Global health as a movement and field of study focuses on the improvement of healthcare worldwide, specifically developing nations. However, indigenous nations are often left out. Either they are mistakenly viewed as part of the dominant nation in which their lands reside, or there is a complete lack of understanding about their status as nations with a right to self-determination. Whenever it comes to global health, Native Americans should always be included because they are nations with their own languages, cultures, histories, spiritualities, and land base that is distinct from the dominant nation in which they reside. Consequently, they are disproportionately affected by various health concerns that threaten the health and stability of their communities.

The unique status of Native Americans as sovereign nations has its roots in the Constitution of the United States (US). Article I Section 8 states, “The Congress shall have Power…To regulate Commerce with foreign Nations, and among the several States, and with the Indian Tribes.”¹ This inclusion of Indian tribes afforded indigenous peoples a legal status that is almost on par with states and foreign nations, and set a precedent for the landmark tribal sovereignty case Cherokee Nation vs. Georgia, presided over by Judge John Marshall in 1831. Judge Marshall stated that Indian tribes are “more correctly…denominated domestic dependent nations. They occupy a territory to which we assert a title independent of their will, which must take effect in point of possession when their right of possession ceases.”² The ruling acknowledged that indigenous peoples were nations, in the sense that they have a right to self government and a right to engage with the US in a government-to-government relationship. However, the inclusion of “domestic dependent” signified that indigenous nations were not the same status as foreign nations. Tribes can exercise a limited amount of sovereignty over their land and citizens, but ultimately must abide by federal law.

From 1953-1959 Congress sought to diminish tribal sovereignty even further and absolve their relationship with certain tribes altogether during what would be known as the “Termination Era.” The key legislation of this era was House Concurrent Resolution 108, passed in 1953, which stated that: “all of the Indian tribes...located within the States of California, Florida, New York, and Texas...should be freed from Federal supervision and control and from all disabilities and limitations specifically applicable to Indians.”³ With this resolution, 109 Indigenous tribes were dissolved of their nationhood status and the US government no longer had an obligation to provide any federal funds, social and educational services to these tribes or interact with them in a government-to-government relationship.⁴ The devastating impact that the termination era had on tribes cannot be overstated. It revoked already limited sovereignty and funding, which plunged the affected tribes into crushing poverty and marginalization. Since these tribes were no longer eligible to receive services reserved for Native Americans, they had severely limited access to health services. This is especially pertinent because the Indian Health Service was created during this time, yet members of terminated tribes could not access it because their status as tribes had been revoked.⁵ The legacy of the “Termination Era” demonstrates how crucial sovereignty is to maintain the health and well being of tribes.

The Indian Health Service, officially formed in 1955, was created out of past treaties, Supreme Court decisions, and executive orders which legally obligated the US to be responsible for providing health care to members of federally recognized tribes.⁶ The treaties are of particular interest because the US has only made treaties between foreign nations and indigenous nations. Though indigenous nations are not awarded the status of foreign nations, their nationhood is important enough to warrant the necessity of treaties and legal arrangements in any significant decision between tribes and the US government.⁷ If Native Americans were seen as an ethnic or racial group with no nationhood status, then legally the US would have no obligation to provide health care services specifically to them. Therefore, federally funded health services like IHS exist only for Native Americans.

IHS has played a crucial role in Native American health by offering a variety of health care services, employment opportunities, intervention programs, and culturally appropriate care to federally recognized tribes. Tribes can choose whether to:

“…receive health care services directly from the Indian Health Service (IHS),… contract with the IHS to assume control over administration and funding for individual programs and services the IHS would otherwise provide (referred to as “Self-Determination Contracts”), or … compact with the IHS to assume control over health care programs the IHS would otherwise provide (referred to as “Self-Governance Compacts).”⁸

The “Self-Governance” option has proved the most flexible in allowing tribes to design health care services that best address their community’s needs. As of February 2010, “the IHS has negotiated a total of 76 Self-Governance Compacts and 97 funding agreements with Indian tribal governments and tribal organizations. Currently, 330 Tribes participate in these 76 compacts with the IHS.” ⁸ The 330 tribes that currently utilize the self-governance option are a positive sign that more tribes actively participate in their health care delivery. The tribes that do not participate in this option most likely are not financially or organizationally stable enough to do so, and thus receiving health care services directly from IHS is the best option for them. In terms of global health, IHS is an important example of how federal governments can improve access to care for vulnerable populations while still respecting their autonomy.

Today, the US recognizes 564 indigenous nations, with hundreds more state recognized. However, many public health studies classify Native Americans in the same manner as other ethnic groups. This could be due to the fact that most people are not aware that tribes are sovereign nations. The implications of this have not been widely studied, so it remains to be seen exactly how this impacts public health research. Regardless, all indigenous nations suffer from various health disparities compared to the general US population. As Dr. Gerald Hill, President of the Association of American Indian Physicians, details in a 2009 Association of American Medical Colleges report: “ [American Indian/Alaskan Native] death due to diabetes is nearly four times that of the number for all races in the United States, three times higher from injury and poisonings, seven times higher for alcohol-related deaths, 91% higher from suicide, and 20% higher from heart disease.”⁹ Additionally, Native Americans face daunting environmental challenges, as they bore the brunt of many harsh economic ventures that polluted their lands, exploited reservation resources, and caused innumerable health problems.¹⁰

To include Native Americans in the broader discussion of global health would help shed light on health issues that affect Natives at a much higher rate than the general American population. Additionally, inclusion would rightfully acknowledge that Native Americans are sovereign political entities. The philosophy of global health supports the idea of nations working together to address pressing health needs. Including native nations in this process can help bring about real solutions to reduce egregious health disparities while still respecting tribal sovereignty, and set the stage for the involvement of indigenous nations around the world.

Gabriela Maya Bernadett is a first year MD student at Mt. Sinai School of Medicine and a Citizen of the Tohono O’odham Nation. She can be contacted at: gabriela.bernadett@mssm.edu

1. U.S. Constitution online. [online]. 2010 [cited 2010 Mar 2]; available from: URL: http://www.archives.gov/exhibits/charters/constitution_transcript.html
2. Marshall J. Cherokee Nation vs. State of Georgia 1831 [online]. [cited 2010 Mar 2]; available from: URL: http://www.mtholyoke.edu/acad/intrel/cherokee.htm
3. House Concurrent Resolution 108. Digital History [online]. 2010 Mar 28 [cited 2010 Mar 28]; available from: URL: http://www.digitalhistory.uh.edu/native_voices/voices_display.cfm?id=96
4. Robbins, RL. “Self-determination and subordination: the past, present, and future of American Indian governance.” The state of native merica: genocide, colonization, and resistance. Jaimes, A. ed. Massachusetts: South End Press, 1992. p. 99.
5. Dresang, D. “A chance to remedy errors.” Indian Country Today [online]. 2008 Nov 7. [cited 2010 Mar 28]; available from: URL: http://www.indiancountrytoday.com/opinion/letters/34082119.html
6. Indian Health Service Introduction [online]. 2010 Jan [cited 2010 Mar 2]; available from: URL: http://www.ihs.gov/PublicInfo/PublicAffairs/Welcome_Info/IHSintro.asp
7. Wrone DR. Indian treaties and the democratic idea. The Wisconsin Magazine of History 1986-1987 winter; 70 (2): 83-84.
8. Indian Health Service Facts Sheet: Tribal Self-Government [online]. 2010 Jan [cited 2010 Mar 2]; available from: URL: http://info.ihs.gov/TrblSlfGov.asp
9. Hill G. Viewpoint: “the education and importance of American Indian and Alaska native physicians.” 2009 Mar [cited 2010 Mar 2]; available from: URL: http://www.aamc.org/newsroom/reporter/march09/viewpoint.htm
10. Laduke W. All our relations: native struggles for land and life. Massachusetts: South End Press, 1999. p. 11-26, 97-113.