"A Political History of the Indian Health Service" (review)

"A Political History of the Indian Health Service" by Abraham B. Bergman, David C. Grossman, Angela M. Erdrich, John C. Todd, and Ralph Forquera. Millbank Quarterly, 77, no. 4 (1999): 571-604

The authors have utilized the most productive and realistic methods of researching politics, including collecting oral narratives of participants. Every participant tells their perceived truth of the happening as they saw it. That is the Rashomon perspective. All of the perceptions of the events are true but may not be the same individual perceptions. In addition, the authors have reviewed letters and congressional hearing records, which, because of what they are, are not as candid or with the same individual truths as the oral interviews.

Because I was at least a peripheral participant in many of the events and programs discussed in this article, I have my own individual perspective. Further, I knew at least marginally many of the individuals discussed. Therefore, my review is a Rashomon perspective on other Rashomon viewpoints. This is not actually an unusual situation, of course, but the reader should be aware of the phenomenon.

Few bright spots exist in the history of encounters between the federal government and American Indians. One exception, the authors of this article believe, is the campaign of the Indian Health Service to improve Indian health. They also believe that the campaign has raised the levels of Indian health to about the same level as the general U.S. population, with the caveat that mortality and morbidity of Indians remains very different from other American populations.

What makes the story remarkable is that the advances occurred in spite of underfunding and scant support from the Department of Health, Education, and Welfare (now Health and Human Services), where the Indian Health Service (IHS) is administratively lodged. These improvements came about because of vision, stubbornness, and political know-how by Indian Health Service directors and support from powerful allies in Congress and the White House and a few tribal leaders.

The authors focus on the first five IHS directors, beginning in 1955, when the Indian Health Service was transferred from the Bureau of Indian Affairs to the Public Health Service, and ending in 1994. Each of these directors had a different set of strengths and pulled IHS in the directions of those strengths. The authors present these strengths as building on each other in positive ways.

The major political support for the changes the directors sought to make came from some surprising sources: President Richard Nixon, Senator Henry Jackson of Washington State, and Senators Barry Goldwater and Paul Fannin of Arizona. These powerful politicians had the personal clout to push the changes through Congress without serious opposition.

Part of the problem the change makers had to deal with was the viewpoint within the federal bureacracy that the Indian Health Service was a colonial service for one of the poverty-stricken, minority-group islands of contagion in the United States--a poverty-stricken group without political strength. Since there is not a large number of American Indians, they are not a politically significant population. There was, and is still, no idea of the difference between immigrant groups and indigenous peoples in the middle-level government functionaries who actually manage federal involvement with the IHS.

The difference is well stated in Carol Locust's article in Primary Care of Native American Patients: Diagnosis, Therapy, and Epidemiology (reviewed in this issue): "All peoples who undergo colonization tend to experience three stages of health and illness patterns as they become more urbanized and industrialized. The first is marked by famine, high rates of infectious disease, and high death rates, especially among infants and children. The second is marked by declining rates of infectious disease and rapid population growth. The third stage is marked by the rise of chronic and degenerative dieases" (18).

These three stages can be found in different indigenous...