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--> 1 Introduction Gary D. Sandefur, Ronald R. Rindfuss, and Barney Cohen American Indians1 trace their roots in the geographic area that now comprises the United States to an earlier point in time than any other racial or ethnic group, yet ironically, we know less about their current demographic and health situation than that of African Americans, Hispanics, Asian Americans, or European Americans. This volume includes a selection of papers prepared for a workshop on the demography and health of American Indians, conducted by the National Research Council's Committee on Population in May 1995. The papers were intended to summarize the state of knowledge about the demography of the American Indian and Alaska Native populations, about the major health problems they face today, and about their utilization of healthcare. The organizers of the workshop and the authors of the papers also attempted to fill a gap in knowledge about American Indians resulting from the absence of a monograph on the American Indian population based on the 1990 census. After the 1980 census, the Russell Sage Foundation commissioned a series of monographs, including one devoted specifically to American Indians, American Indians: The First of This Land 1 The chapters in this volume use the terms American Indian and Native American interchangeably. Moreover, unless otherwise indicated, both terms include the Alaska Native population, which comprises Aleuts (Aleutian Islanders), Eskimo, and other Native American people residing in Alaska.
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--> (Snipp, 1989). After the 1990 census, the Russell Sage Foundation commissioned only two volumes to report all recent social and economic trends in the United States (Farley, 1995). Several of the chapters in Volume Two, including one on racial and ethnic groups, contain some analysis of data on American Indians from the 1990 census. These two volumes could not, however, cover in any depth the changing demography of American Indians. In addition, no volume has ever pulled together information on American Indian demography along with data on American Indian health issues. The present volume has four major sections. The first contains two chapters that examine major demographic and epidemiological trends among American Indians during the past few decades. These two chapters discuss trends in fertility, mortality, morbidity, and migration. The second section explores issues involved in identifying and studying the American Indian population. These issues are critical in the case of American Indians for a number of reasons, two of which are well known: the above-noted changes in self-identification from non-Indian to Indian over recent censuses, and the more general issues involved in enumerating and/or sampling a relatively rare population. The latter set of issues is of concern because less than 1 percent of the U.S. population identified itself as American Indian by race in the 1990 census; this makes it particularly difficult to use national surveys to study American Indians. The third section examines the social and economic characteristics of the general, reservation, and urban Indian populations. The authors examine the economic situation of urban and reservation Indians, the characteristics of American Indian children and families, and the characteristics of the elderly Indian population. The final section addresses healthcare issues and healthcare access and utilization. This section contains three papers. Two papers summarize and assess our understanding of two major public health issues for Native Americans: alcohol abuse and related diseases and diabetes, especially the adult-onset type. A final paper examines healthcare utilization and expenditures for insurance coverage for American Indians eligible for IHS services. Questions And Issues This volume has two goals: first, to achieve a better understanding of some of the reasons for this relative paucity of knowledge and second, to review and extend our knowledge of the contemporary demographic and health situation of American Indians. The paths to these goals are closely intertwined, and it is difficult to discuss one without considering the other. We know relatively little about the demographic and health situation
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--> of contemporary American Indians in part because they are difficult to study with conventional social science techniques. Conversely, the lack of current and detailed knowledge exacerbates the difficulty involved in studying American Indians. The result is that many of the papers in this volume that treat the demographic or health status of American Indians also address the methodological difficulties involved, while those papers that are concerned with methodological issues bring trends and differentials into their discussion. Indeed, these two sets of issues are so intertwined that the editors vacillated regarding which should be covered first in the volume, and we recommend that the reader keep both in mind when reading the papers that follow. Several factors make it difficult to apply conventional social demographic techniques to the American Indian population: (1) American Indians are a relatively small proportion of the total U.S. population; (2) their residences tend to be either highly clustered in a small number of geographic areas or spread lightly over a large number of geographic areas; (3) they have experienced relatively high rates of marital exogamy, resulting in ambiguity about the extent to which their offspring are ''American Indians"; and (4) over time and across types of data collection systems, there have been shifts in whether self-identifying or being identified as an American Indian is perceived as an advantage or a disadvantage. Alone or in combination, these factors make it more problematic to compare results over time or across studies for American Indians than for other groups. Upon seeing a change, the substantively oriented want to speculate about the causes of that change, whereas the methodologically oriented want to suggest there was no change, invoking one or several explanations involving data "error." These two groups can frequently talk past one another, and the policy-maker can be left wondering which orientation to accept. In fact, one of the main challenges faced by policy-makers is sorting through the changing numbers to identify needs and shifts in those needs over time. A historical example, involving data technologies quite different from those used today, serves to illustrate one of many methodological problems involved in studying American Indians—the problem of using a national survey or census to draw inferences about a small fraction of the total population. In the published tabulations of the 1950 U.S. census, there was a surprising increase in the number of teenage American Indian widowers as compared with either the 1940 census or the patterns one might expect from common sense. In a display of statistical and demographic sleuthing, Coale and Stephan (1962) found that with the punch card data entry technology being used for the 20 percent sample in the 1950 census, a shift of one column to the right would transform a middle-aged
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--> white male into a teenage American Indian widower. They estimated that there was an error rate of approximately 14 to 20 per 10,000 middle-aged white males. This is a very low error rate, one that was invisible for the numbers published for middle-aged white males, but quite visible for the teenage American Indian widower category. The lesson is not that the Census Bureau did a poor job with the 1950 census, but rather that studying the American Indian population with conventional social, demographic, and epidemiological approaches is difficult. Nevertheless, for a number of reasons, it is extremely important that we continue to advance our knowledge of the demographic and health situation of the American Indian population and that our policies affecting American Indians be informed by the highest-quality demographic and health research. The American Indian population is growing rapidly. Between the 1890 and 1960 censuses, it doubled from 248,000 to 552,000, with an average annual growth rate of only 1.1 percent. Between 1960 and 1990, the population increased almost four-fold to just under 2 million, representing an average annual growth rate of 4.2 percent. In the absence of large-scale immigration, this very high rate of population growth is incompatible with what we know about the prevailing fertility and mortality regimes. Indeed, much of this increase is attributable to an increase in self-identification, i.e., people identifying themselves as non-Indian in one census and as Indian in the next. It has been estimated that three-fifths of the growth in the American Indian population between 1970 and 1980 is attributable to an increase in self-identification and two-fifths to natural increase. The increase in self-identification has also affected estimates of the geographic and income distributions of American Indians: many of those newly identifying themselves as Indian live in areas with low concentrations of American Indian populations, and on average they have higher incomes than those living on or near reservations. Issues of race and ethnicity and their interaction with public policy are never higher on the agenda than when policy-makers and planners are designing programs to serve better the needs of American Indian populations. Designing and evaluating alternative plans for the coverage of the Indian Health Service (IHS) population requires projections of tribal enrollment, estimates of current and future utilization of IHS services, and estimates of the availability and utilization of private healthcare coverage among individuals within the IHS service population. Furthermore, planners need to understand how the changing characteristics of American Indians could affect healthcare and insurance needs, as well as future expenditures. For example, the IHS relies on a combination of membership in federally recognized tribes and residence in geographically defined areas to identify the size and scope of its service population. The
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--> effect of changing self-identification on the geographic and income distributions of American Indians noted above has resulted in a population profile that is less concentrated in the West and less poor. Much of the population increase has been among those not eligible for IHS services. Analysts need to estimate the extent to which the observed trends are due to changes relevant to the health service needs of a defined population versus changing ethnic identification. Major Findings What Are the Major Population and Health Trends? In the first of two overview papers in this volume, C. Matthew Snipp summarizes what we know about the classic demographic issues of fertility, mortality, and migration. His analysis, like Passel's research in the next section, shows that the rapid growth of the American Indian population since the turn of the century is due in part to changes in self-identification, but also to the relatively high fertility of American Indians, currently higher than that of either blacks or whites. This represents a major change from the beginning of the century, when the deprivations of reservation life limited American Indian fertility. Moreover, the population would have grown even more rapidly if it had not experienced such high mortality, although there is considerable uncertainty about the relative mortality levels of whites, blacks, and American Indians.2 Careful examination of National Center for Health Statistics (NCHS) data has confirmed systematic inconsistencies in the coding of race and ethnicity between birth and death in U.S. infants (Hahn et al., 1992; Sorlie et al., 1992). Nevertheless, Indian infant mortality rates have improved substantially over the last 15 years, both in absolute terms and relative to the trend among whites and blacks. However, the death rates for American Indian youths and young adults remain high, exceeding those for comparable groups of blacks and whites. With regard to migration and population redistribution, the removal 2 Based on special tabulations of data from the National Center for Health Statistics, the U.S. Census Bureau calculates that life expectancy for American Indians is similar to whites and approximately 6 years longer than for blacks; 76.2 years for American Indians, 76.8 years for whites, and 69.7 years for blacks (U.S. Bureau of the Census, 1996:Table A, p. 2). However, because of the problems surrounding the misclassification of American Indian deaths, we believe that these estimates are seriously in error. For further discussion on this point, see Indian Health Service (1995) as well as the chapters by Snipp and Young in this volume.
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--> policies of the 1800s resulted in a concentration of the American Indian population west of the Mississippi River, a pattern that continues today. The American Indian population has also become increasingly urbanized, a trend promoted by World War II and the relocation programs of the 1950s. Currently, over one-half of American Indians reside in urban areas. Ongoing migration is likely to increase the proportion residing in urban areas, though it is unlikely to alter substantially the regional distribution of the American Indian population. The second overview paper, by T. Kue Young, examines in more depth the trends in diseases associated with mortality trends among American Indians. The major trends include a decline in infectious diseases, though stabilized at a level still higher than that for the non-Native population; an increase in chronic diseases, especially diabetes; and the overwhelming importance of social causes of injury and death—violence, accidents, and alcohol and drug abuse. The latter are important in accounting for the relatively high mortality among American Indian youth documented by Snipp. How Do We Identify, Enumerate, and Sample the Population? As noted above, previous research by Jeffrey S. Passel and others has shown that much of the recent growth in the American Indian population is attributable to changes in self-identification. In his paper in this volume, Passel demonstrates that the shifts in self-identification between 1980 and 1990 were smaller than those in the previous decades since 1960, and that these shifts do not preclude the careful use of census data to examine the demographic characteristics of American Indians, especially in those geographic areas where their populations are most concentrated. A large proportion of those changing their reported identity from one census to the next are of mixed race. However, as Russell Thornton points out, intermarriage not only has affected how people identify themselves, but in some cases has also made tribes reconsider how they define themselves. American Indian tribes are governmental entities with the right to establish their own criteria for membership. As tribes have been faced with increasing rates of intermarriage involving other tribes and non-Indians, some have responded by relaxing their "blood quantum" requirements for membership (that is, the proportion of one's ancestors required to be American Indians). Some tribes use documented descent from earlier membership rolls rather than blood quantum as the principal criterion for tribal membership. Finally in this section, Eugene P. Ericksen reckons with the implications for sampling of both the unstable self-identification and the small size of the American Indian population. He also assesses some of the
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--> other challenges facing those who want to sample the American Indian population: (1) American Indians are not as segregated or as concentrated as some other populations; (2) they are very culturally diverse; (3) the over 300 tribal groups recognized by the federal government and the as many as 200 other non-federally recognized entities have very diverse histories; and (4) visual inspection is often not a good way to identify American Indians because of the long history of intermarriage. Ericksen concludes that there is no easy solution to these identification and sampling problems, but that sampling is possible in most cases where the objective of the study and the purposes of sampling are clear, and where researchers pay close attention to the difficulties involved. His paper is a guide to the issues that must be addressed in studying the American Indian population and segments within it. How Are American Indians Faring Economically and Socially? The first two papers in the third section deal with the economic situation of American Indians in general, on reservations, and in urban areas. The final two papers deal with two components of the American Indian population that are of special concern for health policy: families and the elderly. Analyzing micro-level data from the 1980 and 1990 censuses, Robert Gregory and colleagues characterize the decade of the 1980s as one of "moving backwards" economically for Native American men and women. The average income of American Indian men, for example, was 63 percent that of white men at the beginning of the 1980s, but 54 percent that of white men at the end of the decade. The pattern was similar for American Indian women. The reasons for this decline include both the poor performance of the general economy and factors specific to Native Americans. Two facts in particular emerge: (1) American Indians receive lower returns to education in terms of earnings than do whites, and (2) earnings of American Indians lost ground at each educational level during the 1980s. Ronald L. Trosper looks at the economic situation of American Indians at the macro level by focusing on 23 major reservations and changes in their situation over the period 1969 to 1989. During 1969-1979, the percentage of families who were poor declined on all but 2 of the reservations. In contrast, during 1979-1989, the percentage of all families who were poor increased on all but 3 of the reservations. Consequently, the setbacks documented by Gregory et al. for the overall Indian population in the 1980s are reflected on most of these reservations. Multivariate analysis of macro-level data suggests that changes in federal expenditures on reservations may have an important role to play in explaining changes in American Indian poverty.
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--> Children and the elderly are two of the most vulnerable groups in society. Furthermore, both have unique needs with respect to healthcare access and utilization, and both use disproportionately large shares of total healthcare services. By analyzing trends in family patterns, Gary D. Sandefur and Carolyn A. Liebler show that in addition to economic and housing problems, American Indians have a higher percentage of children residing in single-parent families than does the general population. They also find that trends in marriage and divorce over time among American Indians parallel those in the general population, and that American Indian women are less likely to marry and more likely to divorce than women in general. They find further that the extent of single parenthood, never marrying, and divorce is considerably higher on some of the major reservations than among the general Indian population. As Robert John points out, the American Indian elderly population has grown substantially over the last decade. The proportion of the American Indian population aged 60 and older grew from 8 percent in 1980 to 9 percent in 1990, though it still remained well below the 17 percent of the general U.S. population who were 60 or older. This differential reflects the much lower median age of the American Indian population, resulting from the relatively high fertility and high mortality discussed in other papers in the volume. Significantly, approximately 29 percent of elderly American Indians were poor as compared with approximately 10 percent of non-Hispanic whites in the same age group. In sum, the papers in this section show that American Indian families, adults, children, and elders remain economically disadvantaged relative to the general U.S. population. Moreover, they show that these disadvantages are present among the overall Indian population, as well as among those residing both on reservations and in urban areas. What Are Some Major Health Problems Facing American Indians? The overviews by C. Matthew Snipp and T. Kue Young discussed above show accidents, suicide, and homicide, all three of which are often alcohol-related, to be the three leading causes of death among American Indians aged 15-24 in IHS service areas. Among American Indians aged 65 and older in IHS service areas, heart disease, cancer, cerebrovascular disease, diabetes, and pneumonia and influenza are the five leading causes of death. Alcohol abuse, along with associated diseases and accidents, is a health issue that has been important historically for American Indians and continues to be of concern. Philip A. May's review of previous and ongoing research shows that drinking prevalence varies greatly across tribal communities. Heavy drinking is quite common among some subgroups
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--> in many Indian communities. Because the American Indian population is so young, and heavy drinking is concentrated among teens and young adults, alcohol-involved mortality continues to be a substantial problem for Indians. The bulk of this mortality results from alcohol-related causes such as motor vehicle crashes, other accidents, suicide, and homicide, rather than alcohol-produced diseases such as cirrhosis of the liver. More recent intervention efforts have begun to consider the importance of behavioral patterns in accounting for high alcohol-related mortality. On the other hand, a number of tribes are characterized by a lower prevalence of drinking than is found among the general U.S. population. Moreover, Indian women have a substantially lower overall prevalence of drinking than U.S. women, and many Indian men "mature out" of heavy problem drinking in middle age to become abstainers. A second problem of particular concern among American Indians is diabetes mellitus. K. M. Venkat Narayan reviews what we know about the prevalence, causes, consequences, and prevention of diabetes among American Indians. His assessment shows clearly that the rates of diabetes and its complications, including premature death, renal failure, and limb amputation, are substantially higher among Native Americans than among the general population and that the frequency of diabetes among Native Americans is increasing. Diabetes was relatively rare among American Indians until the middle of the twentieth century. Since that time, it has become one of their most common diseases. One group of Indians, the Pima, has the highest recorded prevalence of diabetes in the world. Several of the causes of diabetes among Native Americans, including obesity, dietary composition, and physical inactivity, are preventable, and recent intervention efforts have shown some progress in addressing these causes. Are American Indians Receiving Adequate Healthcare? Given the clear social and economic disadvantages of American Indians and their well-documented health problems, one may ask to what extent the current healthcare delivery system is meeting their needs. As Snipp points out, the IHS service population numbered about 1.21 million in 1990, or 62 percent of the total population of 1.96 million American Indians enumerated by the 1990 census. Because of the information collected by the IHS for its service population, as well as a federally commissioned study of this population that produced a data set known as the Study of American Indians and Alaska Natives (SAIAN), we know more about how we are meeting the needs of the IHS service population than
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--> we do with regard to the remaining 38 percent of the American Indian population. Peter J. Cunningham uses the SAIAN data to examine healthcare coverage and utilization for those eligible for IHS services. He points out that those who are eligible for IHS services have some advantages over those who are not. IHS beneficiaries do not pay premiums, nor do they pay deductibles or copayments, regardless of personal or family income level. Also, while many in the general U.S. population live in medically underserved rural areas or inner-city areas, IHS facilities and resources are targeted specifically to many rural and sparsely populated areas where eligible Indians are concentrated. On the other hand, because of geographic isolation, many Indians have difficulty reaching IHS service centers, and the amount of money spent each year on services is limited. In addition, expensive diagnostic and treatment services may be delayed or denied if funds are not available to purchase such services through contractual arrangements. Partly for this reason, many members of the IHS service population have other sources of healthcare coverage, either purchased or available through Medicare or Medicaid. Cunningham points out that, given the growing size of its service population and its resource constraints, the IHS will increasingly have to rely on utilizing and coordinating with other sources of healthcare services. Implications For Healthcare And Other Policies One theme that emerges clearly from the chapters in this volume is that the socioeconomic disadvantages of American Indians make them a vulnerable population. American Indians are a relatively young population with higher levels of poverty, unemployment, single-parent families, fertility, and mortality than the general U.S. population. These conditions are present among both urban and reservation Indians, but they are especially pronounced on some reservations. Such conditions call for both short- and long-term approaches. In the short term, safety-net programs, such as accessible healthcare provided through the IHS, are important to ensure that vulnerable individuals—particularly those who live on reservations with poverty rates that sometimes approach or exceed 50 percent—are able to receive preventive and other healthcare services. In the long term, improving the situation of American Indians will require substantial efforts to improve their education and health, along with efforts to provide employment opportunities both on and off the reservations. The IHS may be an important part of such a long-term
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--> strategy, working to improve the health of American Indians so they will be able to take advantage of any enhanced employment opportunities. Existing research on health issues indicates several problems that are more prevalent among American Indians than among other Americans, including alcohol-related problems, diabetes, suicide, and homicide. Addressing some of these problems may require intervention programs targeted at behavior. Both alcohol-related problems and diabetes, for example, are strongly affected by behavior. In recent years, researchers have begun to develop and demonstrate the effectiveness of efforts designed to lead to healthier drinking, eating, and exercise behaviors. The successful programs deserve wider dissemination and utilization. Another set of implications for healthcare and related policies flows from the very reasons why it is methodologically difficult to study the American Indian population. Consider the identification issue. Thornton shows how various American Indian tribes have changed their own criteria for membership. These changes are related to the high rates of marital exogamy among American Indians as compared with whites or blacks (Sandefur and McKinnell, 1986). Further, at the individual level, Passel and others have shown that each of the last three decennial censuses provides overwhelming evidence that individuals and households shifted to identifying themselves as American Indian from one census to the next. From the perspective of the IHS or any other organization whose mandate is to serve the American Indian population, the potential for shifts in either tribal criteria for membership or individual self-identification means that predicting the size of the population to be served is problematic. Further, the size of the population to be served may be influenced by the nature of the federal programs involved, thus introducing feedback into the system. For example, Nagel (1995) has argued that prior federal American Indian policies, by affecting patterns of migration and intermarriage, have influenced the ambiguity of identification of those whose heritage is not completely American Indian and subsequently influenced their increased self-identification as American Indian. Both federal and state policies also influence the advantages or disadvantages accruing to tribes by increasing their size through a change in their criteria for membership or to individuals by identifying as American Indian. Growth of this type could strain the facilities and programs of the IHS, as well as other agencies. Predicting the effect of a change in any given American Indian program on the actual size of the eligible and self-designated American Indian population is difficult, yet deserves consideration. Questions For Future Research It is customary to end papers on American Indian demography or
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--> health with a lament about the lack of good data on American Indians. This lack of data is indeed a real problem. The large national data sets that are used to examine blacks, whites, and Latinos, such as the National Longitudinal Surveys and the Panel Study of Income Dynamics, do not sample consciously among the American Indian population. Consequently, we know less about American Indians than about many other groups in our society. The papers in this volume show, however, that there are data of good quality available for those who wish to study American Indians. These include data from the censuses; the Survey of American Indians and Alaska Natives (SAIAN); and some of the medical studies of specific groups of Indians, such as the study of diabetes among the Pima. The papers in this volume hardly exhaust what can be done with these data. There is room for a good deal more in-depth research on American Indian economic well-being; fertility and mortality; families, elders, and children; incidence, prevalence, and treatment of specific diseases; and healthcare utilization. Nevertheless, given the uncertainties surrounding the size and characteristics of the American Indian population, policy-makers and planners dealing with these populations might best be served by using ranges rather than point estimates for their projections of the potential growth of their service populations. When dealing with an ambiguously defined population, it is particularly important to test the sensitivity of forecasts and cost estimates based on alternate assumptions. References Coale, A.J., and F.F. Stephan 1962 The case of the Indians and the teenage widows. Journal of the American Statistical Association 57:338-347. Farley, R., ed. 1995 State of the Union: America in the 1990s. Volume One: Economic Trends. Volume Two: Social Trends. New York: Russell Sage Foundation. Hahn, R.A., J. Mulinare, and S.M. Teutsch 1992 Inconsistencies in coding of race and ethnicity between birth and death in US infants. JAMA 267(2):259-263. Indian Health Service 1995 Regional Differences in Indian Health, 1995. Rockville, MD: U.S. Department of Health and Human Services. Nagel, J. 1995 American Indian ethnic renewal: Politics and the resurgence of identity. American Sociological Review 60:947-965. Sandefur, G.D., and T. McKinnell 1986 American Indian intermarriage. Social Science Research 15:347-371. Snipp, C.M. 1989 American Indians: The First of This Land. New York: Russell Sage Foundation.
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--> Sorlie, P.D., E. Rogot, and N.J. Johnson 1992 Validity of demographic characteristics on the death certificate. Epidemiology 3(2):181-184. U.S. Bureau of the Census 1996 Population Projections of the United States by Age, Sex, Race, and Hispanic Origin: 1995 to 2050. Current Population Reports, P25-1130. Washington D.C.: U.S. Government Printing Office.
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Representative terms from entire chapter: