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The First Americans and their Second-Class Healthcare

Summary :

• This blog highlights the healthcare inequality faced by American Indians and Alaska Natives in the United States and traces the history of the federal government’s provision of tribal healthcare.

• The blog argues that the federal government’s failure to honour their treaty obligations and provide equal healthcare has led to the preventable deaths of American Indians and Alaska Natives.

• The blog concludes that the solution lies in the restructuring of the provision of tribal healthcare. Funding and support must be given to tribal initiatives to mitigate the inequality that they face.



American Indians and Alaska Natives (AI/AN) face a crisis in health inequality. They have lower life expectancies and are disproportionately more likely to die from wholly treatable diseases. A lack of adequate funding and investment in the Indian Health Service is the prima facie answer. However, the underlying reason for this lack of support, and resultant inequity, is the federal government’s failure to honour their treaty obligations as set out in the Indian Health Care Improvement Act 1976. The Act amended the Social Security Act and promised financial support for services provided in the Indian Health Service and tribal health care facilities. This disparity has become more pronounced as the COVID-19 pandemic has taken hold in the United States and is indicative of the urgent need for an adequately funded and supported health care system for AI/AN tribes.

The history of AI/AN healthcare inequality:

The very conception of the Indian Health Service is rooted in colonialism. Historically, the federal government created treaties with the tribes in their calculated attempt to “acquire Indian land and to avoid hostilities with tribes” [1]. These treaties contained vague promises that funds would be used to develop an Indian Health Service that would materially improve the welfare of AI/AN individuals, “ensur[ing] the highest possible health status” [2]. However, AI/AN healthcare has been chronically underfunded. In 2017, the US Commission on Civil Rights reported that Indian Health Service health care expenditures were $3,332 per person, compared to $9,207 for federal health care spending nationwide [3]. Furthermore, the majority of American Indians and Alaska Natives live in urban settings with limited access to Indian Health Service facilities [4]. This in itself is a flagrant example of federal adherence to the colonialist direction it is renowned for adopting. In the 1950s, the federal government pursued a policy of ‘forced assimilation’ as they undertook to move Native Americans to urban areas in order to free up tribal lands for federal exploitation and stamp out their cultural identity. This was “essentially a one-way bus ticket from rural to urban poverty”[5] . Thus, AI/AN healthcare was destined for inequality.

How has this inequality presented itself in the lives of AI/AN individuals?

Health inequality for American Indians and Alaskan Natives begins from an early age. Inadequate prenatal care and post-neonatal death among AI/AN infants is two to three times those for white infants.[6] Furthermore, AI/AN children are twice as likely to be overweight and three times as likely to be obese”.[7] For adults, the age-adjusted death rate exceeds that of the general population by almost forty percent with deaths due to diabetes, pneumonia, and cardiovascular disease. Mental health problems include disproportionate rates of post-traumatic stress disorder, alcohol dependence and death due to suicide [8].

The COVID-19 pandemic has ravaged Native American reservations and heightened calls for mitigating this inequity. The Navajo nation, one of the largest Native American indigenous tribes, has been fatally affected. AI/AN individuals are among the racial and ethnic minority groups at highest risk from the disease and so the disease “spread like wildfire” as infections reached the highest per capita state in May [9]. The surge in cases was exacerbated by the reservation’s poor water infrastructure, shortage of testing and lack of adequate PPE. Therefore, it is evident that the federal government’s failure to honour their treaty obligations and provide an equal health service to that of other Americans has been a death sentence for many members of AI/AN tribes.

How can this inequality be ameliorated?

The primordial reason for this healthcare inequality is the federal government’s obedience to the bonds of colonialism as it continues to demonstrate that the lives of AI/AN individuals are not on an equal footing to that of other Americans. This inequality is deeply entrenched in American society. However, there are nonetheless measures which the federal government can take to move towards healthcare equality. Many tribal communities have endeavoured to take over the health care provision structure and the federal government must fund these initiatives. The federal government needs to give AI/AN tribes the agency that they have historically been robbed of, allowing them to take the first step to reverse the healthcare disparity that has taken the lives of too many American Indians and Alaska Natives.


It is irrefutable that AI/AN tribes have suffered due to the federal government’s failure to honour their treaty obligations. AI/AN individuals are receiving healthcare that is of an inferior quality, waiting for extended periods of time for urgently needed care and are dying from wholly treatable diseases. The solution is clear. The federal government must fund tribal health and support tribal communities that seek to take over the healthcare provision structure. They must have their agency and dignity restored.


Author Bio:

Ayra Ali is a first-year undergraduate reading Law at Gonville and Caius College, Cambridge. She is broadly interested in international human rights law and humanitarian work.



[1] The Legal Foundations for Delivery of Healthcare to American Indians and Alaska Natives. National Indian Health Board; 2015. Available from: https://www.nihb.org/docs/05202015/Foundations%20of%20Indian%20Health%20Care%20(March%202015).pdf [Accessed 10 December 2020]

[2] Trout, L., Kramer, C., Fischer, L. Social Medicine in Practice: Realizing the American Indian and Alaska Native Right to Health. Vol.20, No.2. Health and Human Rights Journal; 2018. Available from: https://www.jstor.org/stable/pdf/26542057.pdf? ab_segments=0%2Fbasic_SYC-5187_SYC-5188%2Fcontrol&refreqid=fastly default%3A461959794e844be487d7a60e47cb5422 [Accessed 10 December 2020]

[3] Broken Promises: Continuing Federal Funding Shortfall for Native Americans. U.S. Commission on Civil Rights; 2018. Available from: https://www.usccr.gov/pubs/ 2018/12-20-Broken-Promises.pdf [Accessed 10 December 2020]

[4] Broken Promises: Continuing Federal Funding Shortfall for Native Americans. U.S. Commission on Civil Rights; 2018. Available from: https://www.usccr.gov/pubs/ 2018/12-20-Broken-Promises.pdf [Accessed 10 December 2020]

[5] Poon, L. ‘How Indian Relocation Created a Public Health Crisis’. Bloomberg; 2019. Available from: https://www.bloomberg.com/news/articles/2019-12-02/what-s-behind native-american-health-disparities [Accessed 10 December 2020]

[6] Baldwin, L. M., Grossman, D. C., Casey, S., et al. Perinatal and infant health among rural and urban American Indians/Alaska Natives. American Journal of Public Health; 2002. Available from: https://doi.org/10.2105/ajph.92.9.1491 [Accessed 10 December 2020]

[7] Zephier, E., Himes, J. H., & Story, M. Prevalence of overweight and obesity in American Indian School children and adolescents in the Aberdeen area: a population study. International journal of obesity and related metabolic disorders : journal of the International Association for the Study of Obesity; 1999. Available from: https://doi.org/ 10.1038/sj.ijo.0800856 [Accessed 10 December 2020]

[8] Shalala DE., Trujillo MH., Hartz GJ., et al. Regional differences in Indian health. Indian Health Service; Rockville, MD; 1999.

[9] Nelson, C. Covid ravages Navajo Nation as Trump makes election play for area. The Guardian; 2020. Available from: https://www.theguardian.com/us-news/2020/oct/08/ navajo-nation-coronavirus-pandemic [Accessed 10 December 2020]

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