American Indian Culture and Research Journal

In a recent essay, Csordas and Kleinman conclude their discussion of an agenda for future research in medical anthropology by calling for studies that develop an analytic of power in conjunction with the examination of healing as process. The present article takes seriously their directives, applying the most pertinent of their suggestions to a case study of ritual healing among the Tarahumara, or Rarámuri as they call themselves, an indigenous people in northern Mexico. This essay is concerned with examining the process whereby power is restored to a patient through the gradual embodiment of a working identity, that is, an identity that manifests a normative and corporeal self capable of participating with others in the everyday give-and-take of society. On the one hand, Csordas and Kleinman urge describing the “connection among therapeutic, political, and spiritual power in both the practice of healers and the experience of the afflicted.” They recommend a method which strives to recognize “distinctions among healing as a form or reinforcement of oppression, healing as a[n] ... attempt to address the misery of poverty and powerlessness, and healing as a mode of empowerment wherein small changes can mean the difference between effective coping and defeat.” While an examination of the structures of power are significant, they go on to say, “Perhaps more important than any other principle for guiding research is the observation that the therapeutic process does not begin and end with the discrete therapeutic event.” Like the analysis of power, they suggest that this also needs to be comprehended in several ways. “First, therapeutic systems and the events they generate exist in historical and social context, as both products of that context and performances that construct it.... Second, the therapeutic process cannot be understood as bounded by the therapeutic event precisely because it is ultimately directed at life beyond the event.”

The arrival of Spanish invaders on the shores of Alta California in 1769 spawned a biological holocaust among Southern California Indians. The epidemics that swept across the coast, mountains, valleys, and deserts of California were catastrophic, causing Native Californians to attempt to comprehend the sickness and death stalking their various communities. European diseases significantly affected the lives of many Indians of California, including the Tongva of the Los Angeles basin and the Chumash north of them along the Santa Barbara coast. Tongva and Chumash people responded to epidemics brought to their homelands by the Spanish in a manner consistent with their spiritual and practical worldview. In one sense they internalized the diseases, attempting to comprehend the massive suffering and death in a way that made sense to them. Traditional Native views of death and sicknesses shaped their response to them. This was clearly the case of the Tongva people living near Mission San Gabriel. The Tongva of the Los Angeles basin spoke a dialect of the Takic family of languages derived from the larger Uto-Aztecan linguistic stock. The mainland Tongva were divided into two groups, one associated with the San Fernando Valley, and the Tongva proper, whose territory embraced the watershed of the Los Angeles and Santa Ana river basin. Ninety percent of their territory was within the rich Sonoran life zone whose ecological resources included vast quantities of acorn, pine nut, small game, and deer. On the coast, shellfish, sea mammals, and fish were taken. They followed an economy of hunting, collecting, and fishing that supported a population of approximately five thousand just prior to the Spanish invasion. The religious beliefs, practices, and mores of the Tongva centered on the cosmological belief that humankind was not the apex of creation but simply a strand in the web of life. Humans, like plants, animals, and even the landscape, shared reciprocal obligations to one another. According to creation stories, each provided something for the other and required a display of mutual respect and care. Careful stewardship of food resources and sacred places was proscribed.

In 1830, the United States Congress passed the Indian Removal Act, effectively authorizing President Andrew Jackson to dispossess and forcibly remove thousands of Native people from their homelands in the American Southeast to lands west of the Mississippi River. The Removal Era has been explored by American historians over the years using classic historical methods and sources. They have recorded and analyzed the usual political and economic happenings and the prominent men with which these events are associated. White America’s philosophical and cultural beliefs have been examined in an effort to understand the underpinnings of Manifest Destiny and America’s insatiable drive for land and dominance. Various racial and political attitudes have been studied, along with economic factors such as the price of cotton on the world market. What has rarely been examined, however, is what Removal meant to Native people, from a Native point of view. The archives and other written sources that are usually mined by modern scholars are almost exclusively written by non-Native people. Government and military records and accounts, even personal journals and diaries, reflect white authorship. Some of these sources include transcriptions of the speeches and other oral communications made by Native people. But these are, almost without exception, orations that were crafted and intended for white audiences—usually government personnel or national legislatures—and therefore conform to the Native perception of what would be important or meaningful to the larger American culture. Sources that Native people trust to relate their experiences sometimes differ markedly from those considered valid or reliable by mainstream white historians. Most Native groups passed cultural and historical knowledge from generation to generation, not through written records but through oral accounts.

The Yakama Indian Reservation is located on the Great Columbia Plateau of central Washington State. It is the home of fourteen diverse tribes and bands of Native Americans who once spoke several dialects of three distinct languages, including Sahaptin, Salishan, and Chinookan. These Indians form the Yakama Nation, and their health has been closely related to the creation and execution of the reservation system of the United States since 1855 when a few chiefs signed the Yakima Treaty. Beginning in the 1870s, the Office of Indian Affairs placed a large number of Indians onto a limited land base and during the late nineteenth and early twentieth centuries restricted their access to traditional foods and medicines off the reservation. Confinement on the reservation led to changes in subsistence, maternal-child care, and housing that contributed to infant deaths resulting primarily from pneumonia, gastrointestinal disorders, tuberculosis, heart disease, and syphilis (fig. 1). The modal age (the age that appeared most often) of death on the Yakama Reservation during the era from 1914 to 1964 was children under one year of age, with 631 (16 percent) of the 3,899 deaths arising from this age group. This was the largest number of deaths suffered by any age group on the reservation. The first birth and death rates of infants from the Yakama Reservation were recorded in 1914 when an infant mortality rate could be calculated. Thus, although data on deaths exist from 1888, the central focus of this work will be that fifty-year period between 1914 and 1964. The Yakama Treaty of 1855 and its ratification by the Senate in 1859 set into motion a series of events and circumstances that undermined the health of the Yakama people. As a result of the treaty, the various people placed on the Yakama Reservation secured a small portion of their traditional homelands in central Washington Territory. Other segments of their former land became part of the public domain, which the United States opened to white settlement after 1859. The government placed people from several tribes—Yakama, Palouse, Klickitat, Wishram, Wenatchee, Wasco, Wanapum, and others—on the Yakama Reservation, forcing approximately two thousand Native Americans onto the reservation where they competed for limited traditional food resources.

On July 1, 1904, the new school year began at Sherman Institute, a nonreservation Indian boarding school in Riverside, California, with an enrollment of 722 students. By November 14, 1904, nine of these students were dead. Seven of the children died from an epidemic of typhoid fever between October 29 and November 14, and at least thirty-five other students were stricken with the disease. Yet in his annual report to the commissioner of Indian Affairs, Sherman Institute Superintendent Harwood Hall did not mention the deaths of these students. Instead, he stated only that in the fall of the year they had been troubled with some sickness. By most accounts, Hall was a man dedicated to the health and well-being of his young Indian charges, yet he chose not only to dismiss the deaths of the seven children killed by typhoid fever in the fall of 1904, but the deaths of four children earlier in the year as well. This exclusion was particularly relevant because the 1904 mortality rate at Sherman Institute exceeded that of all previous years combined, including those at its predecessor, the Perris Indian School. The death of eleven children, seven of which were from typhoid fever, was clearly an uncommon occurrence. In his official report, however, Hall did not acknowledge that anything out of the ordinary had transpired, apparently deciding that the deaths of these children were irrelevant to his report. Prior to becoming superintendent of Sherman Institute, Hall had been superintendent of the Phoenix Industrial Boarding School (hereafter, the Phoenix Indian School) near Phoenix, Arizona. The school had been established in September 1891 for the specific purpose of preparing Native American children for assimilation. By the time Hall arrived at the Phoenix Indian School in 1893, the school had already experienced considerable growth and was on its way to becoming a major component in the federal assimilation program. During his tenure at the school, Hall fostered this growth, equating it with progress and accomplishment.

In December of 1924, Charles Burke, the commissioner of Indian Affairs, received a letter from H. J. Hagerman, a former governor of New Mexico Territory who had been appointed by the Office of Indian Affairs (OIA) as “Special Commissioner to the Navajo.” Hagerman reported that he had received a troubling piece of correspondence from an OIA physician headquartered on the Navajo Reservation. This physician, Polk Richards, had found some disturbing after-effects among Navajo patients who had been treated by government doctors for trachoma, a painful, infectious eye disease that produced damaged vision or even blindness. Two of these patients could no longer close their eyelids completely, a condition known as lagopthalmos, and at least two others were suffering from entropion, in which the eyelashes had turned inward and were scratching the surface of the eyeball. All of these patients had been treated as part of a national campaign by the OIA to eradicate trachoma from Indian communities. Their condition, Hagerman told Burke, suggested that perhaps the OIA needed to rethink its strategy. The trachoma campaign was based on the use of a radical surgical technique known as tarsectomy, in which the surgeon attempted to treat the disease by simply cutting out the tarsus, the supportive tissue underneath the eyelids. Unless patients were selected very judiciously, Hagerman warned, and unless those who performed the operation were highly skilled surgeons, it was quite possible that the trachoma campaign would produce “very harmful results,” potentially causing Indian patients to lose all confidence in OIA doctors.

American Indians, like many people of minority cultures in the United States, have access to the health care system of the traditional culture as well as hospitals and clinics operated in the biomedical model. Administrators and providers of health care in the federally funded Indian clinics are continually faced with the question of how to manage the persistence of traditional healing practices. Beginning in the second half of the nineteenth century, government officials viewed Western medical services as an instrument of assimilation. The self-defined role of the federal Indian service was to assist the Indians to live in the white society. Medical personnel argued for the construction of Indian hospitals because the use of Indian hospitals would diminish the influence of medicine men. Not until the mid-twentieth century was the value of traditional healing practices recognized by physicians. Since then, Indian health programs have experimented with consultation with traditional healers, facilitation of the use of traditional healing, provision of funds to hire and train traditional healers, and incorporation of traditional health beliefs in health education. These efforts demonstrate that traditional health does have a legitimate role in the delivery of health care by government institutions. Unfortunately, little is known about what Native people consider when choosing between traditional medicine and biomedicine. Nor is there an understanding of how people perceive the role of the two systems of medical practice. An examination of responses from Indian people from one Sioux reservation area regarding integration of biomedical practices into their traditional system of health care will serve as an example of how people make choices about health care. From 1930 to 1950, the Bureau of Indian Affairs (BIA) stationed public health nurses at Indian reservations throughout the country.

INTRODUCTION Genetic inheritance is a multilayered concept enveloped by cultural assumptions, given diverse meanings by physicians who serve American Indians and by their patients. Unfortunately, providers and clients are often unaware of the different perceptions each have. Ethnographic data about perceptions of inheritance enhance an understanding of notions about diabetes and its causes. A broader view of this topic reveals that subtle and explicit cross-cultural misunderstandings are common to individuals and to topics of all sorts, consequently affecting associated prevention and treatment courses. The words genetics and inherited are used frequently during discussions of diabetes, which is a common subject of communication between providers and their American Indian clients due to the prevalence of Type 2 diabetes among the Indian Health Service population. The age-adjusted Indian Health Service-diagnosed diabetes prevalence rate for American Indians is 69 per 1,000, whereas the overall U.S. rate is 24.7 per 1,000. Recent results from the Strong Heart Study reveal that among Arizona American Indian participants, for example, the age-adjusted rates of Type 2 diabetes are 65 percent in men and 72 percent in women. Diabetes is the second leading cause of outpatient visits to Indian Health Service facilities, after the common cold. When confronted by medical information and technology, lay people rarely remain passive. They tend to interpret and evaluate illnesses and treatments actively. Interpretations are greatly impacted by historical, social, linguistic, cultural, and educational factors as well as by the genders of providers and clients. In interviews, California and Arizona tribal members often explain inheritance as a part of biological, social, and cultural ethnic identity, while their providers define inheritance in a biological context. Multiple interpretations of a single concept by professional and lay people alike may represent underlying disagreements about etiologies which in turn influence health care behaviors.

INTRODUCTION American Indians currently face many challenges to their survival. Struggling against racism, substance abuse, and impaired health and striving for sovereignty, economic self-determination, and land rights have not only burdened many Native populations, but also provided a context for American Indian communities to meet these challenges with resources both old and new. One problem exemplifying the need for multiple solution strategies is diabetes, a disease affecting American Indian populations at higher rates than any other population in the world. A closer examination of diabetes among American Indians reveals that it is not just a disease of the body; it is a problem which needs to be understood within the context of Native history, culture, and experience. Medical anthropology is a discipline that has much to offer in attempts to identify the broader contexts of American Indian health problems. Medical anthropologists often focus on the sociocultural parameters of health, which includes an analysis of the influence of cultural beliefs on health and the manner in which social inequalities can negatively impact access to health care. This perspective highlights the extent to which ethnicity, acculturation, history of prejudice, and social position affect the experience of a health problem and the overall quality of health and health care. These are essential factors to consider in order to more fully understand diabetes and why American Indians are experiencing the disease disproportionate to other populations.

INTRODUCTION The American Indian population faces many important health issues including cancer, injuries, diabetes, alcohol and substance abuse, violence, suicide, cardiovascular disease, and obesity. Cancer has become the second leading cause of death for Alaska Native women and is the third cause of death among American Indian women. Due to a large Indian population residing in California, and the fact that American Indian women have a high mortality and low survival rate in certain cancers, California’s American Indian population is an ideal target for cancer control efforts, particularly in the early detection and treatment of breast cancer. Developing a breast cancer early detection and treatment education project for American Indians requires an understanding of American Indian illness beliefs, barriers to breast cancer screening, and the cultural constructs that inhibit or facilitate the utilization of screening protocols and treatment recommendations. This paper describes the steps taken in the development, implementation, and evaluation of the Pathways to Health project, a breast cancer education program targeting American Indian women in California.

INTRODUCTION TO CANCER AS AN ISSUE AMONG AMERICAN INDIANS AND ALASKA NATIVES Cancer is a growing problem among American Indians and Alaska Natives. Unfortunately, both non-Native and First Nations peoples are less aware of the growing cancer dilemma than they are of alcohol, violence, diabetes, and other well-promoted and widely dispersed conditions within Native communities. In the second half of the twentieth century, cancer has become the leading cause of death for Alaska Native women and is the second leading cause of death among Alaska Native men. In fact, cancer is currently the third leading cause of death for all North American Natives5 and is the second leading cause of death among American Indians (both sexes) over age 45. The disease is the third most cited reason for hospital stays among Indian Health Service beneficiaries served by the Alaska Area Native Indian Health Service. Cancer rates, previously reported as less frequent in American Indian and Alaska Natives, have been increasing throughout the last twenty years. Incidence rates among Alaska Natives have exceeded “U.S. All Races” rates for most cancer sites. Rates are increasing similarly for Canadian bands. Within Native American communities, health programs continue to focus on alcoholism and diabetes, although cancer is responsible for more deaths than either of these conditions. Because the word cancer is not indigenous, it translates into some Native languages as “the disease for which there is no cure” or “the disease that eats the body.” Many tribes regard cancer as a white man’s disease because of its rarity before European contact. For many Native cancer patients, the disease is not discussed and is considered a form of punishment, shame, and guilt. A few tribes consider the patient’s suffering necessary in order to ensure the health of the other tribal members (they wear the pain so that their community will be spared). Some tribal members living with cancer—infected with the cancer spirit—are considered contagious and are ostracized by their communities. Other tribal members refuse cancer treatment surgery for fear that their body and spirit will be incomplete, leaving them incapable of finding their ancestors when they move to the other side (death).

In recent years, much attention has been given to the proliferation and emergence of street gangs among ethnic groups in locations formerly gang-free. Navajo tribal members and officials have expressed strong concerns over both the presence of male youth gangs and what has been perceived as growing levels of violence. Such concern is reasonable in a society in which accidents, suicide, homicide, and alcoholism are among the top ten causes of death for males. Thus, “injury mortality” is “the single most important health problem of the Navajo.” In 1997, the Navajo Nation estimated that approximately sixty youth gangs existed in Navajo country. Through the Peacemaker Division of the judicial branch of the Navajo Nation, the tribe secured federal funding to study gangs. The tribe has since been actively pursuing means to ameliorate the conditions that lead to gang formation. Gang values encourage risky behavior. Many of these behaviors are taken to extremes, such as heavy drinking and drug use. Mortality from injuries and alcohol “occur most frequently in young adult males.” Thus, an examination of the history of gang formation, and the extreme forms of risky behavior associated with gang activity holds importance for both law enforcement and public health policy. Although newspaper accounts of Navajo gangs often stress the gulf between gang behavior and that of youths in earlier times, the origins of Navajo gangs in the early 1970s has some connection to Navajo adolescent male peer groups in the nineteenth century. More importantly, however, recent gang formation has been stimulated by off-reservation models and changing social and demographic factors within Navajo country. It appears that gangs have formed around core members who were socially marginal members of their communities. Membership in a gang, although limited to a small minority of Navajo youths, represents one significant contemporary path followed in the transition from childhood to adulthood.

INTRODUCTION Native Americans have been subjected to colonial domination by European nations for five centuries, resulting in a radical destabilization of their sociocultural and economic systems, a general deterioration of health, and rapid depopulation. The resulting effects of cultural differences and conflicts, learned dependency, poverty, and feelings of powerlessness and low self-regard have impacted dramatically the health and quality of Native life. American Indians in the United States today are facing major health and social problems such as diabetes, substance abuse, poor nutrition, obesity, vehicular accidents, and suicides. Alcohol abuse, for example, is implicated in four of the ten leading causes of death among Native Americans. Entire communities are crippled by health problems, which ultimately feed into a cycle of despair, cultural dislocation, and lack of self-sufficiency. This article explores how participants in a self-empowerment program have understood and translated the training into self-sufficiency both at the personal and community levels. In analyzing this process we will listen to the participants’ voices, the words and the meanings they give to what they have learned from the program, and what enabled them to do something for themselves and others.

Suicide among American Indian youth is a matter of serious concern to members of all Indian tribal organizations across the nation and is an important issue confronting the human services professions today. Suicide is the second leading cause of death among American Indian youths fifteen to nineteen years of age, with a rate 2.7 times (37.1 per 100,000) that of youth of all races in the United States, and the fourth leading cause of death among American Indian youth ages five through fourteen, with a rate 2.8 times (2.5 per 100,000)higher than that of all races in the United States. Within the Indian youth suicide group, American Indian children placed in non-Indian homes for adoptive or foster care suffer a rate of seventy suicides per 100,000, six times higher than that of other youth in the United States. While suicide rates for youths fourteen through nineteen years old have decreased somewhat, rates for ten and fourteen year olds are approximately four times higher than that for the general U.S. population and have continued to increase steadily. In 1987 Irving N. Berlin reported, “there are considerable data to indicate that the more than 50,000 American Indian children adoptees in Anglo homes are at considerable risk.” A host of issues are germane to suicide trends. These include data vital to the planning of intervention programs for age groups most at risk, pattern variations among tribes, and common associate factors that include alcoholism, arrest careers, and interpersonal distress such as anomie, helplessness, hopelessness, and despair. American Indian suicide first came to public attention in 1968 when Senator Robert F. Kennedy visited an intermountain Indian reservation. On the day of his visit, the community had suffered the loss of an Indian youth by suicide, and thus Indian suicide was a major topic of conversation.