Commentary From the Committee on Native American Child Health
American Indian and Alaska Native (AIAN) children face higher rates of disease when compared to the general population due to the long-term consequences of colonization. In the 1960s, the leadership of the Indian Health Service (IHS) realized the crisis in AIAN child health and reached out to the American Academy of Pediatrics (AAP) for assistance. By 1964, the Committee on Indian Health was formed, which was renamed the Committee on Native American Child Health (CONACH) in the 1980s. This partnership of those serving AIAN children through IHS tribal clinics and urban clinics and the AAP continues to this day. Through nearly 60 years of collaboration the CONACH provides consultative site visits to IHS urban and tribal clinics. CONACH works closely with IHS and AIAN organizations to provide consultation, advocacy, and education on AIAN child health. We chose these 2 articles to help pediatricians and others caring for AIAN children to understand this unique population’s health needs and to adopt a strength-based approach while cognizant of the current and historical context for these health inequities.
Caring for American Indian/Alaska Native Children and Land Rights
Allison Empey, MD, FAAP1, Alessandra Angelino, MD, MPH, FAAP2
Affiliations: 1Division of General Pediatrics, Department of Pediatrics, Oregon Health & Science University, Portland, OR; 2Division of Adolescent and Young Adult Medicine, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
Highlighted Articles From Pediatrics
- Bell S, Deen JF, Fuentes M, Moore K, Committee on Native American Child Health. Caring for American Indian and Alaska Native children and adolescents. Pediatrics. 2021;147(4):e2021050498
- Burns J, Angelino A, Lewis K, et al. Land rights and health outcomes in American Indian/Alaska Native children. Pediatrics. 2021;148(5):e202041350
The AAP “Caring for American Indian and Alaska Native Youth Children and Adolescents” policy statement recognizes that all child health providers, not just those working on Native American reservations, must be knowledgeable about the unique health care needs of AIAN children and youth. Only 22% of AIAN individuals live on tribal lands, and the majority of the remainder reside in urban areas. AIAN (alone or in combination with other races/ethnicities) is one of the fastest growing populations in the United States. In the 2020 census, 9.7 million people or approximately almost 3% of the population identified as AIAN. This represented a striking increase compared to 1.7% of the population who so identified in 2010. Hence, it is increasingly important for providers to be able to provide culturally appropriate care for AIAN children.
The policy statement was initiated and led by past chair of the CONACH, Dr. Shaquita Bell. Coauthors were selected based not only on their medical expertise in Native American child health but also their lived experience. This paper represents a landmark for the AAP because all authors identify as American Indian. The recommendations of this statement focus on culturally relevant resources and adopt a strengths-based focus, rather than a deficits-based approach. Additionally, they recommend partnering with AIAN communities or tribal organizations to implement changes respecting tribal sovereignty.
This policy statement describes a number of health care inequities that AIAN youth and children experience. It also reviews how the roots of systemic racism persist today and have contributed to health disparities. The paper provides some recommendations for change at the individual, pediatric practice, and advocacy levels that can mitigate factors that promote health disparities and thereby improve outcomes.
The second seminal publication, “Land Rights and Health Outcomes in American Indian/Alaska Native Children” further amplifies the context for many of the disparate health outcomes seen today. The land rights publication was born following the reclamation of Wampanoag lands by the federal government in March 2020. Several members of the CONACH were involved in developing the article. Authors represent broad geographic representation, from Alaska to North Carolina, as well as diverse tribal and ethnic heritages. Further, CONACH continues to support the development of trainees committed to improving Native American child health. At the time of publication, 3 of the authors were trainees: 2 resident physicians and 1 medical student.
In December 2021, shortly after the release of the article, the federal government reversed its decision, and more than 300 acres of reservation lands were returned to the Mashpee Wampanoag. Despite this reversal, Indigenous sovereignty in the United States remains under threat.
Settler colonialism, historical trauma, and the resultant structural racism affecting AIAN communities have set the stage for significant health inequity. It is well supported that AIAN populations are at increased risk of obesity, diabetes, cardiovascular disease, asthma, mental health disorders, and injury. Myriad risk factors associated with these disease processes have their origins in adverse social determinants of health, which in turn are closely linked to issues related to land management and Indigenous sovereignty. In addition to factors pertaining to the relationship between AIAN communities and land, the principles dictating land rights in the United States have allowed for a disproportionate effect of violence on these communities.
Due to these broad impacts, the land rights article aimed to highlight the historical contexts, including colonialism, dispossession, and violence, that have influenced health outcomes for AIAN children and adolescents. Increased attention to cultural considerations and the social determinants of health across disciplines has resulted in discussions that have the potential to transform pediatric health care. By empowering pediatricians and pediatric subspecialists to identify and address racism as a key social determinant of health, we can improve health outcomes for AIAN youth. Still, too often, AIAN populations are excluded from these discussions in medicine as a discipline and across academia.
Given the lack of education on this topic and the critical need to understand these contexts to improve AIAN child health, the article also discusses the nuanced connection between the environment and health for Indigenous communities. More broadly, Indigenous individuals view health holistically, including not only the physical but also the social, emotional, spiritual, and environmental components that contribute to well-being. By acknowledging the ecological relationship between the land and the environment, pediatric providers can work to address systemic inequities and mediate the impact of intergenerational trauma for the improvement of Native American child health. Similarly, the land rights article promotes the importance of celebrating interconnectedness and intersectionality, and model programs and resources that are pertinent to providing culturally sensitive care.
