The status of American Indian health has greatly fluctuated over time as a result of changing actions and attitudes of the United States government, whose responsibility it is to administer healthcare.  One attribute of American Indian Health that continues to be of principle concern is the animosity and tension that plagues the relationship between American Indianís and the medical establishment that serves them.  The result of this strained relationship and the imbalanced state of American Indian health can be seen through an analysis of the general health of the American Indian population.  The dominant organization affecting services to American Indian people today is the Indian Health Services (IHS), an associated organization of the Public Health Service.  Over the course of this analysis I hope to discuss some of the fundamental problems that have created the above mentioned tension between American Indians and the IHS.  Through a brief look at the history and evolution of the IHS, and through analysis of the proposed goal of its creation, I hope to shed some light on the rocky relationship and discuss how it was destined to be a tense relationship.  Analysis of the sterilization campaign initiated against American Indian people in the 1970's under watch and in collaboration with the IHS will provide a clear example of the justified nature of the animosity of American Indian people.  In addition the entire history of relations between American Indians and the United States citizenry and government will also provide a solid foundation for the skeptical view that American Indians have of the IHS the medical establishment and the entire government.  A principle focus of this paper will include a discussion of how this painful history has been the source of historic and unresolved grief that is passed from generation to generation, an idea most effectively discussed by Duran and Duran (1995) in Native American Post Colonial Psychology where they propose a concept called the "Soul Wound" (p.24) to describe the psychological damage that has occurred amongst the American Indian population.  Through a discussion of the ìSoul Woundî I hope to even further bolster my belief that the animosity towards the government I have spoken of is not only justified, it should be expected.  As a conclusion to this paper I will suggest some ideas of my own and others which could lead to improvements in the relationship between American Indians and the medical establishment.  Included in this section will be ideas proposed by Dr. Carl A. Hammerschlag, MD (1998), a physician who currently works amongst American Indian people in the Southwest and has been somewhat innovative and successful in his work with this population.  He is of interest is because of his open minded willingness to incorporate more than just western allopathic methods into his practice, he has chosen to incorporate the culture and traditions of the people he works with to assist in the healing of his patients.

Abbreviated History of Indian white relations

     The rocky relationship between the American Indian Nations and White settlers can be traced back to the basic assumptions which were a prelude to the colonization by those White settlers.  Fundamentally, from the earliest conquest attempts by the Spanish to the current relationship with the federal government, the tribes have been viewed as religiously, culturally and racially inferior.  The foundations of this belief can be traced back as far as 340 AD to a decree by the Church Council of Gangra.  In this decree it was stated that , ìIf anyone, on the pretext of religion teaches another manís slave to despise his master, and to withdraw from his service, and not to serve his master with good will and respect, let him be anathemaî (Castanha, 1978).  Anathema meaning damnation by God, and thus the basic idea possessed in this decree is an assertion of the non-Christian slaves Christian obligation to submit to the authority of his/her Christian master as if submitting oneself to God.  Upon analysis I found this to be the principle shift in the Churchís stance regarding the subordinate nature of non-Christian and the just nature of their enslavement. Prior to this decree the Church taught that, "slaves should despise their masters and free themselves" (Maxwell, 1975, p35).  The importance of this decree regarding the subordinate nature of non-Christians goes even beyond this ideological shift, as this stance was later canonized and became the official stance of the Catholic Church.  Though the Church Council of Gangraís decree in 340 AD was a decree of inequality it was not until 260 years later in 600 AD that you see a clear papal sanction of racism.  In 600 AD Pope Gregory I taught that, "All men are equal in nature before God, yet a hidden dispensation of providence, produced by a hierarchy of merit and rulership exists." (Maxwell, 1975, p122)  His basic premise for this inequality was that as a result of sin, different classes of men have been produced, and that these differentiated classes are, ìordained by divine justiceî.  This was truly a sanction of racism as much of the Christian ideology and criteria for avoidance of sin were contingent upon individuals being not only Christian but also practitioners of Western culture and civilization.  More specifically, if you are not Christian it is impossible to avoid sin and  thus inevitably the only people who will meet this criteria and not reside in a state of eternal sin and damnation to subordination will be white Europeans.  The above mentioned decreeís served as the  basic foundation of what was to come for American Indian people in the coming centuries.  However, these basic premises were greatly expanded upon in future documents used to justify the taking of their land and their persecution.
 Prior to the ìRequerimientoî or ìDoctrine of Discoveryî which I will discuss later, the principal justification in defence of actions taken against people resisting the advances of colonial Europeans was the philosophy of Saint Isidore of Seville.  Saint Isidoreís basic premise was that there were certain individuals whom God considered unfit for freedom and thus through the merciful action of God they were placed in slavery.  From this premise it was assumed that by the benevolent guidance of God, the misbehavior of the unfit needed to be restrained by the hand of the master.  This was the idea which created the notion of the ìsavageî whoís uncivil behavior needed to be controlled by the civilized Christians of the world.  Obviously this idea of the ìsavageî was a significant concept in the relationship between the tribes and the Europeans and Americans.
 Over 1,100 years post the decree of the Church Council of Gangra the document which was essentially a Papal sanction encouraging Spain to conquer the Americaís was issued.  The papal decree was issued by Pope Alexander VI on May 3, 1493. The decree read as follows:

     Full and free permission to invade, search out, capture and subjugate the Saracens and Pagans and any other unbelievers and enemies of Christ wherever they may be, as well as their Kingdoms, duchies, counties, principalities and other properties and to reduce their personís into perpetual slavery.î(Pope Alexander V, 1493)

This decree was then used by the Spanish King Fernando as a ìrationalî justification for the divinely sanctioned war waged against American Indians.  Fernando tried to explain to the tribes that the Church rightly possessed their land due to Christís granting Peter and Paul temporal or worldly authority, a status which by extension places the Church above every earthly dominion.  This line of reasoning became the official stance of the Church and ultimately inspired Palacios Rubios to draft the "Requerimiento", which declared to the Indians that, the Pope as the head of the Church and thus possessor of Indian land through the temporal power granted to Peter and Paul by Christ, had given their land to King Fernando, whom they were to immediately recognize as their ruler.  In addition the "Requerimiento" informed the Natives that they were to freely submit to the Christian faith or war would be waged against them.  This last add in became the justification for ìjustî war in future Federal treaties and acts of Congress such as the Northwest Ordinance of 1787 (Deloria, 1999, p17).  In addition the ìRequerimientoî came to be known as the ìDoctrine of Discoveryî, which was the legal document which became the justification for European nations claims of original and legal title to tribally held lands.  Europeans claimed this legal and original title as they believed that Native people were not able to ever possess legal title as they were non-Christian savages(Deloria, 1999).  Though the driving motivation behind the Churchís original decree by Pope Alexander VI was to spread Christianity to the ìsavagesî, thus saving their souls from eternal damnation, I feel that the adoption of King Fernandoís justification signaled a shift in the Churchís primary intention.  In essence I feel that the churchís primary interest in giving the divine go ahead to Spain became one of economics, as the Church realized the immense wealth of resources the Americaís possessed.  The fact that the Church Council of Gangra decree was the Catholic Churchís official stance on slavery and the inferiority of non-Christians until the 1965 Vatican II decree (1965), which follows, is testament to the racism that prevailed for so many years.

     Whatever violates the integrity of the human person, such as mutilation, torture inflicted on body or mind, attempts to coerce the will itself; whatever insults human dignity, such as subhuman living conditions, arbitrary imprisonment, deportation, slavery, prostitution, the selling of women and children...  all these things... poison human society, dishonor the Creator, and do more harm to those who practice them than those who suffer from the injury...  Human institutions, private or public...  should be bulwarks against any kind of political or social slavery and guardians of basic rights under any kind if government.

     These ideas addressed prior to the adoption of Vatican II in 1965 became the foundation of all dealings with the American Indian population immediately upon conquest and on into contemporary times.  Fundamentally the view that American Indian people are savages and inferior to white Christian Europeans in every possible way remained as the mindset of future individuals who continued and propagated the persecution of American Indian people.  Over the course of the Federal governments relationship with the tribes, the federal government has broken more treaties then it has honored.  I chose to focus on the foundations of the future persecution of the tribes as you can easily infer what the next several hundred years had in store for American Indian people.  Therefore I will provide a brief overview of the generalized periods in post-contact American Indian History.
       During the period following the initial contact, American Indian people were in a state of shock as they saw the Europeans acting under a value system that was diametrically opposed to their value system.(Duran & Duran, 1995)  The tribes caught their first glimpse of the value held by Europeans that man is dominant to all other life forms and the Earth.  This was expressed in the disrespectful and utilitarian manner in which Europeans related to the Earth and all its creatures.  In spite of this shock the tribes status as sovereign nations was more stable than in the future years.  Following this period of initial contact the United States government initiated a warring and genocidal campaign of extermination through the use of military force.  As a consequence of this violent campaign, the government initiated the reservation period by forcibly moving tribes to unfamiliar lands and by making coercive and unreasonable treaties with the tribes to get them to move.  Along with the reservation period came the Boarding school era which was a direct attack on the very foundation of American Indian life, the family.  During this era children were forcibly removed from their homes and ushered into government or Church run boarding schools where these Indian children were beaten into submission and assaulted if they spoke their language.  In addtion they were forced to adopt Christianity and Western culture, and completely abandon all they had been taught throughout their lives.  There was a great deal of abuse including physical, psychological, emotional and spiritual that occurred at these institutions and this painful part of their history continues to plague the American Indian population today.  Essentially the final period which can be clearly labeled occurred in the 1950ís and has been labeled as the termination period.  This period was a rather unstable period whereby the United States government implemented a termination policy through use of the legislative process.  Termination refers to the removal of recognition on the part of the Government of the tribes status as sovereign nations and thus by extension termination of the governments trust responsibility to the tribes. These fundamental documents decrees and the brief history of post contact American Indian life should provide some insight into the world view of American Indian people today and thus will serve as a solid foundation for the rest of this paper.
 
 

Brief History of the Indian Health Services and the Federal governments responsibility to provide health care to Indian people

     The federal trust responsibility with American Indians is outlined in a complex arrangement of treaties, Congressional legislation, Supreme Court decisions and formal agreements.  However the responsibility of the government to provide for American Indian medical services is rarely specifically addressed, yet by extension, the federal trust responsibility requires the federal government to care for the health of American Indian people.  This creates a rather vague situation regarding the health care responsibilities of the federal government yet treaties are always supposed to favor American Indians in their interpretation (Pevar,1992) and thus health care is assumed to be a part of the federal trust responsibility for this reason.  Prior to 1954 the responsibility of administering health care to American Indian people was entrusted to the Indian Health Services under the control of the Bureau of Indian Affairs (BIA).  In 1954 the second session of the 83rd Congress passed an act transferring the responsibility of administering health care from the BIA to the United States Public Health Service.  This shift marked the beginning of an experiment to determine, "to what degree could the tribes safely become a part of the general governmental structure of the nation without risking their special status and their special relationship with the federal government through the Bureau of Indian Affairs." (Philip, 1986, p199)  This transfer of responsibility can in many ways be considered an assault on trust responsibility on the part of the US government if it is considered in the historical context of the time.  Specifically this was a period in history were the United States was attempting to terminate its trust responsibility to the tribes, a period known as the Termination era.  Clearly, transferring the trust responsibility of administering health care to a non-Indian specific governmental organization undermines the sovereign status of tribes, as you would never see the United States government provide services such as foreigh aid to soveriegn nations using organizations which were set up to service the general citizenry.  This shift in power lead to the inclusion of contract health care facilities in the health care loop, administering health care to American Indian people.  The inclusion of contract facilities was designed to provide services to Indian people who were not serviced by a local Indian Health Service (IHS) hospital and thus it was a valuable improvement in the potential quality of health care for Indian people, yet as will be shown later it was a major contributing factor in the sterilization campaign against Indian people and the continuation of that campaign in these contract facilities after the IHS campaign had been halted.  Clearly, with this shift in power the health status of American Indian people did improve, yet you must always consider compromises of sovereign status when you assess the value of government action concerning Indian people.  Certainly this was a deterioration of tribal sovereignty.
 Their are individuals who prefer to dramatize the success of the Indian Health Services since the transfer to the United States Public Health Services (SPHS) and as a result of the improvements in the status of American Indian Health it is very easy to look uncritically at the IHS since 1954.  However it is still a very flawed and disorganized organization and I would use caution in any analysis of the IHS.  I do not feel that IHS facilities should be considered to be, ìequal in quality of care to many other regional facilitiesî(Lewis, 1990, p158), nor would I over emphasize the community acceptance of the IHS as stated below by Thomas Lewis (1990), "Across the Years a large number of talented and dedicated people have contributed to its signaled success and community acceptance" (p.159).  These statements and the analysis of the IHS by Thomas Lewis seems to portray the IHS as an idealized center of health care delivery.  The fact that the IHS operates on an almost day to day basis with little or no emphasis placed on firmly establishing concrete goals and objectives, points to its unstable and imperfect status.  This instability must also be attributed to some of the attacks levied by senators on the Committee on Indian Affairs which is the authorizing committee for administration of programs of the Indian Health Service.  The fact that a known anti-Indian senator, Slade Gorton of Washington, sits on this committee is testament to its political potential for dysfunction and Indian opposition.  Gorton has essentially tried throughout his tenure to, ìtake away certain fundamental rights of Indian tribes that have been undisputed since the beginning of the republicî(Deloria, 1999, p.48).  Obviously having a man of Slade Gortonís ideology determining Indian policy is not going to encourage stability on the part of Indian organizations controlled by the committee on Indian Affairs.  As a result of this ambiguous operative procedure and inconsistency in funding and initiative the IHS has been accused by some people of providing inadequate and inconsistent patient care (National Center for American Indian and Alaska Native Health [NCAIANH], 2000).  "This inconsistency goes so far that often the services available to patients will vary from day to day entirely depending on unpublished decisions made by the large IHS bureaucracy and commitments and conditions contained in, ìvoluminous appropriations hearings."(NCAIANH, 2000).  The very disorganized arrangement of the IHS obviously sets it up for the mismanagement and lack of accountability that it has been implicated in.  As will be revealed in the section on sterilization, the IHS was operating with very little directive or control in regard to their policy of sterilization after they had been ordered to cease performing sterilizationís on women under 21 years of age.  The principle area plagued with lack of accountability were the facilities that IHS was contracting out to, facilities which would normally be subject to government standards but whom were not required to meet these standards by the IHS.  This lack of monitoring allowed these contract care facilities to continue sterilizationís following the US District Court order in 1974 demanding a moratorium on sterilizationís of women under 21(United Nations, 1977).

Sterilization
     In 1974 a Choctaw Indian physician named Connie Uri took notice at the large number of sterilization surgeries that had been performed.  Out of curiosity and concern Dr. Uri chose to conduct a series of interviews with some of the women who had been sterilized at her Claremore, Oklahoma IHS hospital and surprisingly found that many of the women had been sterilized within a day or two of giving birth.  An additionally surprising facet of Dr. Uri's investigation was the fact that non-standard procedures of sterilization had been performed.  Normally the principle procedure used for purposes of sterilization is the tubal ligation, yet many of the women in question were given hysterectomies, a procedure normally reserved for women with cancer or other ailments.  Possibly the most startling part of what Dr. Uri uncovered was the fact that many of the women sterilized claimed to have been harassed or coerced into signing the consent form and having the procedure.  Their were many different coercive methods used to receive consent from women including:  threatening to take away a mothers children and place them in foster care if the mother did not agree to the procedure,  Not agreeing to perform an abortion on a woman if she did first not agree to be sterilized(Dillingham, 1977).  Following Dr. Uriís initial revelation of the sterilization scandal many tribal leaders began to initiate investigations of their own tribes and IHS facilities and found that Dr. Uri's findings were not isolated to the IHS facility in question.  One such investigation involved the Northern Cheyenne Reservation  and the research efforts of the tribal judge, Maria Sanchez.  Ms. Sanchez interviewed 50 women and found that 26 had been sterilized(Jarvis, 1977).  In many of these cases the women reported being lied to or coerced into consenting to the procedure.  As an example of the method of coercion used, several woman were told that they could still have children after the operation, while several other women were told that it was time they stopped having children as they already had enough.  Though these investigations into sterilization were very disturbing they received little to no national attention, even after Dennis Banks and Lee Brightman embarked on the Longest Walk across the United States to hopefully draw some attention to the sterilization campaign, it was not until several months later that national attention was received (Means, 1995).
 Eventually the scandal was brought to the attention of senator James Abourezk of South Dakota and steps were taken to terminate the sterilization assault on Indian women.  Abourezk commissioned the General Accounting Office (GAO) to investigate the matter and determine if their was in fact an immoral movement to selectively sterilize Native women.  The GAO report, though important, did not investigate thoroughly enough as it focused only on the medical records provided by the IHS and the consent forms used.  They did not even attempt to interview women or investigate the case histories of women who had been sterilized.  In addition they confined their investigation to twelve IHS hospitals (American Indian Health Council, 1998) and did not investigate the contract care facilities that had become so important in health care delivery since the transfer of the IHS to the US Department of Public Health.  The end result of this investigation was an underestimation of the number of women sterilized and a report which also seemed to minimize the questionable nature of this sterilization campaign.  The number of  sterilizationís reported by the GAO in the years  1973-1976 was 3,406 (United Nations, 1977, p3)  women, yet other investigations have reported numbers at least four times as high.  In essence it is not known nor will it ever be known how many American Indian women were sterilized during this campaign.
    In response to the ongoing investigation and the scandalous reports in the press, the US Congress defined the term ìvoluntary sterilizationî to mean.. "the requirement that the individual have at his disposal the information necessary to make his decision and the mental competence to appreciate the significance of that investigation."(Department of Health Education and Welfare, 1979)  In addition to this definition their was already a requirement in place which required that, ìIndividuals seeking sterilization be orally informed at the outset that no federal benefits can be withdrawn because of failure to accept sterilizationî(Dillingham, 1977).  In light of this above mentioned rule the GAO was only willing to go as far as stating that there was a lack of clear statement to notify the patients of the above quoted federal requirement.  They failed to implicate anyone in the matter of the reported coerced sterilization or the sterilization of  minors which considering the reports cited by women who had been sterilized, they clearly had been coerced under the definition of coerced sterilization: ìcaused by outright deceit; offering sterilization as a means to escape further obligation to an institution, such as an asylum; threats to a person; sterilization of minors, or mentally or physically disabled persons; failing to explain procedure in a language that the patient understands.î(England, 2000, p6).  The fundamental difficulty in proving coerced sterilization is that the patient has her signature on the bottom of a consent form and thus the only way to prove it is through testimony which probably explains why the GAO did not endeavor into this legalistic arena.  They were willing to investigate only what would not lead to a long and more importantly expensive process of financial retribution and political destruction for many.  The conclusions of the GAO report stated that IHS consent procedures lacked the basic elements of informed consent, specifically informing a patient orally of the advantages and disadvantages of sterilization.  In addition the form did not contain the legally mandated statement usually located at the top of the consent form stating that no Federal benefits would be taken away if the patient did not consent to sterilization.  Upon final analysis of the GAO report, it did not seem to go deep enough in its search for both accountability and in its determination of the actual numbers of Native women sterilized.  The only fundamental change of policy that the GAO initiated was the revision of consent procedures at the IHS.  In addition very few health care professionals were ever held accountable for their actions as they had covered their tracks and were able to produce signed consent forms if a particular case ever did go to court.
     In 1977 the United Nations (1977) released a report prepared in conjunction with Native American Solidarity Committee which outlined the genocidal practices of the United States government, including the sterilization of American Indian women.  In that report it was revealed that 24 percent of Native women had been sterilized and that 19 percent were of child bearing age(p3).  This is included in the report on Genocide as Genocide is defined as follows by the United Nations(1977):  In the present Convention, genocide means any of the following acts committed with the intent to destroy, in whole or in part, a national, ethical, racial or religious group, as such:  a)  Killing members of the group;  b)  Causing serious bodily or mental harm to members of the group;  c)  Deliberately inflicting on the group conditions of life calculated to bring about its physical destruction in whole or in parts;  d)  Imposing measures intended to prevent births within a group;  e)  Forcibly transferring children of the group to another group (p1).  Clearly the United States government is guilty of committing all of these crimes against Native American people at some point in history, however, of greatest interest for my purposes is letter d.
       One interesting point which was addressed in the report was the fact that the IHS did not require the contract facilities to comply with the federal guidelines regarding the construction of the consent forms or the monitoring of consent procedures.  This is rather disturbing as generally any agency that the government contracts to is required to adhere to the Federal Government guidelines, whether that be federal wages or federal mandates on informed consent.  The fact that these contract facilities were essentially acting with no guidelines certainly suggests that they were in a very unaccountable position if they did decide that it was profitable or in the ìbest interestsî of these Indian mothers to be sterilized.  An equally disturbing facet of the report documents the numerous suggestions by the federal government that they are in favor of the sterilization of American Indian women.  Firstly the report states that (1977), ìThe Federal Government reimburses the hospital or doctor 90% of the costs of sterilization for welfare women, compared to 50% reimbursement for abortions.î(p.2), clearly this suggests that the Government is favoring the sterilization procedure and thus this by extension suggests to doctors and hospitals that in accordance with the wishes of the Government they should push for sterilization as they will be almost fully reimbursed by the Federal Government.  In essence the Government created an incentive for Doctors and Hospitals to sterilize welfare women, which clearly affects Native women as their are many Native women who are on welfare.  In addition the IHS contract care facilities will be reimbursed in a very similar way and thus will favor sterilization for Indian women.
     My basic premise in presenting all of this information was that an abnormally large percentage of American Indian women were sterilized in the 1970ís and that the Federal government played an important role in the initiation of this sterilization campaign.  This is of additional importance because the Federal Government has a trust responsibility to act in the best interests of the tribe with the end result being equalization of socio-economic status and increased sovereignty for the tribes.  Clearly the Government violated this responsibility through initiation of this sterilization campaign, furthermore this was yet another calculated genocidal assault on the American Indian population.
 
 
 

"Soul Wound"

 "At the beginning of the colonization process in North America there were over 10 million Native American people living on the continent.  By the year 1900 there were only 250,000 people left."(Thornton 1986).  This figure is only the beginning once you begin to investigate the tragic and painful history of American Indian people since the initial contact with Europeans.  I presented the sections on the 1970ís sterilization campaign and the brief history of Indian White relations to establish a historical context for the American Indian worldview and the discussion of what Eduardo and Bonnie Duran (1995) referred to as the ìSoul Woundî (p24).  The "Soul Wound" is essentially the physical, psychological and spiritual damage which is the direct and residual result of the mass genocide and colonization campaign that followed the initial contact between American Indianís and Europeans and Americans.  The "Soul Wound" is the result of the shameful history of persecution of American Indians which continues to this day to be propagated by all of society.  Another very important facet of the ìSoul Woundî concept is that it includes a recognition by Duran and Duran (1995) that American Indians are also greatly affected today not only by continuing actions of oppression by society, but also by intergenerational posttraumatic stress disorder(p30).  This essentially means that the trauma of over five hundred years of oppression has been instilled and passed from generation to generation.  This is not to suggest that it is a genetic ailment, only that it is passed from parents and other family and friends on to their offspring, through the demonstrated behaviors observed by the child.  The fact that today American Indian people are still exposed to a great many injustices remains one of the principle reasons that they are unable to heal from this pervasive and all consuming wound.  The fact that the Holocaust committed against American Indian people has yet to be acknowledged by most of the world and certainly not the United States remains a principle impediment to the healing process.
     In addition to this wound of the soul which plagues American Indian people their is also a general misunderstanding of how to effectively conduct research within the American Indian community in order to develop culturally specific ways of treating American Indian health problems.  This block on research affects not only the necessary treatment of the "Soul Wound", it also decreases the tendency for American Indian people to seek treatment for any health problem that plagues them.  Essentially the "Soul Wound" and the society at large create a self sustaining situation whereby the "Soul Wound" is the principle reason for the distrust by American Indian people of anything administered to them by the white world, including health care, and as a result effective treatment methods and consistency in treatment are not easily attained.  As I have demonstrated through the discussion of sterilization, this animosity towards the Health care available to them is not unfounded.  Research needs to be conducted to determine how to effectively treat American Indian health in a culturally specific manner, however, this research can not be conducted in a fashion that mimics the intellectual imperialism of the past.  By intellectual imperialism I am referring to the tendency of anyone conducting research on a culture they are not familiar with to assume that issues affecting a group with another world view can be addressed from an entirely different world view.  Throughout history the medical establishment has been guilty of this and their relationship with American Indians is not an exception.  When working with American Indian people in any setting where healing is the goal their world view must always be carefully incorporated into the process.  Their world view today inevitably is going to be greatly influenced by the "Soul Wound" and thus all health care professionals must be aware of this.  As an example of the lack of cultural competancy I am alluding to, I once observed how physicians dealt with American Indian people in a hospital intensive care unit.  One of the most common complaints from the hospital staff was that American Indian people who are admitted to the hospital often are accompanied by a very large family unit.  As the hospital has a policy against having more than one person at a time visiting the patient, their solution to the problem was to abruptly move everyone out, upsetting both the family members and the patient.  What I am suggesting would have been a more culturally sensitive way to deal with this problem would have been to allow as many people to stay as did not endanger the health or safety of any of the other patients.  My fundamental reason for believing this is my awareness that one of the principle views of American Indian people regarding healing is that,  The need for healing can be explained by the fact that the client/community  has lost the ability to be in harmony with the life process of which the client/community is a part (Duran, 1995, p15).  This is only a recognition of the Native belief that they are only one integral part of all creation and thus everything in the universe is interrelated.  This by extension leads to a recognition that healing requires the support and presence of more than just a physician.

Suggested Solutions  

     Improving the status of American Indian health is certainly going to be somewhat dependent upon improving the relationship between American Indian people and the general medical establishment that services them ( the IHS).  However improving this relationship between the IHS and the American Indian community is going to depend on more than just increases in funding, available technology and improved consistency regarding what is available at IHS and contract care facilities.  This relationship is strained because of the lack of cultural competency and cultural respect in the administration of health care and as a result of the denial of the shameful history that has been the reality of Indian white relations.  Thus, in order for the IHS to be a viable and effective source of healing for Native people, it needs to start to reshape the way it handles and administers health care to American Indian people.  In other words, the western models of health and healing can not be completely applied to the American Indian population,  these models need to be reframed, altered and in some cases thrown out for more culturally specific models.  The IHS needs to act to end the intellectual imperialism that is so often used against Indian people, meaning that the IHS needs to stop assuming that Western medicine is the only effective medical model.
     A very good example of the kind of openness and culturally specific health care that I have been suggesting involves Carl Hammerschlags approach to healing in the Southwest.  Though Hammerschlag has come to accept that his rigid Western allopathic and purely scientific approach is not an effective way to heal Indian people, when he initially arrived in Indian country he states that, "ìI thought I was bringing truth, healing, and knowledge to a backward people."(1988, p137).  This view is very typical of young doctors who arrive in Indian country with an arrogance about their ability to heal, they forget that they were taught only one way to heal.  Over the course of several years Hammerschlag began to realize that if he wanted to help these people he needed to change his methods to account for their culture and world view.  In my view the principle step that Hammerschlag took was to recognize that he new some valuable information regarding healing but also that he needed to learn from the community what information they new.  Specifically he started to reach out to urban and reservation communities by commuting by airplane, where he set up meetings with, "groups of community health workers, nurses, doctors (and their spouses), Head Start teachers, tribal jailers and inmates, and the participants in alcoholism programs.  And in the process, I learned about the history, the beliefs, the lives of people in those communities."(1988, p 19).  In essence Hammerschlag recognized that he needed to know about the culture, history and pain of the people he was working with if he was ever going to heal them.  In addition to the learning that he experienced regarding the Indian people of this region, he also came to realize that a community approach to confronting healing was a more effective way to heal the people.  Along with the meetings with the professionals serving the American Indian community, Hammerschlag began to conduct large extended family and community based healing sessions where issues that were affecting the entire community were discussed.  He had inadvertently stumbled upon a approach to healing that was more culturally specific to Indian people as they have an orientation regarding the family that goes beyond the American nuclear family and depends on the entire community being in harmony with the life process.
     When healing in an American Indian community you have to consider the role that a traditional healer plays in the healing process.  This was another strength of Hammerschlags, he was willing to recognize the power of the traditional healers and thus he had and open relationship of reciprocal referral with them.  In essence this meant that if he confronted a problem which he felt the traditional healer was well equipped to deal with he would recommend to the patient that they see their traditional healer.  Conversely, if the traditional healer came to recognize a problem that could be dealt with more effectively by a Western practitioner he would then refer the individual to a physician.  The respect that Hammerschlag was able to secure from many of the traditional healers resulted from his ability to admit that he did not know everything their was to know about healing which was very difficult and counterintuitive as most medical schools teach physicians to be authoritative and all knowing when it comes to the practice of medicine.  Alternativley, in traditional cultures their is a respect for the unknown and the mystery of the universe and thus people are not expected to know everything (1992, p74).  In retrospect Hammerschlag was able to receive greater respect from his patients and other traditional healers by simply recognizing the mystery in the world and recognizing that he had a great deal to learn about healing in the American Indian community.
     One of the principal issues that I feel needs to be recognized in the American Indian community setting is the existence of the previously discussed "Soul Wound".  If an individual is a non-Indian practitioner serving Indian people as Hammerschlag is, you must recognize some of the anger that may exist in a given Indian community.  Specifically, this anger may be directed at you as a non-Indian whom an individual associates with a lifetime of persecution.  Hammerschlag confronted this on a regular basis and thus in order to transcend this boundary he had to give up the power that he possessed as a non-Indian physician, which goes back to the previous paragraph and requires you as a physician to recognize your limitations and show respect to the Indian culture and views on healing.
     Fundamentally I think that the most important idea that I hoped to communicate to my readers throughout this paper was that all of American Indian peoples behavior and actions must be considered in the historical context of the "Soul Wound" and the persecution that Indian people still endure today.  Though the status of American Indian health is not ideal, it does have a great deal of potential to improve.  As more Indian people gain control over the institutions that affect them, hopefully these institutions will begin to change the way they operate to more closely correspond with American Indian culture and the American Indian worldview.  I included all of the information on Indian white relations and the sterilization campaign to highlight the fact that in spite of hundreds of years of sustained persecution and genocide, American Indian people are still here.  Not only are they still here, they are entering an era of increasing self determination which will inevitably lead to a more harmonious population of people.  A people who can begin to shape the institutions like the IHS into organizations which are truly designed to service the American Indian population in the context of the American Indian experience.

References

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