Indigenous communities in California and throughout the United States face striking health disparities. At 71.8 years, American Indian and Alaska Native individuals have the lowest life expectancy compared with other races and ethnicities. They are 2.3 times more likely to die from diabetes than white people and they have the highest rate of suicide compared with all other racial and ethnic groups (28.1 per 100,000). In addition, American Indians are 2.5 times more likely to experience sexual assault compared to all other races, and one in three women reports having been raped during her lifetime.
The explanations for these health disparities are complex, and are certainly rooted in Indigenous people’s experiences of disenfranchisement, displacement, discrimination, resulting poverty, and intergenerational trauma over centuries of American colonization. Today, as California health care and social service organizations work to support the well-being of Indigenous communities, ameliorate past harms, and advance health equity, it’s important to first better understand this historical trauma and the ongoing impacts on people now. Here, we discuss three ways that organizations can address these inequities: partnering with Indigenous Tribes, embracing a mindset of “cultural humility,” and increasing the number of Indigenous people in the health care workforce.
To speak to this, Gayle Zepeda, a tribal leader and adjunct professor at Mendocino College in Ukiah, recently shared her own family’s history as personal examples during a webinar hosted by the California Improvement Network, a program managed by Healthforce Center at UCSF. She described the many deleterious policies that have impacted them, including enslavement, forced separation, forced displacement, and forced sterilization.
A History of Trauma, Abuse, and Resilience
Like many Indigenous children in the 19th and 20th centuries, Zepeda’s mother and aunts was forcibly sent to a boarding school. There, Indigenous children faced shaming and abuse, were taught their culture was inferior, and were often gone so long that they forgot their native languages when they returned home, if they returned at all. The severity of white people’s attitude and approach toward subjugating Indigenous people at the time is clear in the saying used then, “Save the man and kill the Indian.” Mass cemeteries and unmarked graves have been discovered at boarding schools throughout the United States and Canada.
In the 1960s, Zepeda’s grandmother protected her from being taken away on an “assimilation vacation” in the San Francisco Bay Area, where children would “learn how other families live” and potentially be adopted away from their rightful families. Zepeda and her siblings lived with a constant fear of being taken from their home, often being told by their grandmother: “You better behave because if you don’t, white people are going to take you away.” It wasn’t until 1978 that the Indian Child Welfare Act prohibited the removal of Indigenous children from their families.
Further alienating Indigenous people from their roots was the repression of their spiritual beliefs and practices going back to the 1850s. Until the American Indian Religious Freedom Act passed in 1978, many people practiced secretly while participating in mainstream religion. For example, Zepeda’s great grandfather was a tribal medicine person, but also an altar boy for a Catholic priest.
Owning land contributes to economic and societal stability as well as long term wealth. While the United States government was obliged for many generations to honor treaties and debts with native tribes, the Termination Act of 1953 sought to disband tribes, sell their lands, and relocate American Indians. For Zepeda, this meant that she was no longer Indian and was not eligible to receive services from the Indian health clinic. The policy also had long-term and devastating economic consequences for tribal communities who lost their land.
In 1983 with Hardwick v. United States Government, Zepeda was considered Indian once again. “We have reorganized and reestablished ourselves.” Now, she lives again on the land that had been her grandma’s.
Recommendations to Help Tribes Thrive
With a better understanding of the abuses that Indigenous people have suffered over centuries, efforts to improve health care and social services delivery should consider these three recommendations.
1. Organizations must partner with Tribes. Health care and social services organizations should reach out to tribes in their area and establish relationships, Zepeda said. By partnering with Tribes to define their needs and co-design responsive services, then this effectively centers the communities in their own care. The Bureau of Indian Affairs or Indian Health Services have listings and maps for tribes and California Indian Health Service clinics by county. When approaching this work, it’s important to recognize that different tribes have their own histories and needs and cannot be approached in a one-size-fits-all fashion.
2. Non-Indigenous clinicians must embrace cultural humility. Similarly, individuals have their own lived experiences and unique needs. When talking about cross-cultural considerations, Zepeda prefers the term “cultural humility” over “cultural competence.” She explains, “Humility is more of a lifelong pursuit involving self-evaluation, self-critique, and understanding.” To understand another culture, one must reflect on one’s own values and biases.
Zepeda recommends using the RESPECT framework to embrace cultural humility when non-Indigenous people work with Indigenous people:
- Respect: Become familiar with communication styles. Understand how respect is shown in Indigenous cultures and show respect through verbal and nonverbal communications. Learn to listen. Become comfortable with silence.
- Embrace humility when working with tribes.
- Sociocultural context: Recognize how many factors affect care decisions: tribal affiliation, culture, language, gender, gender roles, education, socioeconomic status, values, community, family, sexuality, social organization (e.g., matrilineal), geographic location, etc.
- Participation: Appreciate that Indigenous people may have different expectations, perspectives, and attitudes about participation in their care. Take time to discuss and understand these aspects, as well as the role and level of participation an individual prefers.
- Empathy: Express, verbally and nonverbally, the significance of concerns so that they feel you understand. If possible, share some of your own experiences.
- Concerns and fears: Elicit concerns and apprehensions about health care and social service systems.
- Trust/Therapeutic alliance: Commit to behaviors that enhance an effective partnership; recognize that trust is not inherent but that you must earn it.
3. Boost the number of Indigenous people in the health care workforce. Greater cultural concordance between health care clinicians and patients has a positive impact on health outcomes. To improve the ratio of Indigenous clinicians to patients, educational and health care systems must boost the pipeline of Indigenous people in the health care workforce. Below are five strategies from researchers at Healthforce Center at UCSF that support this goal.
- Shorten the training pathways for select job categories that prioritize diverse cohorts of learners
- Provide access to learning and networking opportunities to ensure pipelines and mentoring for Indigenous individuals in training
- Leverage innovations, such as distance learning, to broaden access to programs for Indigenous people
- Expand social supports (such as childcare assistance) to enable entry-level and middle-skill workers to participate in the workforce and in career ladders
- Educate and support employers on effective strategies for recruiting and retaining Indigenous health workers
During the past few centuries there has been a near genocide of Indigenous people on the North American continent, and this legacy continues to starkly impact the health and well-being of individuals. People who work in health care and social services – from frontline administrative staff to clinicians to educators to executives – need to practice cultural humility and work with Indigenous people to promote ongoing healing and flourishing. As Zepeda said at the close of the CIN webinar, “Travel with humility as you move forward.”
The webinar on which this article is based was hosted by the California Improvement Network, which is a project of the California Health Care Foundation and managed by Healthforce Center at UCSF.
