indian
Health Service facilities has been
estab-lished in the Oklahoma area. It is also
planned that medical students, during their
elective at the University of Oklahoma
School of Medicine, will have the
opportu-nity to participate, under appropriate
supervision, in Indian Health Service
facili-ties. Using this pilot program as a proto-type, we hope to initiate similar programs in other areas.
Short-term Assignments of Physicians
A growing number of pediatricians have
expressed interest in participating on a
short-term assignment
(
e.g., vacations)
inactivities relating to Indian health, and
sev-eral have taken such assignments.
STATUS OF HEALTH OF AMERICAN
INDIANS AND ALASKAN NATIVES
Extent of the Problem
Many Americans, including physicians,
have the impression that the American
In-dian population is dwindling. Because of
this impression and other factors, many
people believe that no major health
prob-1cm exists. Nothing could be further from
the truth. Since 1900 the Indian population
has more than doubled; it is increasing at a
rate of betsveen 1.4 and 1.7% a year-a rate
higher than that of the total population of
the United States. The majority of Indians
live in each of the 50 states. Each of the
more than 250 tribes is a separate group in
language, culture, level of acculturation,
and receptivity to services, and must be
treated on an individual basis.
The most pressing health problems
among Indians are those of infants and
chil-dren.
Indians and Alaskan natives differ
exten-sively from the general population in their
demographic, social, and economic charac-teristics. They are a younger population, on
the average, with a median age of about 17
years, compared with a median age of
about 30 for the United States population
as a whole. Data from the national census
of 1960 on educational attainment showed
that the median number of school years
completed by Indians 14 years and over
was approximately 8 years; this compares to
10.6 for the population as a whole. The
dis-crepancy would be greater if comparisons were made on the basis of persons 25 years
and older; however, comparable data for
Indians are not available.
Economically, Indians also compare
un-favorably with the total population. Most
Indians reside on land marginal in
produc-tivity and in areas of limited employment
opportunities. Data from the 1960 census,
though not representing complete coverage
indicated a median family income of
$1,900. Data for subsequent years collected by the U. S. Bureau of Indian Affairs sub-stantiated this figure.
Housing conditions bear similar
unfavor-able comparisons. Data collected by the
In-dian Health Service over a period of years
on a number of reservations indicate that
more than half of the American Indians and
Alaskan natives live in one- or two-room
dwellings, with an average occupancy of
5.4 persons.
Program Highlights of the Indian Health Service
The health program for American
Indi-ans was transferred in July 1955 from the
Department of the Interior to the U. S.
Public Health Service, Department of
Health, Education, and Welfare. At that
time, only a small health staff centered
around a nucleus of physicians and nurses
existed. Since then, significant advances in
the health care of American Indians and Alaskan natives have taken place.
There are now almost four times as many
physicians and dentists serving in the
pro-gram as there were prior to 1955. There
have also been increases in many other cat-egories of health personnel, such as phar-macists, medical social workers, health edu-cators, engineers, and sanitarians. Thirteen hospitals, 15 health centers, and 54 field health stations have been built since 1955, and major alterations have been made at 11
other facilities. Under construction now are
one health center and three health stations.
Two hospitals, one health center, and one
health station are currently under design. A
total of 147 hospital beds have been added
in 18 community hospitals to meet Indian
and Alaskan native needs. A total of 51
hos-pitals and more than 400 health centers,
stations, and locations are now active.
Public Law 86-121 enables construction
of sanitation facilities; and, since the law
was passed in 1959, projects have been
thorized to provide new or improved water
supplies and/or waste disposal facilities for
some 52,200 Indian and Alaskan native
homes.
The American Indians and Alaskan
na-lives have responded well to the health
pro-gram efforts. Since 1955, annual admissions
to Indian and contract hospitals have
nearly doubled; outpatient visits made to
hospitals, health centers, and field clinics
have more than tripled; and, the number of
dental services provided has almost
quadru-pled.
Health levels among the two indigenous
populations have substantially improved.
From 1955 to 1968, infant death rates
de-dined from 62.5 to 30.9 per 1,000 live births, tuberculosis death rates are down 75%, gastroenteric death rates are down
53%, and death rates from influenza and
pneumonia are down 35%.
AMERICAN ACADEMY OF PEDIATRICS 661
scourge of Indians and Alaskan natives, has
been drastically reduced. In 1956, for
exam-pie, the Indian Health Service had 3,606
admissions to U. S. Public Health Service
Indian and contract hospitals because of
hi-berculosis. In fiscal year 1968, there were
only 738 admissions because of
tuberculo-sis, a decline of 80%. Rates for new, active
cases of tuberculosis among Indians and
Alaskan natives also have been reduced
dramatically by 35.1% since 1963.
In addition, life expectancy for Indians
and Alaskan natives has substantially
in-creased; although it is substantially lower
than that of the general population, the gap
is narrowing.
A summation of the trends shows the
evolvement of a health pattern which more
nearly approximates that of the general
population. The health status of Indians
and Alaskan natives is in transition toward
a position typical of the rest of the United States.
The major program thrust now must be
on greater community development and
in-volvement of Indians and Alaskan natives
in their health programs.
One of the most significant program
de-velopments-and one with the greatest
po-tential impact on the future of Indian
health-is the development of the
Commu-nity Health Representative program. This is
a program in which the Indian Health
Ser-vice provides health and community
dcvci-opment training to Indians who are selected,
paid, and supervised by their respective
tribal councils to perform the health duties
most needed by their reservations or
corn-munities.
There are a number of special health
problems among Indians and Alaskan
na-lives which require extraordinary efforts
and continued program expansion. Mental
health is a major problem. As the Indian
people have been caught more and more in
the conflict between their old traditional
culture and the demands of modern
Amen-can society, mental health problems have
increased and are not limited to adults. The
suicide rate among Indians and Alaskan
na-tives is one and a half times higher than in
the general population, and the homicide
rate is three times the rate for all races.
Al-coholism, with attendant child neglect and
family disorganization, is prevalent.
Emo-tional problems and behavioral disorders
are frequent among Indian children. Otitis
media and resulting deafness, trachoma,
dental disease, and nutritional deficiencies
are extraordinarily common among Indians.
The hostile, physical environment in which
Indians and Alaskan natives live-with
sub-standard housing, unsafe water, and
unsat-isfactory waste disposal facilities-has
seri-ous adverse effects on the health of the two
populations and contributes, to a great
ex-tent, to the high mortality and morbidity
and the excessive rates of infectious
dis-eases.
RESEARCH ACTIVITIES
Committee Activities
One of the directives given to the
Com-mittee at the time of its establishment was
“to conduct or sponsor research projects
and other studies of health problems for
American Indian and Alaskan native
chil-dren.” The Committee believes strongly in
the importance of this goal and endorses
the Board’s recommendation.
Health Program Systems Center
To accelerate the translation of research
on delivery of health services in the public
health and medical care practice to Indians
and Alaskan natives, the Health Program
Systems Center
(
HPSC) has beenestab-lished in Tucson, Arizona. HPSC is the
ap-plied health services research center of the
Indian Health Service. Its mission is to
de-velop, test, refine, and demonstrate optimal
ways of planning, budgeting,
implement-ing, and evaluating the Indian Health
Ser-vice’s comprehensive program for
individ-ual and community health services for
American Indians and Alaskan natives.
To-ward this mission, diversified operations
research and systems analysis techniques
are being used to develop
(
1)
more662
priorities,
(
2) responsive healthinforma-tion systems,
(
3) simulation models ofhealth service delivery systems, (4
)
optimalresource allocation models,
(
5)
methods forefficient utilization of professional and
aux-iliary manpower, and
(
6) meaningfulmethods of planning and evaluation.
Although the basic responsibility of the
Indian Health Service is to deliver patient
care services rather than to conduct
re-search, the Committee believes there are
several ways in which it can serve as a
cata-lyst to bring to fruition certain significant
research projects relating to health
prob-lems of the Indian population. The
Com-mittee recognizes the need to involve both
Indians and the Indian Health Service in
implementing these research projects. Even
if the conduct of research were included in
the charge to the Service, it is unrealistic to
think that this agency would be in a
posi-tion to carry out extensive research; in most
instances, the time of its medical officers is
completely occupied with the delivery of
patient care services to Indians and Alaskan
natives.
The Committee is now exploring ways in
which the Academy can serve as an
offi-cient, intermediary repository for research
funds specifically earmarked for research
among American Indian populations.
Medical Student Participation in Indian Health Activities
Several medical students from selected
universities have participated in activities
of the Indian Health Service during
elective and other periods under the
aus-pices of COSTEP. The Committee has
cor-responded with each of these students;
almost invariably, the experiences of the
stu-dent were productive and educationally
beneficial. Parenthetically, it should be
noted that it is the plan of many of these
students to enter the Indian Health Service
on completion of internship. Interesting
medical students in Indian health is an
im-portant means of recruiting physicians for
service in the Indian Health Program.#{176}
OTHER ACTIVITIES AND
ACCOMPLISHMENTS
The Committee and the Indian Health
Service jointly developed and sponsored an exhibit relating to Indian health which was
presented at the 1965 Annual Meeting of
the American Academy of Pediatrics.
The chairman of the Committee has been
appointed a member of the National
Com-mittee on Indian Health of the Association
on American Indian Affairs, Inc.
Members of the Committee have testified
before Congressional committees in support
of increased funding for the Indian Health
Service.
The Committee has prepared a section
on delivery of health services to American
Indians and Alaskan natives for the
forth-coming publication on the delivery of
health care to children, prepared by the
Council on Pediatric Practice of the
Amen-can Academy of Pediatrics.
The Committee has been gratified with
the cooperation of the staff of the Indian
Health Service in its various activities. The
Committee wishes also to acknowledge the
assistance and contributions of various
con-sultants and liaison members from other
Academy Committees.
CoiMIrraE ON INDIAN HEALTh
Hnms D. RILEY, Jrt, M.D.
Chairman
WILLIAM D. ALSEVER, M.D. PHILIP L. CALCAGNO, M.D.
GEORGE CUNNINGHAM, M.D.
SIDNEY R. KEMBERLrNG, M.D. HENRY STATJB, M.D.
JOHN C. TOWER, M.D.
ALLYN C. BRIDGE, M.D., Consultant
ThEODoRE A. MONTGOMERY, M.D., Consultant
WILLIAM M. MOORE, M.D., Consultant
DAVID B. POST, M.D., Consultant KENNETH D. Rocrns, M.D., Liaison
Representative
0 For information about opportunities in the
