Where is the outcry, outrage and outpouring for various tribes: with the highest levels of diabetes in the world; where a baby boy born today has an average life expectancy in the 40s; where death rates are more than double than for U.S. all races rates to age 44; where there is unprecedented violence against women; and where TB is alive and well at 850% the rate for U.S. all races (according to IHS Trends in Indian Health 2003)? One does not need to leave U.S. borders to find nations living in poverty, fear, sickness and desperation. And yet, they remain largely unfound.

Why does the picture look so bleak for certain tribes? There is a lack of comprehensive, accessible healthcare inclusive of the whole life span. There are the multitudinous disparities seen in the social determinants of health. And finally, U.S. policies over 200 hundred years have likely contributed to the health status of federally recognized tribe’ members and by ethnic Indians.

The Indian Health Service (IHS) is charged with providing health services for members of federally recognized tribes. They state on their ‘About Us’ page that, “The IHS provides a comprehensive health service delivery system for approximately 1.9 million American Indians and Alaska Natives who belong to 564 federally recognized tribes in 35 states.”

Having worked for several years at an IHS hospital, I have nothing but praise for those providing care to American Indians with a lot of "making do" and workarounds. They are earnest and talented. However, services are in fact shrinking rather than becoming more comprehensive as is IHS’ stated goal. For example, in 1991 the Santa Fe Indian Hospital was a "full-service" hospital. It had an emergency room, intensive-care unit, a step-down unit, labor-and-delivery, a 29-bed medical/pediatric service, surgery and outpatient clinics. By 1995, critical care levels had decreased to urgent-care and step-down only. Today its size, level, operational hours and services provided are almost unrecognizable by comparison. This facility serves nine Northern Pueblo Tribes in New Mexico. It is but one example of shrinking services.

My interest is largely in aging. IHS has had little funding or focus for eldercare beyond swing bed demonstrations and small grant programs. Tribes themselves have had some innovative programs and can fill some gaps. Culturally, elders are treasured and one would hope for more solid efforts by the IHS. The Indian Health Care Improvement Act (IHCIA) has been folded into the Affordable Care Act; new provisions for eldercare have been authorized, but unfunded.  On the one hand this was a coup as the IHCIA was previously left to languish for years and years without re-authorization.  However, no one can say what the health law will look like in practice, let alone the American Indian provisions.

One view of health is that a relatively small portion of one’s health status is the result of healthcare utilization. A large component of one’s health is manifested from social determinants of health, genetics, and any resulting behaviors. If solid education, poverty eradication, job building, optimum nutrition, clean water, safety, housing, drug and alcohol programs, and language and culture revitalization contribute a larger percentage to one’s health than the healthcare system does, then maybe we shouldn’t be cutting these programs to bolster healthcare. Instead, we need complete, sustained attention and conviction in Indian country around these “causes of the causes" (Marmot, 2005, Lancet).

Historical trauma has undoubtedly fed into the health and well-being of America’s indigenous people. This is trauma suffered by one’s ancestors and is manifested in the present-day individual. Historical trauma can result in depression, anxiety, loss of role, identity, shame and all the behaviors that may be sought to alleviate the these conditions. A further complication is that there may be contemporaneous individual trauma occurring. Homicide, suicide and violence numbers are all elevated for American Indians by comparison to U.S. all races numbers. Historical trauma in part is a result of the federal policy periods beginning in the 1800s, such as removal (spawning the Trail of Tears), reservation, termination, and allotment and assimilation. American Indians were not granted citizenship widely until the Snyder Act in 1924. These policies and the histories they generated are undoubtedly feeding into the health of American Indians today.

With earlier onset of disease, shorter life spans, higher levels of poverty, lower levels of education and the lack of truly comprehensive care, Indian Country needs focused attention, assistance, and an influx of real dollars for health and infrastructure. Health care for American Indians was to have been an unquestioned provision, as a result of lands already ceded, treaties signed and law. Unfortunately, I have been a nurse for over 20 years and the things I saw then I am still writing about today. The status quo is deafening. Again I ask, where is the moral outrage and where is the call to action?

Dr. Margaret P. Moss is a member of the Three Affiliated Tribes of North Dakota. She is an associate professor at Yale University School of Nursing and specialty director of Yale’s Nursing Management, Policy and Leadership program, and former Robert Wood Johnson Foundation Health Policy Fellow. Visit her blog at https://goingoffthereservation.wordpress.com.