*This is the first in a series of position papers requested by the American Public Health Association on the health status of special American populations. Future papers will focus on Native Hawaiians, and on other health conditions including cancers, cardiovascular disease, injury, alcohol, oral health, and other conditions that affect native health.
The American Public Health Association,
Recalling its longstanding commitment to the health of American Indians and Alaska Natives (AIAN), we reaffirm and extend Resolutions 9810, 9811, 9812 and 9904,1–4
Observing that approximately 1.34 million AIAN belong to the more than 556 federally recognized tribes and qualify for Indian Health Service and Bureau of Indian Affairs services, and that rural/reservation and urban AIAN health status is lower than the general U.S. population,1–4
Understanding that poverty, unemployment, inadequate education, unsafe water supplies, inadequate waste disposal facilities, and other social and economic factors play an important role in influencing the health status of both reservation and urban Indians,1 for example, finding that the AIAN high school graduation rate is lower than the general U.S. population at 56% in 1980 to 66% in 1990, compared to 67% to 75%4;
Recognizing tribal sovereignty and the unique Government-to-Government relationship between Tribes and the U.S., including, The President’s Memorandum of April 29, 1994, titled, “Government-to-Government Relationship with Native American Tribal Governments”4;
Affirming that the Federal trust responsibility for AIAN health care is grounded in treaty obligations, case laws, the Snyder Act of 1921 (PL 83-568), the Indian Health Care Improvement Act (PL 94-437 as amended), as well as other federal legislation and historical obligations,3,4
Appreciating that AIAN are citizens of their Tribes, their states and the United States of America and that the Tribes are governments with the inherent right to govern themselves3,4;
Recognizing the health status and issues regarding (1) the growing need for long-term care; (2) HIV/AIDS; (3) infant mortality; and (4) diabetes mellitus2; as described previously,1–4 and below, shall serve as a reference document to be updated as necessary. Three out of four of the areas in this paper are in the President’s initiative “Eliminating Racial and Ethnic Disparities,”5 which commits the Nation to the goal of eliminating disparities in infant mortality, diabetes, HIV/AIDS, immunizations, cancer screening and treatment, and cardiovascular disease by the year 2010.
A Growing Need for Long-Term Care
Acknowledging that the life expectancy of AIAN has increased rapidly in the past thirty years. This increasing life expectancy will contribute to older persons (defined as age 65 and over) increasing from 5.6% of the AIAN population in 1990 to 12.6% of the AIAN population in 20506;
Understanding that approximately one-half of AIAN age 65 and over report functional difficulties,7 indicating that demand for long-term care services will continue to increase as the AIAN population increases from 156,000 to 321,000 over the next twenty years7;
HIV/AIDS
Knowing that in 1996, the estimated acquired immunodeficiency syndrome-opportunistic illness incidence rate was 10 cases per 100,000 population for AIAN, compared to 11 per 100,000 for non-Hispanic whites. The rate was four times higher for men than for women (22 per 100,000 versus 5 per 100,000).8 Current data show that human immunodeficiency virus (HIV) is experienced differently in the AIAN population compared to the US All Races, in that a higher percentage of HIV (without acquired immunodeficiency syndrome (AIDS)) cases occurred in women (33% versus 21%), in adolescents (5% versus 1%), and in persons aged 20-29 years (40% versus 21%)9;
Affirming that in order for HIV/AIDS prevention to work well state and local health departments must partner with local AIAN people and organizations by creating community advisory boards or steering committees, and utilize traditional and religious consultants9;
Observing that there are many indications that AIAN populations are at substantial risk for HIV (e.g., high rates of sexually transmitted diseases (STDs), teen pregnancy, and alcohol and other drug use). However, there are limited data on HIV prevalence rates. Current data on incidence, prevalence, and mortality data likely underestimate the impact of HIV in AIAN communities. This is due to underreporting and misreporting of AIAN racial/ethnic classification10,11;
Infant Mortality
Knowing that the infant mortality rate (IMR), as defined as the number of infant deaths under 1 year of age per 1,000 live births, has dramatically decreased in the last century for all races including AIAN.12 The rate for AIAN infants is 10.9 per 1,000 live births, after adjustment for racial misclassification, compared to 6.8 per 1,000 live births for the white population in 1994.13 Although, the neonatal IMR for AIAN (5.0/1,000 live births) is slightly higher than the US All Races (4.8/1,000 live births) and is higher than the white population (4.0/1000 live births), the post neonatal mortality rate of 4.3 is over twice that of the white population PNMR of 2.0.
Acknowledging that Sudden Infant Death Syndrome (SIDS) (defined as the sudden death of an infant under one year of age which remains unexplained after a thorough case investigation, including the performance of a complete autopsy, examination of the death scene, and review of the clinical history14) has, until recently, been the leading cause of post neonatal infant death among American Indians. Although, the rate for SIDS has declined across all races, the ratio of AIAN rate (1.51/1,000) to the white SIDS rate (0.66/ 1,000) is 2.3 times higher and is higher than any other race including African Americans.15 In some areas of the country, the rate for SIDS is almost 6 times higher at 3.8/1,000 live births in the Aberdeen Area and almost 5 times higher at 3.1 per 1,000 live births in Alaska compared to the white population.16 If SIDS deaths could be reduced in AIAN infants, the resulting difference between AIAN and non-Hispanic whites would be reduced by one fourth.15
Understanding that smoking during pregnancy is a known risk factor for SIDS and alcohol during pregnancy is a suspected risk factor for SIDS and infant mortality.17–19 In 1998 linked birth record, 21% of American Indian women smoked during pregnancy compared to 14% for white women, 9% African American women and 3% Asian/Pacific Islander.20
Noting that using 1995 birth certificate information, Ventura et al.,21 showed that 1.5% women of all races drank alcohol during pregnancy compared to 4.3% AIAN women, while Randall et al.,15 showed in their study that as many as 79% of mothers of SIDS babies drank before or during pregnancy. Faden et al.17 looked at the relationship of drinking to birth outcome using a large national data set, and using multivariate logistic regression, showed that alcohol was significant for low birth weight, fetal death and infant death for all races.
Affirming that if these two issues could be addressed in AIAN communities, the risk of SIDS could be significantly reduced, and that working with the Tribal communities to address culturally competent ways to deal with these issues is the only tenable solution.
Seeking to understand and eliminate disparities in the health of AIAN populations, therefore;
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