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

American Rehabilitation, Autumn, 1989 by Jamil I. Toubbeh

IHS: State of the Art in Disability and

its Prevention

The responsibility for prevention and alleviation of chronic illness and disability in IHS today is a function of local facility administrators. Because this responsibility is not based on an IHS servicewide policy, its assumption by these administrators is subject to local policies. As a rule, disabling conditions are considered high cost, non-emergent, and low priority conditions, subject to budgetary thresholds and to IHS servicewide management philosophy, constraints which limit not only the range of services rendered, but the number of people served by local facilities. Across IHS areas, prevention activities targeted at disability are limited and disparate.

While there is little disagreement within IHS today over the need for an articulated policy that would address the needs of disabled Indians, there is disagreement over the nature and extent of IHS involvement in disability and over the potential adverse effect that such involvement would have on IHS extant operations. The issues of concern, however, are overwhelmingly administrative and do not take into consideration changing health needs of Indian populations, particularly those related to disability.

The health of Indians today is a minor reflection of what it was three decades ago when IHS was established.(1,4-8) Life expectancy has been extended, infant mortality has been reduced and many infectious diseases that once plagued these populations are under control. Today's needs are different. The price paid for acculturation and improved health care has been an increase in the prevalence of disability. Changes in diet, for example, have increased the susceptibility of Indians to diabetes, which, in turn, has effected increases in end-stage renal disease, retinopathy and loss of limb. Decreases in mortality at either end of the age spectrum have increased the prevalence of mental retardation, epilepsy, congenital abnormalities, stroke, heart disease, and cancer. In addition, Indian accessibility to alcohol has led to increases in fetal alcohol syndrome and its related problems. These examples represent the tip of a larger iceberg of problems that have not bee lored b IHS, and ones that, nonetheless, are now being felt by Indian leadership and service providers.

The absence o a ge scale epidemiologic studies on disability in Indian populations is an indication that IHS has not, to date, considered its priorities in the light of the increasing prevalence and incidence of these conditions in these populations. An analysis of the agency's priorities indicates continued emphases on primary medical care, generally described as health maintenance and promotion activities. Although the agency employs a limited range of support staff, including social workers, nutritionists, audiologists, and health educators, staff activities are confined to health treatment and continuity of health care plants. The absence of a priority on disability has inhibited the development of essential activities to meet current needs. Its absence moreover, has negated the evolution of prevention schemes at any stage - primary, secondary or tertiary (see Note). It is in this specific area that change is needed and where change can directly affect the benefits that Indians receive from the immense pecuniary resources allocated by Congress for disability.