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Status as the "First Americans" is a matter of considerable pride, and, as indigenous peoples, American Indians and Alaska Natives point to the sophistication and complexity of their societies at the time of European contact. Although some were nomadic hunters and gatherers living in groups of 30 to 100, others were members of more numerous tribal groups of sedentary agriculturalists who tilled fields of domesticated plant foods and had political structures that forged alliances between settlements. Still others were organized into larger and more socially complex groups, with massive ceremonial structures, elaborate artistic motifs, and extensive trade relationships with groups at distances of up to a thousand miles.

EARLY IMPACT OF DISEASE AND A LEGACY OF DISTRUST

All aboriginal societies had healers who aided the sick, and in such a context distinctions between religious practices and health practices, as understood by most white Americans, are a largely artificial dichotomy. However, these traditional ministrations had little effect on the variety of diseases introduced by Europeans. "Old World" diseases included "smallpox, measles, the bubonic plague, cholera, typhoid, pleurisy, scarlet fever, malaria, yellow fever, diphtheria, mumps, and whooping cough, and probably typhus and syphilis." Epidemics were recurrent, and accompanying them were ''direct and indirect effects of wars (and genocide), enslavements, removals, and relocations, and the destruction of 'ways of life' and subsistence patterns. . . ."3 For example, smallpox had a profound impact on mortality in children under age five, fetal loss and infertility in women, and possibly infertility in men.

Depopulation from morbidity and mortality also led to general social disorganization and breakdown in performance of social roles. An epidemic of measles that occurred within the last quarter-century in a South American aboriginal group with no immunity provides a glimpse of deteriorating conditions that occurred in the wake of smallpox (and other) epidemics from the seventeenth to the nineteenth century. Caring for children, obtaining food, tending the sick, and attention to sanitary conditions were sufficiently disrupted to increase morbidity and mortality.4 Previously healthy women and men were so demoralized that many turned their backs, assumed a fetal position in their sleeping hammocks, and awaited death.

Native people recognized that diseases followed encroachment of Europeans, and most believed that epidemics were spread deliberately. For example, major smallpox epidemics occurred during the mid-nineteenth centuries, when "missionary barrels" containing clothing and blankets formerly used by persons infected by smallpox ("fomites") were sent to needy and unsuspecting remnants of displaced tribes. Between 1829 and 1833 outbreaks of malaria decimated coastal native settlements from Vancouver southward to California and



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