Health

by Allie Nishi

“In the United States, AI/AN [American Indian/Alaska Native] groups continue to have higher uninsured rates, poorer access to health care, and poorer health outcomes compared with other racial or ethnic groups. The life expectancy of AI/AN individuals remains more than 5 years shorter than that of the general US population (73 years versus 78.5 years). A study of death certificate data highlighted the continued impacts of mental health and substance use disorders, with premature deaths increasing each year among AI/AN groups from 1999 to 2014... In terms of health care use and access, avoidable hospitalizations are 72% higher for AI/AN men compared with other Americans living in the same counties and 52% higher for AI/AN women. AI/AN people suffer disproportionately from colon and lung cancer, with incidence rates nearly 20% higher compared with whites” (Kruse et al. 2022:565).

If you look up the terms “Native American” and “health,” you will likely find yourself faced with some version of this numerical narrative. It seems straightforward enough: Native Americans are sicker and dying sooner than white Americans. These quantitative health metrics are treated as definitive, as simple, as truths. They sort individual experiences into easy-to-digest dichotomies: avoidable versus necessary care, insured versus uninsured, premature versus timely death, sick versus healthy. In doing so, however, these narratives overshadow the nuances of each person’s lived experience as it relates to health, neglecting facets such as connection to culture, community, and land. They ward off questions about what values and measurements health can and should encompass, about health and healthcare’s constancy in meaning across cultures, identities, and experiences, about what purposes health as a concept serves, and about who is responsible for health. This keyword essay is an attempt to reach beyond the statistics and examine these questions through the lens of Native American and Indigenous studies.

“poorer health outcomes”

A good starting point in this journey is asking what “health” means and how its “outcomes” are measured and assigned value. Kruse et al. (2022:565) begin their discussion of

Native American health with language about “poorer health outcomes.” Their subsequent dive into quantitative, biological statistics creates an image of health as a concrete, static, objective state, obscuring the social and cultural nuances that shape which metrics we see as valuable. This is a common strategy in colonial frames of thinking. It mirrors the way in which race has been biologized and legitimated as an objective truth, obscuring the complex power dynamics and social contexts behind the concept (Witzig 1996). The commonplace colonial metrics assigned to health minimize other perspectives, such as cultural continuity and connection to land, that relate to health and that colonialism itself has worked so hard to destroy among Indigenous peoples.

One such aspect of health that many scholars consider particularly salient for the situation of Indigenous peoples who have been impacted by the violence of colonialism is cultural continuity. Reading & Wien (2013:21) describe cultural continuity as “the degree of social and cultural cohesion in a community”-- something closely tied to “traditional intergenerational connectedness.” Auger (2016) similarly relates the concept of cultural continuity to transfer of knowledge through generations and “cultural connectedness,” or the amount of integration an Indigenous person feels with their Indigenous culture, whether that be traditions, languages, or other meaningful practices and ways of life. Reading & Wien (2013), Auger (2016), Greenwood and de Leeuw (2007), and Lines et al. (2019) all emphasize the salience of these concepts to Indigenous health and wellbeing on a holistic community level. Auger (2016) and Moghaddam, Momper, and Fong (2015) even reference studies that demonstrate a correlation between cultural continuity and the quantitative, biological metrics of health that Kruse et al. (2022) rely on.

Critical to this idea of cultural continuity are relationships to land and the cultural practices that come from and are strengthened by them. Yellowknives Dene First Nation youth, for instance, identify the strength of their community’s relationship to their land– one based in

reciprocity, respect, and survival– as an integral factor in their community’s health. These youth emphasize the salience to health of “actively being connected to the land by being respectful to animals and plants, traditionally harvesting and preparing foods, and practicing their cultural skills” by, for example, learning traditional practices to hunting and preparing fish from other community members (Lines et al. 2019:5). Greenwood & de Leeuw (2007) similarly emphasize the role that ties to land play in fostering a more holistic sense of health. While cultural continuity and connection to land are often absent from colonial conversations about health, many scholars emphasize their role as both social determinants of quantitative health and as salient health “outcomes” to consider, particularly in the context of Indigeneity and colonial violence and erasure.

“health care use and access”

Outside of health itself, another important facet to consider is how Indigeneity informs health care practices, values, and goals in ways that differ from colonial frameworks. Just as Indigenous conceptions of health often extend beyond colonial ones, health care in Indigenous communities often operates differently from western healthcare. Redvers and Blondin (2020) and Moghaddam et al. (2015) emphasize the importance of holistic health care in many Indigenous cultures’ traditional medicine. For instance, in the Navajo culture, traditional medicine people “[see] a person not simply as a body, but as a whole being with body, mind, and spirit seen to be connected to other people, to families, to communities, and even to the planet and universe” and treat people in a more holistic way, given this understanding (Redvers and Blondin 2020:8). This conception of health care differs substantially from a western healthcare model that often ignores “the connection between the mind and the body,” instead focusing solely on physical ailments (Moghaddam et al. 2015:309). Loyd (2021) also emphasizes the ways in which individualist,

colonial medical systems contrast with community models of care that reflect a community’s shared role in facilitating holistic health (including healing from settler colonial violence). Such traditional healing practices serve two purposes: they both address health concerns in a more holistic fashion and provide a sense of cultural connection which, as discussed earlier, is salient to many Native peoples’ sense of health. Such phenomena highlight the reciprocal relationship between connection to culture, healthcare, and health itself.

Considering this more holistic model of healthcare raises questions about the value of tendencies to focus on Indigenous peoples’ healthcare access as access to western healthcare. Data show that western healthcare and its failure to account for health outside of the biological often does not resonate well with Native peoples; Moghaddam et al. (2015) explain, for instance, that AI/AN patients are likelier to not return to a health service or discard treatment advice from western healthcare providers. What’s more, many Indigenous peoples find value in traditional medicine and healing outside of the western model, such as sweat lodge ceremonies and herbal remedies. In a survey of 150 Native people spanning 30 tribal affiliations, over 3⁄4 of respondents expressed interest in seeing a healer such as an herbalist, spiritual healer, or medicine person (Marbella et al. 1998). This discussion does not serve to prioritize one type of medicine/healing over another; in fact, many Indigenous peoples acknowledge that there are a spectrum of concerns for which traditional and western medicines are more or less applicable (Moghaddam et al. 2015). Rather, such information helps us to acknowledge that for many Indigenous peoples, access to western healthcare encompasses only a fraction of what healthcare can and does mean.

“compared with whites”

These expanded understandings of health and healthcare highlight the inconsistencies in meanings and metrics of health across cultures, identities, and social positions and call into

question colonial health researchers’ tendency to discuss Indigenous peoples’ health exclusively in comparison with that of white settlers. Many scholars indicate that these comparisons fall short in capturing the nuances of health in a settler colonial society on even the most basic level. A common health metric that Kruse et al. (2022:565) highlight in their discussion of Native-white health disparities is Native folks’ “higher uninsured rates.” Kruse et al. later go on to highlight, however, that health insurance carries different meanings in terms of access and health for Native and white peoples. Not only does a focus on insurance fail to account for access to traditional medicine and healing; for many Native Americans who live in remote settings without nearby healthcare facilities, health insurance does not even grant access to western healthcare in the same way that it might for white folks living in more populated areas. Moreover, many Native peoples are insured by or interact with health care facilities connected to the Indian Health Service (IHS), and as such, their experiences with health insurance are uniquely marked by treaties, questions about sovereignty, and a unique type of government responsibility and intervention shaped by settler colonialism (Kruse et al. 2022). Even health “outcomes” that appear to be as dichotomous as insurance do not make for simple comparison between Indigenous and white folks’ experiences.

What’s more, some of the facets of health that Native American and Indigenous studies scholars highlight do not carry as much meaning for white settler experiences of health. Questions of cultural continuity inherently are not as salient to white settlers’ health, as they have not been subjected to hundreds of years of colonial violence that aims to erase their cultures. And in terms of relationship to land, a key strategy of settler colonial logic is the reduction of land to property (Manjapra 2020). White folks in the United States, given their role as settlers, thus have relationships to land much more defined by production, ownership, and wealth rather than by

survival, traditional knowledge and cultural skills, community and teamwork, and active connection and respect (Lines et al. 2019). Comparisons of Indigenous and white settler health through metrics such as cultural continuity and relationship to land, therefore, are relatively unproductive and demonstrate a broader disconnect between white and Indigenous experiences that cannot be reduced to numbers. An expanded understanding of what health means renders the health of Indigenous and settler populations much harder to compare in a generative way.

Comparisons between white and Indigenous health can also be actively harmful. As Loyd (2021:105) writes, conceptions of health and disease are often used to “naturalize what are profoundly political projects.” In the case of settler colonialism, these political projects work to justify the exclusion and erasure of Native peoples through dehumanization and fear. Kristof (2020) emphasizes, for example, that health, particularly in the context of contagion, can be weaponized as a source of stigma that paints Indigenous folks who struggle with disease as “potential health threats” to white settlers. This stigmatization relies, at its core, on comparisons between Indigenous and white health. It employs a clear “us/other” dichotomy and draws a comparison whereby the health of Indigenous peoples is perceived as a threat to that of whites. At times, focusing on comparative levels of health between two groups is used to justify the marginalization and suffering of one group as necessary to the wellbeing of the other.

Comparisons of Indigenous health to that of white settlers serve many ends– some beneficial, some well-intentioned yet ineffective, and some actively and intentionally harmful. While such comparisons can be useful in highlighting health disparities as a result of colonial powers’ historical and continued violence toward Indigenous peoples, they risk obscuring the full impact of colonialism on health by minimizing some of the facets of Indigenous health that (i) do not apply as directly to white settlers and (ii) are directly harmed by colonial violence.

Moreover, drawing comparisons between the health of Indigenous communities and that of white settlers is one way by which colonial narratives weaponize health to further the exclusion, erasure, and dehumanization of Native peoples. While it is unreasonable to label all such comparisons as good or bad, it is important to acknowledge the productive and limiting natures of them and keep a critical awareness of their context and effects.

Looking Ahead

Considering “health” from the perspective of Native American and Indigenous studies highlights the shortcomings and harms of centering quantitative health metrics from a colonial perspective, as well as the ways in which using white settler health as a baseline when evaluating Native peoples’ health is often not only ineffective but potentially a damaging perpetuation of colonial violence. But where do we go from here?

This ties back to questions about responsibility in health. Loyd (2021) explains that colonial, capitalist systems construct health as an individual responsibility reflecting moral character. In acknowledging the role of colonial violence and social determinants in harming Indigenous peoples’ health, however, many scholars move away from this individualist view on health responsibility and instead recognize the impact that a broader social and cultural context has on health. Accordingly, many of these scholars grapple with the responsibility that harmful systems may or may not hold in mitigating subsequent disparities. Kruse et al. (2022), for instance, highlight the expectations that treaties between the U.S. government and Indigenous nations lay out in terms of the U.S. government’s responsibility to provide healthcare to Indigenous peoples. Their emphasis on treaties implies that the colonial power structure has a responsibility toward the health of Indigenous peoples, particularly given the context of historical and ongoing colonial violence. McPhail-Bell et al. (2015) complicate this stipulation

by recognizing the potential impingement on sovereignty that colonial powers’ healthcare provision could create, particularly given the narrow, static metrics by which health is evaluated and cared for in a colonial perspective. Currently, in the United States, efforts to manage this tension have led to a “very complex” structure where “the federal government, Tribal governments, and urban Indian groups all have input into IHS operations” (Kruse et al. 2022:565). Scholars such as Martin (2012) and Cohen-Fournier, Brass, and Kirmayer (2021) invoke frameworks to bridge the potential gaps between colonial and Indigenous understandings of health that could cause tensions in colonial involvement in Native American health and healthcare, such as “two-eyed seeing” and “decolonizing healthcare.” Such models would require deeper integration of Indigenous conceptualizations of health into health care frameworks and evaluations. They shift focus away from who is responsible for health and bring to light the importance of identifying health and wellbeing goals that align with the Indigenous peoples who are the subjects of these conversations. Ultimately, the responsibility lies beyond providing healthcare that brings Native Americans’ “health outcomes” closer to those of white folks; it comes back to an active support of Indigenous cultural continuity and revival, sovereignty, and return of land.

Considering health and health care from a Native American and Indigenous Studies perspective invokes questions about connections to land and culture and holistic understandings of people and their connections to others. The ways in which such conceptions diverge from colonial constructs of health and health care complicate the efficacy and impact of comparing Indigenous and settler health. In the context of colonialism, it is crucial to approach questions of health with both a critical eye and an open mind, appreciating the ultimate goal of supporting all peoples in achieving what health means to them in the way that feels best for them.

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