Stephen J. Kunitz
It has been recognized for several decades that there has been a dramatic transformation in the epidemiologic regimes of many populations around the globe, with a decline of infectious diseases, an increase in life expectancy, and an increase, both absolute and relative, of chronic degenerative and man-made diseases (Omran 1971). Among the most dramatically rapid of these transformations has been the one experienced by indigenous peoples of the advanced industrial nations, including Australia, Canada, New Zealand, and the United States (Kunitz 1994).
The topic of this chapter is the transformation that has occurred among Indians of the United States. The decline of infectious diseases in this population owes a good deal to the availability of free, high quality public and personal health services since the 1950s. For instance, immunization rates of Indian children aged 0-27 months are higher than the rates for non-Indian children in the United States (IHS 1998-99). However, the increasing relative and absolute importance of some non-infectious conditions reflects in part a failure of that same health care system to address emerging problems in a timely fashion. This is not a unique situation, for in general health care systems have dealt more effectively with the infectious diseases of public health concern than they have with the non-infectious diseases.
Part of the reason that Indian health programmes have not dealt effectively with these problems is budgetary; health care costs have been increasing more rapidly than the money available for prevention and treatment. But another part of the reason has to do with the fact that at the same time as population-based primary prevention has received less attention than it deserves, genetic theories are becoming the dominant mode of explanation of non-infectious diseases. These various factors reinforce one another in ways suggested below.
The major causes of morbidity and mortality among American Indians have changed dramatically since World War II. Table 10.1 displays the ten leading causes of death in order of importance in 1951-53 and 1994-96, as well as life expectancy for Indian and non-Indian men and women in each period. It is evident