Culture-Sensitive Health Care: American Indian

From What Language Does Your Patient Hurt In?: A Practical Guide to Culturally Competent Care.
Diversity Resources, Inc. Amherst, MA. 2000.

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

  1. Make the patient welcome. First meetings are important! To make the patient feel welcome, extend a warm greeting and smile. The smile may not be returned, but it will be appreciated. Shake hands, introduce yourself, and allow the patient to do the same (thereby showing respect to his or her ancestors). Thank the patient for having chosen your health facility. Although a western-style handshake is appropriate and appreciated, don't be surprised if it is returned by an unusually weak or strong one. The traditional Navajo greeting is not to shake hands, but to extend the hand and gently touch the other person's hand.
  2. Use eye contact judiciously. Although eye contact is expected during the initial handshake and occasionally during the interview, prolonged eye contact is considered a sign of disrespect and should be avoided.
  3. Take your time. It is important to spend time with the patient and to avoid appearing hurried or nervous. Patients often travel great distances at great financial hardship to see a physician; if the physician spends only five or ten minutes with them, the message is clear and negative.
  4. Speak plainly. During an examination, avoid medical or other terms that may not be understood, but at the same time, don't talk down to the patient or appear to treat him or her as a child. A soft, concerned voice will do much to make the patient feel at ease.
  5. Respect silence. Be concise and give the patient time to reflect on what you are saying. Don't try to fill up the time. American Indians are taught the value of silence and may also need time to mentally translate what they hear into their own language.
  6. Understand tribal diagnosis. Because traditional and scientific medicine are not mutually exclusive, the patient may have come to you following diagnosis by a tribal diagnostician. Because tribal diagnosticians use different procedures, the patient may be unfamiliar with the technique of identifying the specific location of pain. Rather than asking "Where is the pain?", ask the patient to point to the most intense area of pain.
  7. Accommodate tribal healing. Patients may wish to perform certain tribal healing ceremonies, even in the hospital (e.g., sprinkling corn or cornmeal around the bed before surgery or treatment, burying the umbilical cord after childbirth). Try to accommodate these ceremonies as a means of improving both the patient's and the family's confidence in the care.
  8. Show special respect to the elderly. Great respect is given to the elderly, in spite of taboos connected with death. Caregivers gain approval by treating the elderly with kindness and respect and not appearing to criticize or scold them.
  9. Think carefully about family care. Poverty, distance from the medical facility, and taboos against dying in the home may make it impractical to release to the family a patient needing long-term or terminal care. Discuss options with the family and try to ascertain their attitudes about caring for the person at home before releasing a person into family care.
  10. Involve the extended family. The extended family plays an important role in health care decision making. Often many family members will appear with a patient who is to be admitted for a hospital stay. Try to accommodate them close to the patient's room or at least close to the hospital. Include family members when decisions regarding treatment options are needed. Very often, a patient will postpone surgery because the consent of the family leader, often the eldest female, must be obtained first.
  11. Accept a different sense of time. Most American Indian peoples are present-oriented and take a casual approach to clocks and time, which is viewed as a continuum with no beginning and no end. This can cause difficulty in organizing future events, such as the regulation of medication. Caregivers should be wary of telling patients to take medications with meals, as the patient may have three meals today, two meals tomorrow, and four meals the day after that. In addition, many Indians are task-conscious rather than time-conscious, paying more attention to finishing a task than to a clock or to an appointment schedule. If possible, ask the patient for help in linking appointments or medication schedules to events that are certain to happen in the patient's life.
  12. Give and expect generosity. Indian culture discourages competitive behavior and encourages giving, sharing, and cooperation. Generosity and doing things for others are regarded highly.

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.

  1. The infant death rate is high, a fact attributed to a high incidence of diarrhea and a harsh physical environment. Moreover, because pregnancy and birth are considered normal processes, and health care facilities are associated with illness and disease, women may choose not to seek prenatal care. In fact, pregnancy and disease are starkly separated: pregnant Navajo women are forbidden to attend traditional healing ceremonies to avoid contact with illness or disease. For this reason, one researcher advises holding maternal and child care clinics in a location separate from other clinical services.
  2. There is a high incidence of non-insulin-dependent (Type II) diabetes, which has increased dramatically since 1940 even among those in their teens and early twenties. American Indians now have a genetic predisposition to diabetes, triggered by a radical change in eating habits and increase in obesity following American Indians' military service during World War II. The military experience, with its exposure to different groups and its comparatively high pay, produced a drastic change in dietary habits and lifestyle. High-cholesterol fast foods began to replace the traditional diet.
    Among the Sioux, Chippewa, Pueblo, and Cherokee, about one-third of adults over age 35 have Type II diabetes. The incidence among the Pimas—about one-half the population—is the highest in the world. The prevalence of diabetes among the Ute Indians is 4 times the national average, and the rate of diabetic neuropathy 43 times that of the non-Ute population in Utah. Complications such as amputations occur at a rate 2 to 3 times, and renal failure at a rate about 20 times, that of the general population. The Indian Health Service is trying to combat diabetes through education, including classes in cooking and nutrition. One important ally in these attempts has been the traditional belief in a harmony of body, mind, and spirit.
  3. The incidence of tuberculosis among some Indian peoples is high, ranging from 2 percent among Apaches to 4.6 percent among Navajos. This may be largely due to socioeconomic factors, such as overcrowding and poor nutrition.
  4. A 1988 study of myocardial infarction showed a considerable increase, compared with earlier studies, among Navajo men and a gradual increase among Navajo women. About 50 percent of those who suffered acute infarcts were hypertensive, and the other 50 percent were diabetic; 31 percent were both. Although hypertension is low among residents of reservations, it is common among Indians who live in urban areas.
  5. In a 1974 study, alcoholism accounted for about 5 percent of deaths among the Navajos. Another study (1975) reported that out of the 355 deaths attributed to cirrhosis of the liver within the 35 reservation states, there was mention of alcoholism in 228 of them (64 percent).
    Although alcoholism is reported to be more significant in men than women, a recent pilot study of fetal alcohol syndrome (FAS) found FAS in 3.9 percent of live births. This figure may underestimate the true rate because parents or guardians are reluctant to bring children suspected of FAS for evaluation, because some physicians don't diagnose possible alcohol-damaged children out of reluctance to label the child, and because many infants die before they are tested for FAS. Researchers studying FAS in the northern plains region urge a counseling and treatment program for all pregnant women who drink alcohol and more careful surveillance for FAS.
    Alcoholism, or at least drinking, has also contributed to a large percentage of motor vehicle deaths, homicides, and suicides.
  6. Navajo children have low length-for-age and high weight-for-length measures because of suboptimal nutrition. One study suggests that growth abnormalities among Navajo infants are the result of intrauterine growth retardation and low birthweight.
  7. Of the 10 leading causes of death among American Indians, 5 are related to diet. Navajos classify foods in terms of strong and weak foods. Strong foods—for the most part, the nineteenth century reservation foods, such as mutton, game, and other animal foods; fried bread; Indian corn; and potatoes—are believed to promote health. Milk is the most frequently mentioned weak food. It is probably no coincidence that about 79 percent of American Indians are lactose intolerant. It is believed that it is all right for the old to drink goats' milk and for the infant to drink mother's milk, but milk, in general, is not considered a healthful food.

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.

  1. Life comes from the Great Spirit (or Supreme Creator) and all healing begins with Him.
  2. Man is a threefold being made up of body, mind, and spirit.
  3. Health or wellness is due to a preservation of harmony among the body, heart, mind, and soul.
  4. Plants and animals, as well as humans, are part of the spirit world that exists alongside, and is intermingled with, the physical world.
  5. Death is not an enemy but a natural phenomenon of life.
  6. The spirit existed before it came into a physical body and will exist after the body dies.
  7. Spirituality and emotions are just as important as the body and the mind.
  8. Our relationships with others and with the earth itself are an essential component of our health.
  9. Illness affects the mind and spirit as well as the body.
  10. Illness is an opportunity to purify one's soul.
  11. Disease is felt not only by the individual, but also by the family.
  12. Natural unwellness is caused by the violation of a sacred tribal taboo; unnatural unwellness is caused by witchcraft.
  13. The individual is responsible for his or her own wellness.
  14. Mother Earth provides numerous remedies for our illnesses.
  15. Traditional healers can be either men or women, young or old.

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

Care-seeking Behaviors

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.

Home Treatment

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