Disease Change and the Role of Medicine: The Navajo Experience

6. Changing Mortality and the Role of Medicine

6 Changing Mortality and the Role of Medicine I BEGAN with a comparison of current mortalitypatterns among several different tribes and showed that as epidemicinfectious diseases have waned, man-made and degenerative diseases with an important psychosocial component to their etiology have become increasingly significant. Among the tribes considered in chapter 1, there is a relationship between prereservation patterns of ecological adaptation and contemporary mortality patterns , which I explained by the degree of fit between preexisting mechanisms of social control and the demands of reservation life. When I turned to an examination of Navajo economic and demographic patterns in chapter 2, it was to show that the stagnant reservation economy coupled with an increasingly sophisticated social service and health care system had placed a floor under the Navajos below whichimmiseration wasunlikely to fall and a ceiling above which development wasunlikely to rise. The result has been that for large segments of the population, traditional forms of social organization have remained a viable adaptation for the sharing of limited resources within families. Such an adaptation involvesa paradox, however, since it is related to lower utilization of contraception and hence to increased numbers of children among the poorest part of the population. I then went on in chapter 3 to trace changes in causes of morbidity and mortality over the past century and to indicate that in several important instances medical therapy has had an 180 I The Role of Medicine impact upon the course of death rates, especiallyfor adults. That is to say, even in the face of continuing economic stagnation, mortality fell perceptibly so that by the time the U.S. Public Health Service assumed responsibility for Indian health care, death rates were already at a relatively low level. It was the infectious diseases and maternal mortality from sepsis that had declined. However, man-made and degenerative diseases increased both in absolute and relative importance. The discussion of mortality patterns and the reservation economy in the first three chapters led to the following conclusions . First, there isevidence that during the first several decades of the present century, mortality rates actuallyincreased as economic conditions deteriorated. Second, medical intervention resulted in a decline in some important causes of death beginning in the late 1940s and 1950s. Third, as these infectious diseases declined, even in the absence of significant economic improvements , accidents increased in both absolute and relative importance as a cause of mortality. Fourth, the emergence of accidents was the result of a growing use of motor vehicles and other implements by people who are especiallysusceptible to accidents because of their marginal position in traditional Navajo life and in the larger society. Acting-out behavior which is reflected in accidents of all sorts is not randomly distributed among Indian tribes, however, but is related to traditional patterns of social organization and social control. To the degree that economic nondevelopment encourages the persistence of these older behavior patterns even asaccessto motor vehiclesand other implements increases, accidents will remain an important cause of mortality. Fifth, there issome evidence that the same segment of the Navajo population that has the greatest likelihood of dying from accidents—young adult men—also has the highest levelsof hypertension, suggesting that in the future, morbidity and mortality patterns may continue to evolve as this cohort ages. In chapters 4 and 5, I turned my attention to changes in Navajo health care beliefs and practices. Navajo theories of disease hold that symptomatic relief may be obtained from any number of practitioners, including physicians, while the true cause may be treated by traditional means. Thus when Anglo medical care proved effective, first in the case of surgery and then with antibiotics,increasingnumbers of people made useof The Role of Medicine I 181 it without necessarily calling into question their own religious beliefs. In recent years, however, there has been a decline in the number of singers and simultaneously an increase in other religions —notably Christianity and the Native North American (peyote) Church—which also have healing aspects and are better suited to present economic and social conditions. These new conditions are related to the decline in the livestock economy which makes it increasingly difficult to sponsor long and expensive ceremonies; and to the long absences from home of many men in search of wage work, which make them unavailable for the rigorous apprenticeships that must be served in order to become singers. Chapter 5 described patterns of utilizationof Anglo...