Land Rights and Health Outcomes in American Indian/Alaska Native Children

Pediatricians have a unique opportunity to care for and advocate for American Indian and Alaska Native (AI/AN) youth. Although AI/AN youth live across the country in varying geographic settings, the majority live in urban settings.¹  As a result, they may access care within academic and community hospital centers, community-based primary care clinics, and other nontribal and/or non-Indian Health Service health facilities. There are significant documented health inequities and poor health outcomes of AI/AN youth compared with the general population, and a number of barriers to care exacerbating this inequity including few AI/AN pediatricians.²  The historical and sociocultural contexts surrounding inequities are often unfamiliar to pediatric providers, limiting ability to identify, advocate, and best care for this population. In this article, we aim to provide pediatric providers with an understanding of these contexts and inequities, along with their relation to land rights and sovereignty, to increase awareness and empower them to advocate for the protection of AI/AN youth. We also aim to foster support for systemic change addressing health inequities AI/AN youth face, illuminating opportunities for future research, advocacy, and policy work by pediatric providers. Despite these inequities, there are many strengths within AI/AN communities we can draw on to decrease inequity and promote better health for these youth.

Settler colonialism, the process whereby settlers aim to establish a home on “new land” through the erasure of Indigenous practices and the subjugation and/or elimination of Indigenous peoples,^3–5  has significantly influenced AI/AN land rights, sovereignty conflicts, and health outcomes. Relationships to land are closely tied to culture, health, and wellbeing for Indigenous peoples, and because settler colonialism ultimately eliminated self-determination and access to resources, AI/AN people were predisposed to experience traumas and health disparities. Furthermore, the process of settler colonialism has had continued impacts on Indigenous individuals and communities, as demonstrated by present-day struggles for land rights with the Keystone and Dakota Access Pipelines.⁶  Similarly, individuals in urban and rural settings still experience detrimental effects of the separation from culture and displacement from traditional lands.

There have been numerous forced removals of AI/AN tribes, with some of the most prominent including the Indian Removal Act of 1830, the House Concurrent Resolution 108 of 1953, and the Indian Relocation Act of 1956.⁷  One of the most notable of the forced removals sanctioned by the US government was the “Trail of Tears” (1830–1840), displacing ∼100 000 AI/AN people from their homelands, resulting in 15 000 deaths from exposure, malnutrition, and disease.^7,8  Furthermore, House Concurrent Resolution 108 (1953) lead to the loss of 109 tribes, 1 362 155 acres, and the displacement of 11 466 AI/AN people from sources of income, community, identity, and basic needs (access to traditional food, housing, clean water, and health care).⁹  It is estimated that 90 million acres, nearly two-thirds of all reservation lands, were taken from tribes without compensation.¹⁰  It is important to note these stolen lands were initially considered autonomous nations. Following this, the Indian Relocation Act (1956) moved AI/AN people into urban centers where they lost connections to land, language, and culture.^11,12 

Forced relocation and attempted elimination of culture were supported by the Indian Boarding School era (1850s–1960s). These institutions served to “civilize” Indigenous children by changing their manner of dress, cutting their hair, teaching English, and forcing assimilation into the neighboring white communities.¹³  Boarding schools were also associated with significant rates of physical, emotional, and sexual abuse, perpetuating the trauma of separation from families and the systematic eradication of culture. Attendance at these schools has been associated with significant health disparities among Indigenous attendants.¹³ 

These examples represent formal policy actions by the US government to subjugate AI/AN populations and instill the spirit of settler colonialism, although countless examples have occurred since the arrival of the first Europeans and continue today. Pediatricians with an understanding of these contexts will be better able to care for their patients.

Conceptualizing health beyond purely biological factors in AI/AN communities can inform assessment of AI/AN pediatric health outcomes. Many AI/AN individuals view health as the intersection of mental, spiritual, emotional, and physical domains. The natural environment and notions of place are strong determinants of health in Indigenous communities because they serve as protective factors and sources of healing.¹⁴  However, the natural environment is also closely tied to traumas for many AI/AN populations in the context of settler colonialism and displacement from homelands.

Historical trauma (HT) refers to the cumulative, permeating effects of systematic traumas which target individuals and communities who share a specific group identity.^15,16  In AI/AN communities, settler-driven traumas involved the loss of language, separation of families, elimination of spiritual and cultural practices, and disruptions to relationships with land as discussed previously.^15–17  Federal policies focused on environmental dispossession of AI/AN people destroyed subsistence practices and disrupted spiritual and cultural connections to the land, setting the stage for increased vulnerability to traumas, stress, and illness among AI/AN populations.^18–20 

Adverse childhood experiences (ACEs) are one result of the intergenerational and epigenetic impacts of HT on AI/AN children. ACEs may include psychological abuse, physical abuse, household dysfunction, mental illness, violence, criminal behavior, or exposure to substance use and have a strong dose-response relationship to morbidity and mortality as adults.²¹  Increased childhood ACEs are associated with increased risk of smoking, severe obesity, physical inactivity, depressed mood, suicide attempt, alcoholism, drug use, and sexually transmitted disease.²¹  They are also associated with higher rates of ischemic heart disease, cancer, emphysema, hepatitis, fractures, and poor self-rated health.²¹ 

In South Dakota, rates of ACEs in the AI/AN population are significantly higher than non-AI populations across all domains. For example, 20% of AI/AN respondents in one study had experienced 6 or more ACEs, compared with 4% of non-AI respondents.²²  Furthermore, childhood experiences of physical neglect (lacking food, clothing, protection, and medical care) were greater in AI/AN respondents (15.9%) compared with non-AI/AN respondents (2.8%).²²  Higher ACE score was also positively correlated with mental health conditions as adults, including depression, anxiety, and posttraumatic stress disorder.²²  Similarly, AI/AN children 6 to 17 years old with more than 2 ACEs required more medication and services compared with those with less than 2 ACEs.²³  Children with an increasing number of ACEs also reported poorer emotional control and increased school problems, depression, anxiety, and attention-deficit/hyperactivity disorder.²³ 

Pediatricians have a unique role in mitigating toxic stress in that they can identify experiences of stress and trauma and recommend points of intervention for AI/AN youth. Although screening for ACEs is critical to accomplishing successful intervention and healing, it is important to consider that the current conceptualization of ACEs does not capture the impact of the sociological and historical factors on Indigenous health.²⁴  Pediatric providers can thus include exposure to HT, access to public services, exposure to discrimination, and community connection as additional screening questions for ACEs in AI/AN children.²⁴  Using screening results, providers can provide support by encouraging participation in evidence-based programs such as Head Start and Reach Out and Read, which can address ACE-related disparities and reduce inequity. In addition to adaptations in ACEs screening, there is a need to assess the prevalence of ACEs in AI/AN communities across urban, rural, and reservation settings. These can help direct policy and advocacy efforts aimed at reducing the long-lasting effects of settler colonialism and improve health outcomes for AI/AN youth.

AI/AN children also experience violence and physical, sexual, and emotional abuse at rates higher than any other demographic in the United States, with the Indian Health Service (IHS) estimating 20% of children experience physical or sexual abuse by age 18 years.²⁵  This is seen in the setting of the Missing and Murdered Indigenous Peoples (MMIP) crisis, the significant prevalence of violence and murder of AI/AN individuals across the US without action or repercussion taken against perpetrators. Violence has been connected to poor physical and mental health outcomes.²⁶  For instance, physical abuse, sexual abuse, and experiences of violence during childhood are associated with increased substance abuse, revictimization, and depression into adulthood.²⁷ 

Among AI/AN girls 11 to 17 years old, 30% have experienced sexual abuse and 11% have reported rape.²⁷  Studies regarding violence in residential schools have revealed rates of child abuse at 70%, sexual activity in 65% of youth, and forced sexual activity in 14% of youth.²⁸  These statistics may be even higher given the paucity of data due to underreporting, misclassification, and decreased media coverage of these cases.²⁸  Abuse and violence also occur across geographic settings, ranging from rural and reservation settings to urban environments. For instance, the rate of physical abuse in AI/AN girls in an urban Indian population (New York City) was reported as 28%.²⁹  Urban violence may result from displacement from ancestral lands and lack of social or structural support in an unfamiliar environment. Gender-diverse youth, including lesbian, gay, bisexual, transgender, queer, nonbinary, and Two Spirit individuals (someone who is AI/AN and expresses gender, sexual, and/or spiritual identity in Indigenous, non-Western ways), are at increased risk of experiencing MMIP-related violence.^28,30  There are >5000 reports of missing AI/AN persons in the US, although only 118 cases are federally documented.³¹  Although data on age of AI/AN victims are limited, reports show that the youngest victim was less than one year old.³¹ 

Youth who experience violence and abuse are at increased risk of human trafficking. Risk factors for human trafficking also include increased rates of ACEs, HT, poverty, involvement with child welfare system, and substance misuse, making AI/AN uniquely vulnerable to human trafficking.³²  Because AI/AN children are overrepresented in the foster care system (2.4 to 14 times the rate of the general population), and children in the foster care system are more likely to become homeless, Native youth are increasingly vulnerable to human trafficking.^33–37  Of reported trafficking cases to the National Human Trafficking Hotline (2011–2017), 37% of cases involved AI/AN minors.³⁷  This number is again striking given underreporting and the fact that Native youth and adults represent 1.7% of the US population.³⁷  Similarly, authors of a study among AI/AN adolescents in Minnesota report 34% of participants had traded sex, 26% had a family member involved in prostitution, 41% had friends in prostitution, and 26% had been a victim of sex trafficking in their childhood.³⁸ 

Human trafficking and MMIP-associated violence are also correlated to land allocation. In human trafficking research, remote and rural settings are considered “optimal conditions” for sex trafficking.³⁹  In urban settings, risk factors for trafficking include living near casinos and strip clubs.³⁹  Thus, AI/AN youth who live in rural, remote, and urban settings may all face land-related risks for human trafficking. Furthermore, differences in tribal versus nontribal jurisdiction for reporting and punishment of crimes for perpetrators on Indian land also varies and may lead to difficulty with prosecution.

Pediatric providers can work to prevent violence, abuse, and human trafficking by remaining aware and systematically asking about risk factors for violence and trafficking during patient encounters. Advocating for inclusive data collection is also critical, creating space for AI/AN patients to disclose their identity not only as AI/AN but also tribal affiliation. This can help move data collection away from the process of “othering” AI/AN communities. For gender-diverse youth, creating affirming environments and facilitating connection to community and culture is critical. Providers also have ample opportunity to advocate for legislation aimed at prevention of human trafficking and related risk factors.

Although there is limited research surrounding environmental health in AI/AN communities, poor health outcomes can be linked to assimilation policies resulting in displacement and land loss.⁴⁰  AI/AN individuals were forced to relocate to resource-poor reservations or unsafe living situations in urban environments.⁴⁰  The World Health Organization has identified “polluted indoor and outdoor air, contaminated water, lack of adequate sanitation, toxic hazards, disease vectors, UV radiation, and degraded ecosystems” as factors associated with suboptimal health outcomes in children across the globe; AI/AN children may experience these factors in both reservation and urban settings.^41,42 

AI/AN children in rural and reservation settings often lack access to necessities such as clean and running water, predisposing them to poor health outcomes.⁴³  Many communities lack access to electricity and therefore heat homes and cook using open fires, increasing exposure to smoke and air pollution, factors proven to increase the risk of asthma, pneumonia, and other respiratory infections.⁴³  AI/AN children have a 60% increased risk of asthma compared with non-Hispanic white children.⁴⁴  AI/AN children are also more likely to be exposed to persistent organic pollutants, heavy metals, and open dump sites located on or nearby reservations, found to have associations with cardiovascular conditions, reproductive abnormalities, cancer, autoimmune disorders, neurologic disease, and diabetes.^45,46  Furthermore, loss of land, resettlement, and provision of low-cost processed foods contribute to the high rates of obesity and diabetes in AI/AN youth. AI/AN children 2 to 5 years old have a higher combined prevalence of overweight and obesity (58.8%) compared with non-AI/AN children (30%).⁴⁵  The incidence of type 2 diabetes among AI/AN youth 10 to 19 years old increased by 3.7% per year from 2002 to 2015.⁴⁵ 

Lack of access to clean water, clean air, and electricity in resource-poor areas also increases vulnerability to infectious disease in these communities. These are compounded by the lack of access to care in rural settings. The negative impacts of poor health care access have been demonstrated through and exacerbated by the coronavirus disease 2019 pandemic, where, depending on age demographic, rates of mortality among AI/AN individuals were 8 to 12 times higher than among White individuals.^47,48 

Children are the most vulnerable to environmental hazards because of their physical, physiologic, and cognitive immaturity and are thus more likely to suffer disproportionately from environmental health-related illness along with the impacts of climate change.⁴⁹  AI/AN individuals in rural and reservation settings are more vulnerable to injury and death from extreme weather, natural disasters, increases in climate-related disease, air pollution, and heat-related disease.⁴⁹  Beyond these direct effects, additional considerations include reduced food availability, compounding already increased food insecurity, and mass migration from coastal regions further inland due to abrupt climate change, rising sea level, natural disaster, and/or political upheaval due to limited resource availability.⁴⁹  It is critical that governments and institutions respond proactively to preserve natural resources and reverse climate change to prevent these deleterious effects on child health.⁴⁹  For pediatricians caring for AI/AN youth, it is imperative to understand the importance of connection to land and environment and its critical role in health and healing for AI/AN communities.

Access to health care for AI/AN children is closely tied to land allocation patterns. For federally recognized tribes, health care is primarily delivered through 3 methods: the IHS, Tribally operated health organizations, and Urban Indian Health organizations.⁵⁰  In 2014, of the 2.1 million individuals eligible for IHS services, 31% of individuals were under age 15.⁵⁰  Funding for each method varies, ranging from federal allocations in IHS sites to tribally funded medical clinics. It is important to note the IHS has the lowest per capita funding of any federal health care program, including federal prisons, leading to gaps in care.⁵⁰  Because allocations for the IHS often shifts with changes in political priority, IHS funded sites may receive less resources or funds. Those that are allocated may be directed toward programs or services AI/AN communities do not see as a priority. In contrast, a tribally run health facility may be able to decide fund allocation but may have difficulty developing the funds. This is especially true in scenarios in which tribes are not affiliated with large income producing enterprises, such as casinos or tobacco sales.

Approximately 70% of the AI/AN population in the US resides in urban areas, with 25% living in counties served by Urban Indian Health programs.⁵¹  Only 21 of these are full ambulatory care centers, leaving a large majority of individuals unable to access care.⁵¹  This is further complicated by the lack of insurance in the urban AI/AN population, because there are more uninsured AI/AN individuals relative to non-Hispanic White populations in the same urban areas.⁵²  Even so, individuals living in urban settings may be able to access care from medical systems outside of the Indian Health Service/Tribal/Urban health systems. Conversely, individuals in rural or reservation settings face additional barriers including limited number of health facilities, proximity to health centers, and lack of transportation options.

Land allocation and location of IHS and tribal health centers in remote and rural areas also significantly impact recruitment of qualified physicians for roles within the IHS. Vacancy rates range from 13 to 31% and average at 25% across all health professions.⁵³  Hiring and retention are an issue in part because of salary deficits, especially problematic for health providers who have accrued significant debt during their training. Adequate housing close to work, lack of job opportunities for spouses, and poor educational opportunities for children are all barriers to longer-term service reported among IHS employees.^51,54  In this way, there is a clear overlap between land allocations to AI/AN communities and provider shortages, ultimately contributing to poor health.

Although there are numerous challenges in AI/AN land rights, recent examples highlight persistent injustices facing AI/AN communities. These negatively impact health for all AI/AN individuals, but especially children because of their more pronounced sensitivity to environmental pollutants and disruption of educational and housing systems.

The Keystone XL Pipeline (2010) traverses the Fort Belknap Indian Community of Montana and the Rosebud Sioux Tribe of South Dakota.⁵⁵  The central argument in this struggle lies in the Treaties of Fort Laramie in 1851 and 1868, which recognized land as the sovereign properties of the Great Sioux Nation.⁵⁶  The Native American Rights Fund attests that the National Environmental Policy Act and National Historic Preservation Acts were violated because there had been no analysis of trust obligations, treaty rights, hunting and fishing rights, water systems, or health and cultural impacts of this construction.⁵⁷  Although President Biden revoked the 2019 construction permit, this decision was overridden in federal courts in June 2021.

Similarly, the Dakota Access Pipeline (2014) passes under the Missouri River, the primary source of drinking water for the Standing Rock Sioux as well as a sacred burial ground.⁵⁸  Despite initial increased national awareness of the issues of land rights and settler colonialism, an executive order was issued in January 2017 to complete the project, and the pipeline is now fully operational.⁵⁹  There is an ongoing environmental review to assess the impact of the pipeline on the water quality of the Missouri River,⁶⁰  with likely impacts on drinking water placing undue risk on the health of its youngest consumers.

There is a need for extensive research on the impact of land rights and environmental health on AI/AN child health. Pediatric providers play a critical role in caring and advocating for AI/AN children and have unique opportunities to temper the impacts of HT at each visit. Although historical contexts and an understanding of land rights and sovereignty are outside of typical provider education, we posit knowledge of these complex topics can allow pediatric providers to serve AI/AN patients and communities.

Recognizing the relationship between the natural environment and the exacerbation of HT allows providers to understand the social and historical determinants of AI/AN child health. These traumas serve as an undercurrent for ACEs, because parents and communities that have suffered for generations are predisposed to stressors and violence that begins in childhood. Such traumas, coupled with structural and systemic racism, perpetuate health inequities based on land allocation and budgeting of federally provided health care. This pervasive inequity further exacerbates the indifference in reporting and investigation into cases of MMIP and lack of inclusion of AI/AN populations in research.

Current data support the negative impacts of environmental factors including air and water pollution, exposure to toxins and heavy metals, lack of access to fresh foods, and decreased sanitation and adverse effects on the biological health of AI/AN children. In addition, social determinants including HT, land allocation, and the continued MMIP crisis pose further threats to the wellbeing of this population. These are not independent risk factors for poor health outcomes but rather an interconnected web of social and biological determinants of health driven by structural racism.

These shortcomings offer opportunities for intervention. Indigenous stress-coping models and connections to land are a major facet in resilience and coping.^20,61  Assessing experiences related to cultural engagement and practices that may serve as protective factors to mitigate the transference of symptoms of HT, settler colonialism, and land disruptions may assist with development of programs directed at undoing these traumas. Literature demonstrates connection and revitalization of culture can help to foster resilience, leading to healing from historical and present-day trauma.⁶¹  Thus, pediatricians can work to foster and facilitate reconnection to culture and community in AI/AN youth, in-person or virtual. As a result, providers can better understand their pediatric AI/AN patients, their families, and their communities.

Pediatricians can also screen for exposures to abuse and violence and expand the scope of ACEs to include questions about HT, racial discrimination, and lack of access to public services. Further investigation of ACEs screening tools in AI/AN children in a research setting is warranted to investigate their validity in AI/AN children. Similarly, each office visit provides the opportunity to transform the life of a child and improve the understanding of the critical impact of land allocation on health outcomes in AI/AN children. Connecting youth to affirming resources is a way to facilitate this. For example, the “Celebrating Our Magic” Toolkit is a culturally based, community-driven resource providers can share with AI/AN Two Spirit and LGBTQ youth and relatives.^62,63 

Partnering with local, state, and national organizations to offer a health-centered perspective on the impact of land rights on AI/AN child health presents another manner of advocating for this vulnerable population. Many communities are already leading initiatives to overcome barriers and improve health, and we have the best chance of improving health for AI/AN youth if we engage in community-based participatory research and program development. The development of health policies and environmental policies in partnership with tribes will also prove extremely beneficial.

Aside from direct partnership with tribes, pediatricians can also connect with national and local organizations, including Generation Indigenous and the Seattle Indian Health Board, to explore available services in their areas. In addition, the American Academy of Pediatrics Committee on Native American Child Health maintains listings of model programs and best practices that may be implemented in communities across the country. Furthermore, connecting with networks including the Indian Health Special Interest Group and the Collaborative of Pediatric American Indian Trainees offers a simple way to connect with providers across the United States to share updates, ideas, and emerging projects to foster an engaged community, committed to the transformation of AI/AN child health.

Lastly, medical education is a key factor in improving health for AI/AN youth. Incorporating environmental health into curricula and emphasizing land rights and allocation as important determinants of health may transform health care for AI/AN populations for generations to come. Curricula can be developed by application of existing tools, including the National Institute on Minority Health and Health Disparities (NIMHD) research framework, a model that includes the physical/built environment among the domains of influence of health outcomes.⁶⁴  The use of this framework in both educational and clinical environments may better allow pediatric providers to assess AI/AN child health and disparities while identifying areas of future research, outreach, and advocacy.⁶⁴  Education surrounding the identification and elimination implicit and explicit biases is also critical. Providers have leadership obligations to establish a culture that eliminates bias, especially for communities that may not always have a voice. Including this work in medical education and giving trainees a chance to work in these communities will thereby reduce inequities and improve recruitment of talented providers to care for this unique population.

The authors acknowledge the Matinecock, Manhasset, Lenape, Montaukett, Unkechaug, Shinnecock, Mericoke, Massapequa, Nisequaq, Secatague, Setauket, Patchoag, and Corchaug and the many original inhabitants of Queens and Long Island, New York. We also acknowledge the state and federally recognized tribal nations of North Carolina: Coharie, Lumbee, Meherrin, Occaneechi Band of Saponi, Haliwa Saponi, Waccamaw Siouan, Sappony, and the Eastern Band of Cherokee. We acknowledge and thank the original caretakers of the land that our centers occupy and are built on: the Multnomah, Kathlamet, Clackamas, Tumwater, Watlala bands of the Chinook, the Tualatin Kalapuya, Molalla, Wasco, and the many Indigenous nations of the Willamette Valley and the Columbia River Plateau. We recognize all of the people for whom these were ancestral lands and for those who live and work in these regions today.

ACE

adverse childhood experience

AI/AN

American Indian and Alaska Native

HT

historical trauma

IHS

Indian Health Service

MMIP

Missing and Murdered Indigenous People