What’s Really Behind the Native American Health Gap?

Growing up as a member of the Ojibwe tribe, Melissa Walls knew that that diabetes ran in her maternal family. “I’ve lost two very close family members, my great grandfather and an uncle, to complications related to type 2 diabetes,” she says. But it wasn’t until she began studying American Indian health in graduate school, at the suggestion of another uncle who served as a liaison between academics and local tribal communities, that she understood that her family’s plight was part of a much larger problem.

American Indian adults are more than twice as likely as white adults to be diagnosed with type 2 diabetes, according to the Office of Minority Health at the U.S. Department of Health and Human Services. Native American youth experience the highest and fastest-growing rate of the disease of any racial or ethnic group. But those statistics only scratch the surface of the kinds of health disparities that indigenous people face.

Nationally, the average life expectancy for a Native American person born today is 73 years—5.5 years below that for all other races. Members of this community, adolescents in particular, also experience much higher rates of depression, substance abuse, and suicide and suicidal behaviors. In fact, while the national suicide rate has gone up 33 percent since 1999, the rates for Native American women and men have jumped by an alarming 139 percent and 71 precent, respectively, according to a recent report from the Centers for Disease Control and Prevention.

“You could take almost any health outcome and find health inequity for tribes,” Walls says. “I mean, take your pick.”

The health statistics reflect a dire economic reality—1 in 4 Native Americans live in poverty, the highest rate compared to all other races—and the massive gap in medical resources available to this population. The Indian Health Service, which runs clinics and hospitals for Native Americans, spent $3,332 per person in 2017, compared to $9,207 spent on each person in the national health care system, according to a 2018 report on funding shortfalls by the U.S. Commission on Civil Rights.

Walls knows from experience: Like the majority of American Indians, she grew up outside a reservation. Her family lived in International Falls, Minnesota, a town of about 6,000 people—mostly white—near the Canadian border. But to access health services, her family had to go to the nearest reservation. “We drove an hour literally to go to the doctor, to go to the dentist, to get our eyes checked,” she says. “But when you grow up in that context, you don’t label it as an inequity or disparity. It’s just sort of your reality.”

More than two-thirds of Native Americans now live in urban areas, not reservations. That reflects 1950s-era federal policy designed to encourage American Indians living on reservations to urbanize, in the name of speeding “assimilation” (and freeing up tribal lands for federal exploitation). The Bureau of Indian Affairs’ Urban Relocation Program of 1952 and the federal Indian Relocation Act of 1956 offered promises of job training and housing for the new arrivals; the hope was that moving to cities like Chicago, Los Angeles, and Minneapolis would allow more Native Americans to participate in the postwar economic boom. But in practice the relocation policy was “essentially a one-way bus ticket from rural to urban poverty,” as former Indian Affairs Commissioner Philleo Nash admitted in the 1960s.

Walls is now the head of the new Great Lakes hub of Johns Hopkins University’s Center for American Indian Health in Duluth, Minnesota, the city of 86,000 located three hours south of where she grew up. Her team currently works with 11 different tribal communities to better understand the health inequities that Native Americans experience, and try to correct them. The hub is just a 15-minute drive from the Fond du Lac band of Ojibwe tribe, with whom Walls has been working closely on diabetes prevention. Among her research interests: how stress impacts can affect type 2 diabetes, and how culture and community can help to buffer the negative effects of modern lifestyles among Native Americans.

CityLab recently caught up with Walls to talk about possible solutions to health inequities among American Indians, and why the damage that government policies inflicted on this population has been so far-reaching. Our conversation has been edited and condensed.

Can you explain how government policy induced historical trauma in the indigenous population?

The historical trauma encompasses a lot of government actions like setting up reservations and marching people across the country. Then in the the 1950s and ’60s, the government started a relocation program to get [Native Americans] into urban areas, and give them job training programs. It failed miserably, like most of these things did, in part because the job training was woefully inadequate, and often [the jobs available] were temp work or summer employment, if anything.

People were taken out of their family support systems or cultural safety nets, thrown into these urban environments, and expected to survive. Certainly in some cities, native people have worked to try build those kinds of networks. But you are very much a minority in the urban context. I think the idea of not having access to not just your friends and your family, which we all need, but those particular aspects of cultural teachings of ceremony that creates a sense of spirituality, purpose, and belonging would be scary to anybody.

[The relocation policy] was rooted in this flawed idea that all people need to look and act like European Americans, and live the way they do. It’s shocking, if you go into some of these government records, just how blatantly plain the language is about how the goal was really to exterminate or assimilate.

That has impact on communities, and we see it play out in terms of mental health, substance abuse, suicide, and other chronic diseases.

You’ve been largely looking at diabetes—how does historical trauma fit into that story?

In the case of diabetes, one really tangible thing is what we call nutrition transition. In the Midwestern U.S., Ojibwe people once had a thing called a seasonal round, where with each season came new sources of food. In the springtime, you tap trees to get maple syrup. In the fall, you gather wild rice off the lake and you hunt deer. Every season had ways of getting [food] that burned a lot of calories.

Moving away from these ways of eating and getting your food, and suddenly relying on government-sponsored commodity programs [that included] flour, sugar, lard, butter, we start to see rates of obesity kind of going off the charts. And we continue to suffer the consequences.

And this trauma has affected multiple generations?

Some of the research we’ve done is really trying to link up negative health outcomes with specific policies. We’ve published a paper that demonstrates how families who’ve gone through those relocation programs have the worst health outcomes that we can track across three generations.

It’s based on survey data from members of eight tribal communities. We were able to track parents’ reports of their parents going through relocation. If they did, we saw a significant pathway where those [first-generation] parents might have had substance abuse issues, which led to substance abuse and depression in the [second-generation] parents. That led to them being not very good parents of their own kids—the third generation—who at the time were in adolescence. They had bad outcomes like delinquency and depression.

The article was published in 2012, but we continue to collect new data every year from that same cohort, so it’s an ongoing study.

Your research is mostly on communities that live within reservations, but what can you tell us about the current urban Native American population so far?

In our cohort study, the kids who grew up on the reservation, a good chunk of them now have moved on to cities, which is another thing that happens. People tend to migrate between cities and reservations. With our new data that’s being collected from that cohort, we’re going to be able to examine urban-rural differences.

What I do know is that the health issues that hit tribal people on reservations, some reports say they’re actually compounded and worse for people in the cities, for reasons like the lack of access to cultural protective factors and social networks. People are more likely to experience discrimination when they’re in an urban area. And there’s tons of research talking about how that hurts health.

What’s a common misconception about the indigenous community that you hope to dispel?

One of the big stories I’ve helped to push forward is that yes, we have these health inequities, but people on reservations and in urban areas also have really amazing positive stories. Like with positive mental health, when we started measuring it, our communities were off the charts compared to non-native people.

We found this measure created by a sociologist called Corey Keyes [that] assesses emotional well-being, psychological well-being, and social well-being across three domains using 14 different indicators. These items assess basically how much you’re flourishing or languishing in those domains. And the outcome was that the percentage of people in our sample who [reported] flourishing was much higher than what we had seen in other studies with non-Native samples.

So you can have these [inequity] issues, but also have vibrant and cultural richness, family centric [communities] with communal, take-care-of-one-another thinking.

And that has implications for all humans: that being embedded in your community is good for you, that being tied culturally to other people is good for you. It’s not just a dismal doom-and-gloom kind of story.