The Indian Health Service (IHS) was founded on July 1st, 1955 and its mission is to serve the population of indigenous peoples who are members of federally recognized tribes in the United States [1]. IHS has hospitals across the country that serve the millions of people who belong to federally-recognized tribes. However, the IHS has been severely underfunded for much of its existence and has time and time again failed to provide high quality, reliable service to the indigenous population of the United States. With these observations in mind, I argue that the United States commits something larger than simply a broken promise by neglecting their relationship to tribal nations, but rather commits egregious bioethical violations.
The obligation for the federal government to provide health services to indigenous peoples is part of the larger doctrine of trust, which was established in a series of court cases and treaties, as well as in Article 1 Section 8 of the United States Constitution, which grants the United States federal government jurisdiction over the commerce and treaties of tribal nations [2]. Within this jurisdictional declaration, tribal nations become a pseudo-subsidiary if you will of the United States, needing to conform to federal law, but still able to in-part retain their sovereignty. With the formation of this relationship, federal systems dedicated to the health and wellbeing of indigenous peoples took shape. This doctrine of trust has only been applicable to the Tribal Nations that are federally recognized and does not encompass all indigenous peoples who live within the border of the United States. This differentiation is important because during the era of termination, a period of time between 1953 and 1969, many tribal nations lost their status as federally recognized tribes, thus relieving the federal government of their obligation to recognize their sovereignty [3]. One example, of many, the Klamath people of Oregon, had their land distributed and lost their status as a federally recognized tribe, which meant the dissolution of the government of the Klamath peoples and the loss of their privileged relationship with the federal government [3]. Even those who are recognized by the federal government are not afforded the same access to health services that other citizens of the United States receive.
The IHS and the funding for healthcare for the rest of the citizens of the United States is fundamentally different. The IHS receives the majority of its funding designated under the category of “discretionary spending” in the federal budget unlike medicare, another federally-funded health plan, which is categorized as mandatory spending [4]. This categorization opens the door for lack-luster appropriations being allocated to the Indian Health Service. The documentary Don’t Get Sick After June describes this very problem. The funding for the IHS begins on the first day of the fiscal year, the first day of October, however due to the inadequacy of funding that the IHS is given, it is financially unable to provide adequate funds to health care institutions on tribal land throughout the entire fiscal year, particularly as funding for the IHS predictably runs out in June year after year [5]. The IHS on average only has 59 percent of its annual appropriations met and in 2013, IHS per capita spending for individuals was $2,849 compared to $7,717 nationally [6].
In addition to the inadequacy of the funding for the IHS, the impacts of settler colonialism continue to have profound health impacts on indigenous peoples. Colonialism not only devastated and displaced indigenous communities, but broke down systems of community health such as access to traditional food sources, clean water, and land [7]. These systems of community based care dependent on the lands in which indigenous peoples were living, and the traditional practices that were tied to these lands, were replaced with systems such as the IHS. Some of the ways these impacts manifest themselves is the presence of higher mortality rates for alcoholism, which is over five times that of the national average, diabetes, which is almost double the mortality rate of the average population, cervical cancer, and maternal deaths [6]. Food insecurity also plays a large role in the disproportionate prevalence of disease and illness such as diabetes. In fact, over a quarter of the indigenous population experiences food insecurity and food deserts are common on reservations [8]. These food deserts leave people to turn to unhealthy options simply out of necessity, which in combination with the inadequate funding of the IHS, leaves people living in these areas unable to improve their health conditions.
Clearly, discrepancies are nested in the underfunding and inadequacy of the IHS, but they are also nested within the structures and conditions within which indigenous peoples currently live. While it seems to have been easy for the United States to turn a blind eye from the needs of the indigenous peoples who live within its borders, it is clear that with regard to the health of these populations, it is carrying out gross bioethical wrongs. One of the principles of bioethics is justice, which is based upon the equal distribution of care to all groups in a society, and that a caretaker must respect and act in accordance with rights and obligations [9]. Another aspect of the justice principle of bioethics is that rights and obligations must be met, which in this case includes following through with stipulations from centuries ago that formed the basis of the “doctrine of trust.”
It would take immense structural change to correct for the health discrepancies in indigenous communities – much more than simply increasing funding for the IHS, but it may be a good place to start. Increasing funding would allow for more consistent care to be provided to these communities and could help to slow the rate at which native peoples are succumbing to disease and illness. Providing more access to food would be another way in which the health of this group of people could be improved. Broad, comprehensive investments into the health and wellbeing of these communities could go a long way, and would be a small step in the right direction on the way to correcting the federal government’s ethical wrongs.
References
"If you knew the conditions..." Health Care to Native Americans: Indian Health Service Today. (2010, November 23). U.S. National Library of Medicine. https://www.nlm.nih.gov/exhibition/if_you_knew/ifyouknew_09.html#:~:text=The%20Indian%20Health%20Service%20.
Basis for Health Services. Indian Health Service. (n.d.). U.S. Department of Health and Human Services. https://www.ihs.gov/newsroom/factsheets/basisforhealthservices/.
1953 to 1969: Policy of Termination and Relocation (n.d.). Stanford Medicine. https://geriatrics.stanford.edu/ethnomed/american_indian/learning_activities/learning_1/termination_relocation.html.
Heisler, E. J. (2022) Indian Health Service (IHS) FY2022 Budget Request and Funding History: In Brief (CRS Report No. R47004). https://crsreports.congress.gov/product/pdf/R/R47004#:~:text=117%2D58.
Ritchie, C. (Director). (2010). Don’t Get Sick After June: American Indian Healthcare [Film]. Rich-Heape Films, Inc.
National Congress of American Indians. (2016). Health Care: Reducing Disparities in the Federal Health Care Budget. https://www.ncai.org/policy-issues/tribal-governance/budget-and-approprations/07_FY2016_Health_NCAI_Budget.pdf.
Jensen, A., & Lopez-Carmen, V. A. (2022) The “Elephants in the Room” in U.S. global health: Indigenous nations and white settler colonialism. PLOS Global Public Health. https://doi.org/10.1371/journal.pgph.0000719.
How Hunger Affects Native American Communities. (n.d.). Move for Hunger. https://moveforhunger.org/native-americans-food-insecure#:~:text=Overall%2C%20over%20a%20quarter%20of,of%20access%20to%20quality%20healthcare.
What are the Basic Principles of Medical Ethics?. (n.d.). https://web.stanford.edu/class/siw198q/websites/reprotech/New%20Ways%20of%20Making%20Babies/EthicVoc.htm#:~:text=Bioethicists%20often%20refer%20to%20the,beneficence%2C%20and%20non%2Dmaleficence.