Disability and its prevention in Indian populations: is it someone else's responsibility?

American Rehabilitation, Autumn, 1989 by Jamil I. Toubbeh

Disability and its Prevention in Indian Populations: is it someone else's responsibility?

Despite a well coordinated and eminently successful federal, state and Indian tribal effort aimed at combatting health problems in American Indians and Native Alaskans (Indians), prevention and amelioration of disabilities in these populations continue to pose questions regarding provider responsibility and service coordination. Obscure jurisdictional boundaries and absence of service coordination among responsible agencies constitute one of the major factors impeding the development of viable habilitation and rehabilitation programs in the majority of reservation and urban Indian communities. In the light of the high prevalence of chronic illness and disability in these populations, it may be assumed that the disabled Indian today is not receiving an equitable share of the benefits that are available to disabled citizens.

Among federal agencies, the Indian Health Service (IHS) plays a central role in meeting the health needs of Indians. The agency's role in disability (or its correlate, chronic illness), however, has been at issue for at least a decade. Although its legislative mandate addresses comprehensive health and rehabilitation needs of Indians, its role in these areas has been blurred not only by a public health delivery model, but by new laws affecting disabled U.S. citizens and by responsibilities ascribed to other federal agencies under these laws. Considering the high costs associated with treatment of chronically ill and disabled people and the number of agencies that are either directly or indirectly involved in the provision of services to these populations, questions arise as to whose responsibility is the disabled Indian.

This article will examine issues associated with disability and its prevention in Indian populations (see Note). The assumption is made that, since IHS has the primary responsibility for ensuring the availability of comprehensive health services to Indians, it is the agency most likely to ensure the provision of comprehensive care for disabled Indians, as well as the one most able to play a major role in the prevention of disability in these populations. This responsibility resides in the agency's mission, its operational objectives and in its historic and legal relationship with Indians.

Disability and its Prevention

The subject of Indian health care and the controversies surrounding it are well documented in a recent Congressional report titled, Indian Health Care.(1) While the intent of this paper is neither to trace the history of Indian health care nor to assess its relative impact on the overall health of Indians, acquaintance with this report may be useful in understanding the crucial role that IHS plays in the broad area of health care in Indian populations, particularly in disability and its prevention.

Among the three operational objectives of IHS are two which have a direct impact on disability and its prevention in Indian populations. These are:

* to deliver the highest quality of comprehensive health care to Indian people; and

* to act as the Indians' federal advocate in health matters.

In implementing these objectives, IHS avails Indians of hospital and ambulatory medical services; preventive and rehabilitative services; and community and environmental health programs. In their implementation, furthermore, the agency assumes the role of primary federal advocate for all Indian health and health-related needs.(2)

Historically, IHS strategies evolved from public health models extant when IHS was established. Activities under this model were directed toward prevention of illness, chiefly through sanitation and control of contagious diseases and environmental hazards. With changing patterns of disease, resulting from either further exposure of Indians to the Anglo-American culture or the changing Indian lifestyle, IHS modified its health delivery model, incorporating new elements in response to dynamic Indian population needs. The focus on alcoholism, otitis media and diabetes are recent IHS foci reflecting the agency's response to these needs. Notwithstanding, elements of the original model have persisted. Despite an overall shift in the philosophy of public health in America, IHS philosophy continued to reflect perceptions of illness that are inconsistent with those of other public health agencies. This is particularly evident in the agency's manpower mix where the focus clearly reflects overemphasis on health manpower in service provision and in the management of IHS programs.

Prior to the establishment of IHS, U.S. public health agencies were increasingly focusing their attention on the health problems of individuals and society, directing much of their efforts toward breaking the barriers between prevention and treatment, and personal and community health. The greatest strides were made in the area of prevention. Operationally, prevention became a process that incorporated both the classical definition of prevention of disease onset with a new concept, that which emphasized prevention of the adverse sequelae of disease. This concept effected a broadening of public health programs to include services for the prevention, diagnosis and treatment of communicable diseases; protection of the health of mothers, infants and children of school age; prevention, detection and amelioration of dental, visual, hearing, and other problems; promotion of mental health; and, most importantly, control of chronic disease through more appropriate treatment strategies.