1. Health Equity and Social Disparity Native American Perspective
Fifth Annual Eccles Family Rural West Conference
Santa FE, New Mexico
March 24, 2017
Bret A. Smoker, MD, MPH
Indian Health Service
Santa Fe Service Unit

2. Who Is Native American (or American Indian, or Indigenous . . .)?
5.2 million self-identify as American Indian/Alaska Native (AI/AN), 2.9 million as exclusive AI/AN1
US Congress gives “federal recognition”
Tribes define membership2
1US Census Bureau (2012). The American Indian and Alaska Native Population: 2010, Issued January Referenced on US Census Bureau web site:
2Bureau of Indian Affairs (2014). A Guide to Tracing American Indian & Alaska Native Ancestry. Office of Public Affairs-Indian Affairs. Washington, DC. Referenced on Bureau of Indian Affairs web site:

3. Legal Basis for Native American Rights And Health Care Services
US Constitution
Article I, Section 8 of US Constitution references “. . . Commerce with the Indian Tribes . . .”
1871: Congress forbid further treaties between federal government and tribes (25 U.S.C. § 71)1
1921: Snyder Act
1955: Indian Health Service established
1975: PL—93-638
1976: Indian Healthcare Improvement Act
2010: Affordable Care Act; IHCIA permanently authorized
1Pevar SL (2004). The Rights of Indians and Tribes: The Authoritative ACLU Guide to Indian and Tribal Rights. 3rd edition. New York University Press. New York and London.

4. Overview of Indian Health Service
IHS is an agency within DHHS
2.2 million AI/AN beneficiaries in 35 states
Administratively divided into 12 Areas
FY 2016 budget: $4.8 billion
Over 40 inpatient facilities and more than 500 outpatient facilities nationwide
IHS benefits provided in addition to, not in place of, benefits available to other citizens1
1Indian Health Service (2017). About IHS. Referenced on Indian Health Service website:

6. Native American Health Disparities
Annual per capita personal health care expenditures1
US all races: $9,523; IHS beneficiaries: $3,688
AI/AN vs. all-race US age-adjusted mortality2
4.7 times greater from chronic liver disease and cirrhosis
2.8 times greater from diabetes mellitus
2.4 times greater from unintentional injuries
1.8 times greater from homicide
1.6 times greater from suicide
1.6 times greater from chronic lower respiratory diseases
1Indian Health Service (2017). About IHS. Retrieved from Indian Health Service website:
2Indian Health Service (2014). Trends in Indian Health, 2014 Edition. IHS Office of Public Health Support, Division of Program Statistics

7. Native American Health Disparities
In New Mexico AI/AN have worst outcomes in:1
Late or no prenatal care
Diabetes death rates
Adult obesity
Youth obesity
Adults 65+ ever receiving pneumonia vaccine
Motor vehicle deaths
Youth suicide
Alcohol-related deaths
1New Mexico Department of Health (2013). Health Equity in New Mexico: A Report on Racial and Ethnic Health Disparities, 8th Edition. Referenced on NM Department of Health web site:

8. The Health Impact Pyramid
Adapted from: Frieden TR (2010). American Journal of Public Health, 100(4):590-5.

9. Network/Seek Sustainability
Recommendations
Network/Seek Sustainability
Health Policy
Find regional partners/avoid duplication/seek common goals
Ensure research and interventions are community-based and community-directed
Challenge the status quo; be a “social entrepreneur”1 with creative public-private partnerships
Whenever possible, work low on the Health Impact Pyramid
Respect [legitimate] institutions, both public and private
Hold elected leaders and public institutions accountable
Require health impact assessments with major public works2
Be strategic; remember that:
Native Americans have unique rights, and
Policies broadly benefiting marginalized communities can benefit Native Americans
2The Pew Charitable Trusts (2017). Health Impact Project: A Collaboration of the Robert Wood Johnson Foundation and The Pew Charitable Trusts. Referenced on The Pew Charitable Trusts web site:
1Gaist, PA, editor. Igniting the Power of Community: The Role of CBOs and NGOs in Global Public Health. 1st edition (2009). Springer Science and Business Media. New York.