American Indian Culture and Research Journal

To prepare for writing this article, we reviewed many academic tomes, from anthropology to zoology, and perused many decades’ worth of ethnographic studies of American Indian elders and elders from other groups around the world. We wanted not only to describe elderly American Indians but also to build the argument that elders are of critical importance for American Indian families and communities and have been of critical importance for tens of thousands of years. We wanted to construct the fundamental argument that in virtually all species with large brains and long childhoods, elders are of critical importance. This is as true in caribou as it is in humans; it is as true in American Indians as it is in whites, African Americans, and Asians. It is true because elders are the holders of ancient wisdom about the conduct and management of social behavior and about strategies for protecting the vulnerable from the problems that consistently arise in anyone’s life. In reviewing the literature, it was a bit startling to move from the period that encompassed the late 1800s to the 1940s. This literature includes strong and clear descriptions of the important role of American Indian elders, the wisdom of their words, and the respect that their position held; hundreds of detailed descriptions of the importance of the elders and their knowledge— how their wisdom saved their people—and stories of great personal self-sacrifice made by the elders in order to protect their people; and many discussions about the vast amount of time that elders put into nurturing and educating the young.

Legislation during the past three decades has gradually drawn Indian Health Service (IHS)–funded clinics into the mainstream of the US medical care environment. The Indian Self-Determination and Education Reform Act of 1973 and its Indian Education Amendments of 1984 began a movement away from federal management of health services to local tribal control of the more than five hundred facilities serving American Indians. At the same time the Indian Health Care Improvement Act granted authority to IHS-funded clinics to bill Medicaid, beginning a long and continuing negotiation among the tribes, states, IHS, and Centers for Medicare and Medicaid Services (CMS). In 1990, 6 percent (72,000 individuals) of IHS beneficiaries were more than sixty-five and eligible for Medicare. Some 31.6 percent lived below the poverty level and were eligible for Medicaid. The IHS has facilitated and encouraged enrollment of its beneficiaries in Medicare and Medicaid. By 2008, 18 percent of the IHS budget is assumed to be met by third-party collections, including CMS billing. The Alaska Native and American Indian Direct Reimbursement Act of 1999 gave tribal clinics the authority to bill Medicaid directly for services without using the IHS as an intermediary, thus further facilitating access to CMS programs.

Cancer is a significant problem in American Indian populations nationwide. Recent studies indicate that cancer incidences, mortality, and survival rates vary according to geographic location and tribe. The Indian Health Service (IHS) reports the cancer incidence rate as 7.8 percent for all IHS areas with a range of 14.5 percent for the IHS Aberdeen area, 13.2 percent in the IHS Billings area, and a low of 5.8 percent in the IHS Portland area. The risk for certain cancers, such as cervical cancer, is almost three times greater for American Indian women than for the white population. Although breast cancer rates appear somewhat low, other cancers such as cervical, prostate, colon, and rectal cancers are high. Furthermore, American Indians found to have suspicious symptoms are less likely to receive follow-up care, thus increasing their cancer mortality risk. Less frequent use of prevention measures, such as cancer screenings, are reported among American Indians. Cultural and socioeconomic barriers to cancer screening call for special research attention. Although American Indians experience many of the same barriers to early cancer detection as other populations, such as lack of knowledge regarding the need for cancer screening and treatment methods, the cost of medical care, and lack of transportation and patient advocacy, these problems are compounded by the fact that cancer is a relatively “new” illness among American Indians. Fifty years ago, Indian mortality was often the result of acute illnesses such as tuberculosis, measles, and smallpox. Thus, many Indians did not live long enough to develop cancer. This trend, however, is changing. A rise in cancer incidence among American Indians is expected because their life expectancy has steadily increased during the past twenty years.

It is estimated that by the year 2030, approximately one in five individuals in the United States will be age sixty-five or older. For American Indians, the elder population is the fastest-growing cohort with an estimated one to two million elders reaching the age of sixty-five years or older by the year 2050. As these older cohorts grow in number, so does the possibility that many will experience abuse or neglect leading to early death or disability. Elder abuse continues to grow as a national public concern. Because there are numerous methods of sampling and surveying and several definitions of abuse, the best estimates of elder abuse report that between one to two million elders over the age of sixty-five have been mistreated by someone upon whom they depend for care or protection. Little is known, however, about the abuse of elders in minority populations. Even less is known about elder abuse, barriers to care, and social service needs of elders in American Indian communities. Because of the baby boom generation (birth rates that occurred between 1946 and 1964) and increases in the average life expectancy, it is estimated that in 2050 nearly 21 percent of the US population will be elders over the age of sixty-five. This is up from the current 12.4 percent currently documented by the census. In 2000, there were nearly three hundred thousand American Indian and Alaska Native elders over the age of sixty-five compared to a total of thirty-five million elders in the United States. Likewise, the American Indian population is reported to be one of the fastest-growing populations in the nation. Compared to whites, blacks, Asians, and Hispanics, it is expected that American Indians will have the largest percent change in the population. By 2050, the American Indian population is predicted to double.

INTRODUCTION American Indian adults have the highest smoking rate of any racial group in the nation. By the turn of the twenty-first century, smoking rates for the general adult population were reported to be 24 percent. Among adolescents in the United States, 34.8 percent of high school students reported they currently smoked in 1999. In comparison, American Indian adults report smoking rates ranging from 34 to 79 percent. American Indian youth smoking rates range as high as 50 percent, especially among Northern Plains states. Tobacco use, which includes smoking cigarettes, is the most preventable cause of death in the United States. To date, there is no clear explanation as to why American Indians have extremely high smoking rates. It is known, however, that approximately 90 percent of the general population began smoking in adolescence, most by age eighteen. The age of smoking initiation by American Indians is predicted to be somewhat younger, as young as twelve to sixteen years. Understanding the phenomenon of starting smoking— in terms of how individuals are introduced to cigarettes, influences of smoking initiation, and culture-bound attitudes that facilitated the smoking initiation—is an important step toward ameliorating the problem of smoking-induced health problems. METHODS The purpose of this study was to examine smoking initiation, smoking cessation, and tobacco-control policies among Plains Indian tribes. Seven tribes located in Minnesota, Nebraska, and South Dakota participated in the multi-reservation study from 2002 to 2003. Data presented in this article were collected during the focus-group phase.

In the last decade, the United States has increasingly focused on the reduction and elimination of health disparities in racial and ethnic minority groups. Somewhat neglected in these efforts have been mental health disparities for American Indians. American Indians remain in a precarious position as an underserved community with limited culturally competent resources to address their mental health and substance-abuse needs. The lack of resources continues to prevail despite emerging data that indicate that American Indians’ disparities in mental health and behavioral health occur at alarming rates, which calls for the need for interventions and attention for public mental health, medical, and educational resources.

The American Indian tribal nations and communities have long experienced health status worse than that of other Americans. Although major gains in reducing health disparities were made during the last half of the twentieth century, most gains stopped by the mid-1980s. Consequently, health disparities continue to exist with marked variation across Indian Health Service (IHS) areas and within tribes. This is especially concerning for low-income, elderly members of the American Indian community. Addressing chronic diseases in elderly American Indian communities will help us reach the Healthy People 2010: Understanding and Improving Heath goals of improving the quality of life and increasing the life expectancy of American Indians. In an effort to reduce these existing health disparities, it is important to understand the major illnesses affecting the American Indian community and address mechanisms to address the illnesses within the American Indian community. This is a review of the literature about the major illnesses found among elderly American Indians living on or near a reservation. Four sources, including CINAHL, Google Scholar, MEDLINE, and PsycInfo, were used to review the literature regarding elderly American Indians living on or near a reservation for the three leading causes of death (heart disease, cancer, and diabetes) and suggested recommendations for health intervention programs in these disease areas. DEMOGRAPHIC PICTURE OF AMERICAN INDIANS LIVING IN THE UNITED STATES Approximately 2.5 million people identified themselves as American Indian in the 2000 US census. The American Indian population includes members of more than 550 federally recognized tribes, which represent different cultural traditions and lifestyles.

For many American Indian elders who are poor, uninsured and underinsured, there is a limited range of options from which to choose when seeking medical care. For many decades, the Indian Health Service (IHS) was the primary care for Indians. That may no longer be the case. Because of budgetary restraints and cutbacks within the IHS system, medical care for the poor and elderly in American Indian communities has become severely restrictive. There was once a time when “just being an Indian” meant that entry into an Indian clinic was expected. Although never quite enough, congressional outlays provided funds to run Indian hospitals and clinics in order to meet the demand of those individuals in need of medical care. Then came the “on or near” ruling meant to restrict eligibility to those living within or adjacent to the county boundaries of reservations. One’s definition of eligibility then depended upon tribal status, place of residence, and blood quantum. Now, one more limitation faces those in need: medical provider acceptance. When Freida became an elder—when she was well into her sixties—she found herself being questioned endlessly at the local Alaskan Native clinic regarding her tribe (a California tribe), blood quantum (having a Norwegian last name brought questions), residence (moving from California to live with her son in Alaska), and ability to pay for medical care services. Diagnosed with cataracts, Freida struggled to survive from day to day on meager retirement funds. Having depended upon the IHS clinic to treat her diabetes and rapidly deteriorating eyesight, Freida was initially confident that she could also have her cataracts surgically removed with the support of the IHS. Her need for the surgery could not be contested; as it was, she greeted the morning through filmy gauze, which restricted her ability to see more than a few feet ahead. Although cataract surgery is available in Alaska, the ability to pay for such services is not readily available.

To be the eldest son of a traditional Indian woman has shaped and influenced my life in ways both abundant and momentous, in ways that continue to be revealed. Even now, as an Indian elder, I remain in her cultural shadow, as do my siblings and most of my kin my age and younger. In her eighties, to recall the effort and the sacrifices she’s made for me and her family are memories that are always close at hand. Yet it would be an exercise, an effort in itself to account for and bear witness to the detail of the life she’s lived. There has been so much. This past winter, in a modest rural hospital room, there was a gathering of Indian elders. All were children of the man in the bed and my mother, who was there not only as our comfort but also as his concerned sister and interpreter. Her brother’s essential illness is of the mind, made, on that day, much less apparent by his depleted and fragile form. During that visit home, I could see his awareness of those assembled come and go, and in both, when words were spoken, the language was never English. And so, my mother’s fluency with our Native language and her ability to calm her brother once again reminded us of her central significance in our lives and among our people. Grey heads all, we watched them communicate, much as we did as children and young adults. Limited understanding of the words spoken, but a full knowledge and awareness of them as Indians; more than us. Claims and counterclaims about the closeness and therefore the overall mutual support of Indian families notwithstanding, a sense of loss and the fact of suffering continues to expand. Despite the socioeconomic, educational, occupational, and medical improvements in the lives of American Indian families throughout the twentieth century, a natural toll is being taken on Indian families and people as, I should think, never before!

Recently, I woke up to the fact that I unexpectedly had acquired the role of an elder in my family. Having lost my own parents more than a decade ago, I had aunts and uncles who were eager to offer their wisdom and advice when I needed guidance, or when I was hungry for my Indian roots. Slowly, one by one, they also have passed. Growing up, my family’s “connectedness” was something I could count on. From the outside, the Jefferson clan came together looking like a swap meet. Sibs and cousins shared everything, our parents and our toys. We laughed and fought; we received love and discipline from all of the elders by an occasional knowing gaze, a squeeze, or light pinch. We learned to listen, to hear the bond of our family. It was carried out in the stories of our grandparents, the one-room house, and the trips to town on the buckboard, hunting, and sewing with ribbons. It was a joy to hear of the vigor in their lives, the laughing and the sorrows of family members lost. From our parents we heard the tales of Goodland Indian School where as young children they struggled to stay a family, regardless of separation by their classes and dormitories, or work requirements. The experience of aging naturally assigns a new role; it seems to bridge the gap between the future and the past, a social transmission of culture to inform the younger. It reaffirms who we are, developing from the memory of the ages and from our own life experiences. As well, it is a social experience, slowly perceived by ourselves and others. To age is also a change to the body-based identity, image, and self-identity. For some it is interpreted as a natural experience, a positive or negative transformation, as simply adjustments to our accustomed state. For others it is an unpleasant inequity and disparity of life. Aging, like our lives, mirrors the context in which it occurs; it is certainly culturally produced, and it reflects our exploration of ourselves. Health becomes a primary concern among elders; its impact overshadows how we function and contribute to others.