States and Tribes: A Healthy Alliance: Some of the Health Care Models States and Tribes Are Developing for Native Americans Could Be Used for Other Residents

Article excerpt

The disparities in health between Native Americans and other Americans are nothing short of staggering.

American Indians and Alaska Natives rank at of near the bottom of nearly every social, health and economic indicator, according to a 2004 report from the U.S. Commission on Civil Rights. They are 670 percent more likely to die from alcoholism, 6S0 percent more likely to die from tuberculosis, 318 percent more likely to die from diabetes, and 204 percent more likely to suffer accidental deaths than members of other groups. Although the average lifespan of Native Americans has increased from 51 years in 1940 to 71 years today, it is still six years below that of other Americans.

AN UNEASY ALLIANCE

There's a long tradition of the federal government working with tribes on health issues. The U.S. Constitution states that federally recognized tribes are sovereign nations with inherent rights.

"Health services were guaranteed by treaties entered into between the federal government and sovereign nations in exchange for land, mineral rights, resources and, during certain periods of American history, some personal rights and freedoms," says Charles Grim, assistant surgeon general and director of the Indian Health Service.

But for a number of reasons, tribal nations have not always worked closely with states. It's partly that tribal nations are accustomed to turning to Washington for help. But there are also gaps in culture and knowledge.

"Most state legislators don't have a good knowledge of who the tribes are, what our equal status is, or the unique legal, social and cultural conditions of tribal regulations. They don't know how to reach out to us of who to talk to," says W. Ron Allen, tribal chairman and executive director of the Jamestown S'Klallam Tribe, Sequim, Wash.

Often, tribes are out of sight and out of mind on reservations, Allen added. "As a general rule in most rural communities, they are removed from mainstream society, and are often the hardest to reach."

Lawmakers may be baffled by the sovereign nation status of tribes, as well as the cultural differences and fragmentation of the 562 federally recognized tribes. Some 229 of these tribes are in Alaska; the rest are located in 36 other states.

There also is the impression that casino gaming has made nearly all Native Americans wealthy. "Only about 40 tribes make money on gaming, out of the 562 tribes total," says Dr. Craig Vanderwagen, chief medical officer of Indian Health Services. The commission notes that hall the Native American population is poor or near poor, compared with 25 percent of whites.

"There is an inclination for people to think, 'This is a federal problem, we don't have to deal with it.' That's not true, and it's also short-sighted," says Jim Crouch, executive director of the California Rural Indian Health Board, which operates 11 tribal health programs that provide health services to some 63,000 people in rural California.

Nevertheless, observers say that states are making progress in forging alliances with tribal nations. In some cases, they're developing models of care for Native Americans that could be used for other residents.

Alaska, for example, is "making headway toward having good relationships with the tribes," says Joyce Hughes with the Alaska Primary Care Office. "The mistrust is still there, but it's lessening." It stems in part from the fact that the health system is so complex, she explains. " There are two such different systems, the funding streams are different, and the urban areas have very different issues from the rural ones."

The 49th state is divided into nine healthcare delivery areas, and each area is as large as a state in the lower 48, with low population density, no road systems, extreme weather conditions and a high cost of living. The cost of building clinics in frontier areas and of flying critically ill patients in air ambulances from remote areas to urban hospitals is enormous. …