Culture-Sensitive Health Care: American Indian
The term "American Indian" refers to members of Indian tribal nations who live in the United States. The term "Alaska Natives" refers to the Eskimo and Aleut populations. "Native American," a term that has become unpopular among American Indian groups, refers to American Indians, Eskimos, and Aleuts as one racial and ethnic group.
If Eskimo and Aleut populations are included, Native Americans numbered 2.2 million in 1994, and their numbers are growing rapidly. The Native American group as a whole is expected to reach 4.3 million by 2050, a fact reflecting both the greater efficiency of the Census Bureau in counting Indians living on reservations and trust lands, and the comparative youth and fertility of the American Indian population. In 1990, the median age of Native Americans was 26, with 39 percent under 20. This group is extremely diverse, with more than 500 (300 American Indian alone) distinct Indian nations and Alaska Native and Aleut villages, each with its own unique language, tribal laws, and culture.
Of the American Indian population, half live west of the Mississippi River, with the majority living in Oklahoma, California, Arizona, and New Mexico. Poverty is higher than in the rest of the population and continues to increase. In 1979, 27 percent of the American Indian population lived below the poverty line; by 1989 this figure had grown to 31 percent, compared to a national poverty rate of 12 percent in 1979 and 13 percent in 1989.
Many American Indians continue to practice tribal religions and traditional medicine. One study reported that 70 percent of Navajos living on the reservation use traditional healers, while another found that approximately 28 percent of Indians living in Milwaukee and the San Francisco Bay area continued to use traditional practitioners.
Keys to a Good Professional Relationship with American Indian Patients
Potential Culture-Related Health Concerns among American Indians
American Indians' average life expectancy is 71.1 years, an improvement from 1969-1971, but still lower than all other races in the United States. According to the Indian Health Service of the U.S. Department of Health and Human Services, the leading causes of death among American Indians from 1984 to 1992 were 1) heart disease, 2) accidents, 3) malignant neoplasms, 4) cerebrovascular disease, 5) chronic liver disease, 6) diabetes, 7) pneumonia and influenza, 8) homicide, 9) suicide, and 10) chronic obstructive pulmonary disease.
Many health problems and the high incidence of accidents and suicides may, in part, be due either directly or indirectly to poverty, feelings of hopelessness, and adjustment problems. Specific concerns include the following.
American Indian Religious and Spiritual Beliefs That Can Affect Care and Treatment
In spite of the enormous diversity in tribal cultures, languages, and religious beliefs of the almost 300 American Indian tribes living within the continental United States, these tribes share a number of fundamental health, illness, and illness prevention beliefs.
The Navajo Application of These Beliefs
According to the U.S. Census Bureau, the Navajo tribe has about 219,000 members, the majority living on a reservation of about 27,000 square miles of semiarid land in Arizona, New Mexico, Utah, and Colorado. The information that follows illustrates how one important American Indian culture applies the general beliefs listed above to its health practices. Although the application of these beliefs may vary by tribe, it is hoped that the detailed description of Navajo beliefs will serve to improve the caregiver's understanding of how these beliefs may affect the health behavior of other tribal nations as well.
Navajo society is matriarchal, built on the belief that a goddess known as First Woman, Spirit Woman, Whiteshell Woman, Thinking Woman, or Changing Woman created the universe. In Navajo society, women hold a higher position than men. According to tribal custom, the husband moves into the home of the wife's parents upon marriage. The extended family, often called a "camp," generally comprises the senior married couple, their unmarried children, their married daughters, and the daughters' husbands. Traditional Navajos must obtain the permission of the leading female elder before entering a hospital or undergoing surgery.
The focus of Navajo traditional religion is on maintaining a harmonious relationship with all living things, including the land, one's farm, and one's community. Illness is thought to result from improper thought and behavior affecting oneself as well as the external, natural world of plants, animals, and the environment. Illness also is attributed to an improper use of ceremonies.
As a rule, the Navajo may not seek medical care for a number of discomforts and acute illnesses for which a non-Navajo would seek relief. Illness, like death, is simply viewed and accepted as a natural part of life.
Navajo Etiology of Disease
Unlike modern biomedicine, the aim of Navajo healing ceremonies is to remove the cause of a disease, not alleviate the symptoms. The following are causes of disease according to the traditional Navajo belief system.
Soul loss. The soul or "wind" of a person enters the body at birth, forming the basic personality. Until the baby laughs for the first time—an indication that the wind has attached itself to the body—it is believed that the baby may die easily. In old age, the soul is again loosely attached, making death natural. The ghosts of the very young and very old are not considered agents of disease, but if a person with well-atttached wind dies, the ghost of that person is thought to be an extremely dangerous and potent agent of disease. Therefore, there is a general taboo against touching the dead—possibly due to uncertainty about whether the soul is still attached to the body and will be a disease agent.
Intrusive objects. In a special form of witchcraft called "wizardry," a disease-causing agent can be injected into the skin of the victim by a witch or sorcerer.
Spirit intrusion or possession. This happens when the spirit or "wind" of an individual is displaced by the spirit of a dangerous supernatural being.
Breach of taboo. This is the most frequent diagnosis of illness linked with various taboos. A person who goes into general seizures is suspected of incest. This illness is frequently called "moth sickness," in reference to the mythical butterfly people who committed the first incest. Because the moth is the etiological agent, and the disease may result from contact with it, a witch can cause this illness by making a person touch a real moth.
Witchcraft or sorcery. A witch is a person who has killed someone, generally a relative, and then changed him or herself into an animal (such as a wolf, coyote, bear, owl, fox, dog, crow, eagle, porcupine, snake, moth, or long-horned grasshopper) in order to travel and do evil undetected. Witches band together for rituals and ceremonies involving chants, sand paintings, body paintings, and masks. They are believed to perform their witchery by touching the victim with a powder made from a bit of the flesh of the dead. Signs of having been the victim of witchery are fainting and unconsciousness. Another sort of witchcraft, called "frenzy witchcraft," is associated primarily with love magic. This witchcraft uses the datura plant, which contains scopolamine and hyoscyamine; when ingested, it can produce hallucinations, dissociative reactions, and even coma. It is believed that a mere touch of the potion can cause a woman to tear off her clothes in a sexual frenzy, permitting the witch to seduce her.
Sorcery is only slightly different from witchery. Sorcerers cast spells on people in absentia by using bits of the person's hair, nails, feces, or other body products.
Combined Use of Traditional and Modern Medicine
A Navajo would probably not question the value of using both "modern" medicine and Navajo medicine. The two approaches to health and illness are viewed as distinct but complementary. It is perfectly acceptable for a person to consult a Navajo diagnostician to identify the cause of a disease and to arrange a ceremony to eliminate the cause, as well as to consult a physician to alleviate the symptoms of the disease. Similarly, it is not uncommon for some Navajos to insist that they be allowed to hold a traditional ceremony or ritual before undergoing surgery or treatment at a reservation hospital. An important difference is that whereas a traditional diagnostician or healer may advise the ill person to seek treatment from a physician, the reverse is rarely the case.
Navajo Language and the Classification of Illness
Illnesses are classified by the agents believed to have caused them or the ceremonies used to cure them—such as the Wind Way, the Evil Way, the Night Way, the Plume Way, and the Earth and Beauty Way—rather than by either the symptoms expressed or the parts of the body affected. Since diagnosis does not rely on an understanding of symptoms, many traditional Navajos may be confused by the physician's need to ask questions while taking a medical history or conducting a physical examination. However, studies indicate that the ability to describe the nuances of pain and symptoms in the Navajo language is highly sophisticated and that patients can become good historians of their illnesses if they are helped to understand why the physician needs a good history.
Peyote Religion and Its Impact on Navajo Health Beliefs and Practices
Full traditional ceremonies and rituals—which may last from five to nine nights and often involve hosting large numbers of guests—are becoming increasingly infrequent. The number of qualified medicine men and women has also declined, largely because as many as eight years of training and apprenticeship are needed to learn each major ceremony. Most ceremonialists, therefore, limit themselves to the performance of only two of these major ceremonies.
The Peyote religion, now organized as the Native American Church, offers a simpler and more economical way to hold ceremonies. Peyote is a nativistic religion that began among the Kiowa and Comanche tribes during the second half of the nineteenth century. The Peyote religion has achieved ready acceptance among the Navajo because it neither introduces new beliefs about the causes of disease nor denies any beliefs central to Navajo religion. Its short, one-night ceremonies, performed on weekends, offer a practical substitute for long and expensive Navajo healing ceremonies, especially for working Navajo who cannot afford to take off from work to attend ceremonies that can last as long as a week or even more.
Because Peyote ceremonies are not only short but also easy to learn, Navajo youth who wish to gain status through traditional means can easily become Peyote healers. For similar reasons, the number of American Indians who have joined and become active in fundamentalist Christian denominations, such as the Nazarene, Pentecostal, and Baptist religions, has increased.
However, in spite of the fact that Navajos use Peyote ceremonies, healers from the neighboring Hopi and other tribes, faith healers, Christian ministers, and practitioners of modern medicine, these new approaches have not really become an integral part of the Navajo belief system. This system is sacred and lies at the core of Navajo religion. The fact that many Navajo use other medical systems does not signify any real, underlying change in their understanding of health prevention, health maintenance, or cure, because, as stated earlier, these newer medical approaches relieve symptoms, rather than removing the cause of the disease.
Traditional American Indian Care and Treatment
A 1962 study of the health care decision-making process of 77 American Indians living close to an Indian Health Service (IHS) hospital found that 10 individuals (13%) elected not to seek care of any kind. Of the 67 persons who did seek care, 32 (48%) elected to seek modern medical care exclusively, 26 (39%) used both native healers and physicians, and only 9 (13%) used native practitioners exclusively.
In general, American Indians who have more years of education, were reared off the reservation (and only about 50 percent of American Indians now live on reservations), are Christian, and/or were reared in urban areas are less likely to use traditional methods of healing. It is not uncommon for others to consult first a traditional healer to diagnose or remove the cause of a disease, and then an Indian Health Service physician to cure the symptoms. One researcher has pointed out that the Navajo practice of combining traditional ceremonies and biomedical services may result more from the inaccessibility of hospitals and clinics and the difficulty of communicating with caregivers than from a preference for traditional cures.
Economic factors, knowledge about and access to herbs, and distance from biomedical care often influence the decision to seek home treatment. However, as more over-the-counter remedies become available at trading posts and cash-and-carry stores, these remedies are becoming more popular than herbal remedies for a wide number of symptoms.
Traditional Diagnosis, Rituals, and Ceremonies
When illness is perceived, a hand trembler or star gazer may be asked to diagnose the cause. He or she will use a trance, induced by a simple ritual, to "see" or "hear" the cause of the illness. A ceremonialist or "singer" may then be engaged to remove the illness through the appropriate healing ceremony. In Navajo culture, over 75 different healing ceremonies have been identified. In addition, "blessing way" chants may also be performed as a way to prevent illness, maintain health, and attract the forces of beauty and harmony.
The healing ceremony should be performed four times to ensure the removal of the cause of illness, a requirement that involves a great deal of expense. Because most healing ceremonies are forbidden during summer months, there can be a long waiting period between diagnosis and cure. During these times, an herbalist is often engaged to relieve symptoms. However, it is becoming more and more common for people to self-diagnose simple illnesses or go to an Indian Health Service physician, where care is provided free of charge.
Navajos who live in close proximity to other tribal villages may sometimes use the traditional healers associated with those villages. Hopi healers, for example, are believed to be experts at healing through "sucking cures," which "suck" the intrusive, illness-causing object from the body. Peyote cures are also used.
Sources for Further Reading
Avery, Charlene. "Native American Medicine: Traditional Healing." Journal of the American Medical Association, 265(17), 1991, 2271-2273.
Bell, Roxanne. "Prominence of Women in Navajo Healing Beliefs and Values." Nursing & Health Care, 15(5), 1994, 232-240.
Carrese, Joseph, and Lorna A. Rhodes. "Western Bioethics on the Navajo Reservation: Benefit or Harm?" Journal of the American Medical Association, 274(10), 1995, 826-829.
Dansie, Roberto. "Health from an Indian Perspective." IHS Primary Care Provider, 22(17), 1997, 116.
Hanley, Catherine E. "Navajo Indians." Transcultural Nursing. 2nd ed. Ed. Joice Newman and Ruth Elaine Davidhizar. St. Louis: Mosby, 1995. pp. 237-260.
Hatton, Diane C. "Health Perceptions among Older American Indians." Western Journal of Nursing Research, 16(4), (1994), 392-403
Kunitz, Stephen, and Jerrold E. Levy. "Navajos." Ethnicity and Medical Care. Ed. Allen Harwood. Cambridge: Harvard University Press, 1981. pp. 337-395.
Locust, Carol, and Jerry Lang. "Walking in Two Worlds: Native Americans and the VR System." American Rehabilitation, 22(2), 1996, 2-14.
The IHS Primary Care Provider, a journal for health professionals working with American Indians and Alaska Natives, can be obtained free of charge from this address:
Department of Health and Human Services
Indian Health Service
Clinical Support Center
1616 East Indian School Road, Suite 375
Phoenix, Arizona 85016