The Centers for Disease Control and Prevention reported that American life expectancy had taken a nosedive during the pandemic, with the biggest drop occurring among non-Hispanic American Indians and Alaska Natives. It was reassuring to see coverage of this terrible trend; but largely absent was the context and history underlying these disparities. The reasons why indigenous people were hit hardest by COVID-19 go beyond the fact that they also have very high rates of underlying comorbidities—like obesity, high blood pressure, diabetes, and cardiovascular disease. Instead the roots of health disparities among indigenous people are inextricably linked with the complex history of our nation’s mistreatment of indigenous peoples.
I cared for Native patients at Indian Health Service and tribal health facilities in Arizona, New Mexico, and Maine before the COVID-19 pandemic. I saw firsthand how the doctrine of Manifest Destiny—the belief that colonial settlers had a divine right to eliminate indigenous peoples and appropriate their lands—has been an engine for sickness and death, even today, centuries after our nation was founded.
Manifest Destiny was widespread attack on indigenous lands and peoples. The U.S. military forced relocations of Native peoples disrupting native foodways of hunting, fishing, gathering, and farming. The military intentionally targeted indigenous food sources, destroying crops and livestock. “We were seen as the enemy. And so we were fed like prisoners of war,” said Martin Reinhardt, a professor at Northern Michigan University. The people were given measly rations of flour, sugar, salt, and lard—the ingredients to make fry bread, what many think is a traditional indigenous food, but is in fact a food of oppression, cooked up out of necessity. Later, the U.S. government would provide “commodity foods”—mystery meat, canned vegetables, and yellow cheese—to fulfill their treaty obligations. These commodity foods would become staples of Native kitchens and lead to sky-high rates of obesity, high blood pressure, diabetes, and cardiovascular disease among indigenous peoples.
In the 1800s and early 1900s, as settlers moved west, the federal government dammed rivers and built reservoirs, siphoning water away from the tribes. “The Hoover Dam providing electricity, damming up Colorado River. So you have access to power, access to water. And this is how the West was created,” said Amber Crotty, a Navajo Nation Council delegate. Water is a precious commodity, especially out west. Without access to safe water, indigenous people haul water by truck over long distances or turn to unsafe sources tainted by contaminants ranging from bacteria to uranium. They might not wash their hands or bathe as frequently, increasing their risk for various infections. It’s hard to prepare food safely. They might drink diabetes-promoting sugar-sweetened beverages because they’re cheaper than bottled water.
Indigenous lands have also been under the assault of extractive industries in search of natural resources like uranium and oil. Abandoned uranium mines now dot the southwest. The radioactive waste still hasn’t been cleaned up. Native people exposed to the toxins suffer from higher rates of lung cancer and other cancers, scarring of the lungs, asthma and emphysema, blood disorders, birth defects, and more. In other parts of the country, the oil and gas industry has driven up cancer rates while also destroying the shoreline, displacing indigenous peoples yet again.
Missing in the media coverage of dropping American life expectancy was that among indigenous people, deaths from unintentional injuries, mostly drug overdose deaths, were almost tied with deaths from COVID-19, followed closely by chronic liver disease and cirrhosis, largely related to alcohol use.
Long before the so-called “diseases of despair”—alcohol-related liver disease, drug overdoses, and suicide—drove down life expectancy among low-income, less-educated white non-Hispanic Americans at the beginning of the 21st century, these same afflictions were killing indigenous peoples. The causes are similar: the destruction of a way of life and the decline of family and community. Despair comes from “the loss of meaning, of dignity, of pride, and of self-respect,” write Anne Case and Angus Deaton in Deaths of Despair and the Future of Capitalism. Family separations and the loss of cultural knowledge and identity caused an epidemic of despair among indigenous peoples that’s been passed down over generations.
The attack on indigenous peoples evolved over time. It began with overt genocide—“the only good Indian is a dead one” said General Philip Sheridan in the 1860s. Then came the era of assimilation. “Kill the Indian in him, and save the man,” said Captain R. H. Pratt, the founder of the Carlisle Indian Industrial School, which like so many other Indian boarding schools, sought to “civilize” Native children. Indigenous children were separated from their families and sent to boarding schools or fostered or adopted out to non-Native families. Later in the 20th century, more sophisticated tools were used to control the population, like contraception and even forced sterilization. Indigenous peoples have “…a fear that white doctors don’t have your best interests at heart. And those are not fears that came from nowhere. Those are fears that were passed down from generation to generation,” said Sarah Deer, a Muskogee Creek citizen and a professor at the University of Kansas. Just as mistrust has been a barrier to engagement with the health care system among other communities of color, so, too, is it among indigenous communities.
The violence against Native peoples continues. They are twice as likely to be victims of homicide as other racial and ethnic groups in the U.S., and more than 40% of those murder victims are killed by someone of another race, in sharp contrast to homicide victims of other races who are largely killed by persons of their same race. About half of indigenous women experience intimate partner violence and sexual violence, with over 95% non-Native perpetrators. “Non-natives, in particular white men, know they can come into tribal communities and they can hunt us as Native women with impunity, because they know that we can’t touch them,” said Lisa Brunner, an enrolled member of the White Earth Ojibwe Nation in Minnesota.
Tribal reservations are often in remote places. The FBI doesn’t go out to investigate unless a major crime has been committed, and even then, U.S. Attorneys Offices are far less likely to prosecute crimes perpetrated in Indian Country, including violent crime, than elsewhere. “…[I]magine your own community where certain people didn’t have to abide by the law. And what does that do to a community, when that happens?” said Alfred Urbina, attorney general for the Pascua Yaqui tribe. Victims of violent crime are more likely to adopt high-risk coping behaviors like alcohol and drug use. They’re also more likely to experience poor mental health, chronic pain, diabetes, high blood pressure, and other chronic conditions.
Much of this history has been brushed aside and forgotten. What we’re left with are public health statistics taken out of context and medical diagnoses whose socio-pathophysiology we don’t fully understand. And so, our prescriptions and treatment plans fail. Victor Lopez-Carmen, a Hunkpati Dakota-Yaqui student at Harvard Medical School, says he’s often been told, “[I]f we only will stop eating the bad foods, if we’ll only stop smoking, if only stop drinking, if we’ll only behave ourselves, then we’ll have better health outcomes.” But that’s not why Native people are sick and dying.
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