Native American disease and epidemics

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Native American disease and epidemics pervade many aspects of Native American life, both throughout history and in the modern day. Diseases and epidemics can be chronicled from centuries ago when European settlers brought diseases that devastated entire tribes to the modern day when Native Americans face serious struggles with particular diseases. The current crises in diseases and epidemics are addressed by many different groups, both governmental and independent, through a multitude of programs.

Origins of Native American Disease[edit]

An ill Native American in the 1800s being cared for by a medicine man.

Native Americans have been affected by the disease and health concerns throughout their history, but a major turning point in Native American disease presence was with the arrival of Europeans. This ushered in what is termed the Columbian Exchange. During this period European settlers brought many different technologies and lifestyles with them, but the most harmful effects of this exchange was the arrival and spread of disease.[1]

Native Americans, due to the lack of prior contact with Europeans, had not previously been exposed to the diseases that were prevalent on the distant continent. Therefore they had not built up internal immunities to the diseases or formed any medicines to combat them. Europeans came into the New World bearing various diseases. Those infected with diseases either possessed them in a dormant state or were not quarantined in such a way that distanced them enough from Native Americans to not spread the diseases, allowing diseases to spread into epidemics.[2]

The diseases brought by Europeans are not easily tracked, because there were numerous outbreaks and all were not equally recorded. The most notable disease brought by Europeans was the destructive smallpox disease. The Lakota Indians called this disease the running face sickness.[3] Smallpox was lethal to many Native Americans, bringing sweeping epidemics and affecting the same tribes repeatedly. Within 1837 to 1870, at least four different epidemics struck the Plains tribes.[4] When the plains Indians began to learn of the "white man’s diseases" they began to intentionally avoid contact with the whites and their things. But many tribes enamored with the white man’s things, like metal pots, skillets and knives traded with the whites anyway, and inadvertently spread disease to their villages.[5]

Numerous other diseases were brought to Native American tribes, including measles, scarlet fever, typhoid, typhus, influenza, pertussis (whooping cough), tuberculosis, cholera, diphtheria, chickenpox and sexually transmitted diseases.[4] Each of these diseases brought destruction through sweeping epidemics, involving illness and extensive death. Many Native American tribes experienced extensive depopulation, averaging 25–50 percent of tribal life lost due to disease. Additionally, singular tribes also neared extinction after facing severely destructive spread of disease.[4] The significant toll that this took on Native populations is expounded upon in the article Population history of indigenous peoples of the Americas. A specific example of this devastation was Cortes' invasion of Mexico. Before his arrival, the Mexican population was estimated to have been around 25-30 million. Fifty years after his arrival, the Mexican population was cut down to 3 million, attributable mainly to infectious disease. Here we see the main effect of the arrival of Europeans in the new world. With no natural immunity to help them in their fight against these pathogens, the native Americans died in huge numbers. The eminent Yale historian David Brion Davis says this was "the greatest genocide in the history of man. “Yet it's increasingly clear that most of the carnage had nothing to do with European barbarism. The worst of the suffering was caused not by swords or guns but by germs”.[6]

Certain cultural and biological traits made Native Americans more susceptible to these diseases. Emphasis placed on visiting the sick led to the spread of disease through consistent contact.[7] Smallpox specifically led indirectly to higher rates of suicide. Many Native American tribes prided themselves in their appearance, and the resulting skin disfigurement of smallpox deeply affected them psychologically. Unable to cope with this psychological development, tribe members were said to have committed suicide.[8]

Native Americans first exposed to these diseases also had a unique approach to illness, relating primarily to religious beliefs. There is the belief that disease is caused by either a lack of charm use, an intrusion of an object by means of sorcery, or the free soul's absence from the body. Disease was understood to enter the body if one is not protected by the spirits, as it is a natural occurrence. Religious powers were believed to be related to curing diseases as well.[9] Native American illness has been treated through the practice of shamanism in the past, though this decreased as the influence of Europeans increased.

Disease as a potential weapon against Native Americans[edit]

"You will do well to try to inoculate the Indians, by means of blankets, as well as to try every other method that can serve to extirpate this execrable race." — Jeffery Amherst[10]

The spread of disease from European contact may not have always been accidental. Europeans who were arriving in the Americas had already been exposed to the diseases, attaining immunity, and thus were not affected by them. Therefore, it could be an effective technique to use disease as a biological weapon when others were exhausted.[10]

There is only one documented instance in which disease was proposed to be used as a weapon against Native American tribes. During the French and Indian War, Jeffery Amherst, 1st Baron Amherst, Britain's commander in chief in North America suggested using the smallpox disease to wipe out their Native American enemy. It is quoted from his writings to Colonel Henry Bouquet concerning the situation in western Pennsylvania[10] that the spread of disease would be beneficial to achieve their means and Bouquet confirmed his intentions to do so.

Dissent to the biological weapon theory[edit]

There is current scholarly dissent to the theory that the outbreaks of smallpox may have been aided by the intentional spreading of disease, as for example the allegations of smallpox-infested blankets being intentionally given to Native Americans in 1763 at the Siege of Fort Pitt. [11] The outbreaks that occurred specifically in this region may have resulted from sporadic cases already occurring amongst Indians rather than from this scenario.[10] Historians also say that though blankets containing smallpox may have been distributed to Native Americans by the Europeans, they may have been given with good will and intentions, instead of for the purpose of disseminating disease. Additionally, scholars such as Gregory Dowd, are of the opinion that disease was spread by Native Americans returning from battling infected Europeans. Therefore it may have been carried by Native Americans to their own people and spread.[12] Europeans lack of understanding of basic germ theory until proven by Pasteur in 1865, can precluded a thoughtful and systematic use of infected blankets as a weapon.

Contemporary diseases[edit]

The leading causes of death by percentage for American Indians and Alaska Natives for 2005. Heart disease accounted for 25% of deaths, cancer 22%, accidents 19%, diabetes 7%, liver disease 6%, suicide 6%, respiratory diseases 6%, stroke 4%, homicide 3%, and influenza and pneumonia 3%.

Currently, Native Americans share many of the same health concerns as their non-Native American, United States citizen counterparts. For instance, Native Americans leading causes of death include "heart disease, cancer, unintentional injuries (accidents), diabetes, and stroke." Other health concerns include "high prevalence and risk factors for mental health and suicide, obesity, substance abuse, sudden infant death syndrome (SIDS), teenage pregnancy, liver disease, and hepatitis." Diseases primarily present the greatest threat to Native American life. The top leading causes of death include the following diseases: heart disease, cancer, diabetes, and chronic liver disease / cirrhosis.[13][14]

Though many of these appear to be concerns paralleling those of non-Native Americans, some of these diseases present a much greater threat to Native Americans' well-being.[15] These discrepancies in disease patterns vary significantly between diseases, but have a notable impact on the population. There are many general reasons for the discrepancies in Native American disease prevalence.[16]

The genetic composition of Native Americans and clans can have an influence on many diseases and their continuing presence. The commonly lower socioeconomic status limits the ability of many to receive adequate health care and make use of preventative measures. Also, certain behaviors that take place commonly in the Native American culture can increase risk of disease.[17]

Native Americans have much higher smoking rates than the white, black, and Asian demographics. Native American men are about as likely to be moderate to heavy drinkers as white men, but about 5–15% more likely to be moderate to heavy drinkers than black or Asian men. Native Americans are 10% less likely to be at a healthy weight than white adults, and 30% less likely to be at a healthy weight than Asian adults. On a similar note, they have far greater rates of obesity, and were also less likely to engage in regular physical activity than white adults.[18]

Heart disease[edit]

The leading cause of death of Native Americans is heart disease. In 2005, it claimed 2,659 Native American lives. Heart disease is notable in Native American populations because it occurs at a rate 20 percent greater than all other United States races. Additionally, the demographic of Native Americans who die from heart disease is younger than other United States races, with 36% dying of heart disease before age 65.[19]

Heart disease in Native Americans is not only due to diabetic complications; the increased risk is also due to higher rates of hypertension. Native American populations have been documented as being more likely to have high blood pressure than other groups, such as white Caucasians.[20] Studies have also been conducted that associate the exposure to stress and trauma to an increased rate of heart disease. It has been documented in Native American populations that adverse childhood experiences, which are significantly more common in the Native American demographic, have a positively linear relationship with heart disease, as well an increasing influence on symptoms of heart disease.[21]

Cancer[edit]

Cancer has a documented presence amongst Native Americans, and the rates of certain types of cancer exceed that of the general population of the United States. For instance, Native American males were twice as likely to have liver cancer than white males from 2001–05. Women on the other hand are 2.4 times as likely to have and die from liver cancer as their white counterparts. This has a notable correlation with the rates of alcoholism of Native Americans, which are greater than the general population.[22]

Stomach cancer was also 1.8 times more common in Native American males than white males, in addition to being twice as likely to be fatal. Other cancers, such as kidney cancer, are more common among Native American populations. It is important to note that overall cancer rates are lower among Native Americans compared to the white population of the United States. For cancers that are more prevalent in Native Americans than the white United States population, death rates are higher.[23]

Diabetes[edit]

The rates of death by diabetes for each race and ethnicity in the United States in 2005.

Diabetes has posed a significant health risk to Native Americans. Type I diabetes does not have a notable correlation to Native Americans, and is rather rare. Type II diabetes is a much more significant problem and is the type of diabetes referred to in the remainder of this section. The prevalence of diabetes began primarily in the middle of the twentieth century and has grown into an epidemic. About 16.3% of Native American adults have been diagnosed with diabetes.[24]

Native Americans are about 2.8 times more likely to have Type II diabetes than white individuals of comparable age. The rates of diabetes among Native Americans also continue to rise. During the eight year span of 1990 to 1998, diabetes grew 65% among the Native American population. This is very significant growth, and this growth continues in the present day. [25]

The highest rates of diabetes in the world are also found among a Native American tribe. The Pima tribe of Arizona took part in a research study on diabetes which documented diabetes rates within the tribe. This study found that the Pimas had diabetes rates 13 times that of population of Rochester, Minnesota, a primarily white populace. Diabetes was documented in over one third of Pimas from ages 35–44, and in over sixty percent of those over 45 years of age.[26]

There are multiple causes for diabetes to cast such a presence on the Native American demographic:

Genetic Predisposition 
Native Americans with the "least genetic admixture with other groups"[25] have been found to be at a higher risk of developing diabetes, showing that this minority group has a great predisposition for diabetes which increases the risk of its contraction
Obesity 
Native Americans have a significant health problem with obesity, as they are 1.6 times as likely to be obese.;[15] obesity is known as a general causative factor of diabetes
Low Birth Weight 
The notable association between low birth weight and increased risk in diabetes has been documented in Native American populations[25]
Diet 
Changes in Native American diets have been associated with the increase in diabetes, as more high calorie and high fat foods are consumed, replacing the traditionally agriculturally driven diet[27]

Impact[edit]

Along with this significant presence of diabetes comes the notable presence of complications. Each of these are more prevalent in the Native American population.[28] Diabetes has been seen to cause premature death of Native Americans by vascular disease, more notably in those diagnosed with diabetes later in life. It has been reported among the Pima Indians to cause elevated urinary albumin excretion. Native Americans with diabetes have a significantly higher rate of heart disease than those without diabetes, and cardiovascular disease is the "leading underlying cause of death in diabetic adults" in Native Americans.[27]

Diabetes has caused nephropathy among Native Americans, leading to renal function deterioration, failure, and disease. Prior to the increase in cardiovascular disease among diabetic Native Americans, renal disease was the leading cause of death. Another complication documented in diabetic Native Americans, as well as other diabetic populations, is retinopathy.[27]

Lower extremity mputations are also notably higher among Native American populations with diabetes. In studies of the Pima Indians, those with diabetes were found to have much higher prevalence of periodontal disease. Additionally, those with diabetes have higher instances of bacterial and fungal infection. This is seen in statistics such as "diabetic Sioux (Lakota people) Indians were four times as likely to have tuberculosis as those without diabetes."[27]

With such alarming numbers of type II diabetes it is important to understand how the Native American population got to this point and see if there are any trends in common with the world situation today. Prior to the 1940s diabetes was virtually unheard of, but ever since the 1960s the prevalence has been on the rise. This rise is thought to be in part due to their food history and culture. Native Americans had a diverse food history prior to colonization, but after colonization the natives were forced to live on non-traditional lands and eat government hand-outs for food. Much of this food was of low quality, meaning that here is not much nutritional content for the caloric intake and led to many Natives being malnourished.

It is important to note that Native Americans with diabetes have a death rate three times higher than those in the non-Native population. Diabetes can shorten a person's life by approximately 15 years.[24] As of 2006, diabetes was not the leading cause of death for Native Americans itself but contributed significantly to the top leading causes of death.[13]

Alcoholism[edit]

Further information: American Indian alcoholism

Another significant concern in Native American health is alcoholism. Alcoholism in the modern day is approached as a disease, and has been strongly linked to genetics and social circumstances. The rate of death from alcoholism in Native Americans is about five times that of all races in the United States.[29] However, due to the nature of alcoholism and the behaviors involved, the disease model is not always applicable. It is clearly a disorder that has many factors, but the behavioral component distinguishes it from many other diseases, such as those previously discussed.[30] Alcoholism, along with drug use, is discussed in Modern social statistics of Native Americans.

HIV/AIDS[edit]

HIV and AIDS are growing concerns for the Native American population. The overall percentage of Native Americans diagnosed with either HIV or AIDS within the entire United States population is relatively small, but noting the percentage of the population that is Native American this is a notable figure. Native American AIDS cases make up approximately 0.5% of the nation's cases, while they account for about 1.5% of the total population.[15]

Native Americans and Alaska Natives rank third in the United States in the rate of new HIV infections.[31] Also notable is the fact that Native Americans, when counted with Alaskan Natives, have a 40% higher rate of AIDS than white individuals. Also, Native American and Alaskan Native women have double the rate of AIDS of white women.[15]

These statistics have multiple suggested causes:

Sexual behaviors 
Previous studies of high rates of sexually transmitted diseases among Native Americans lead to the conclusion that the sexual tendencies of Native Americans lead to greater transmission[32]
Illicit drug use 
The use of illicit drugs is documented to be very high among Native Americans, and not only does the involvement of individuals with illicit drugs correlate with greater rates of sexually transmitted disease, but it can facilitate the spread of diseases
Socio-economic status 
Due to the poverty and lower rates of education, the risk of getting AIDS or any other sexually transmitted disease can be increased indirectly or directly
Testing and data collection 
Native Americans may have limited access to testing for HIV/AIDS due to location away from certain health facilities; data collected on Native American sexually transmitted diseases may be limited for this same reason as well as for under reporting and the Native American race being misclassified[32]
Culture and tradition 
Native American culture is not always welcoming of open discussion of sexually transmitted diseases[31]

Stroke[edit]

Other diseases pose notable concerns to the Native American demographic as well. Stroke is the sixth leading cause of death in the Native American population. Native Americans are sixty percent more likely than white adults in the United States to have a stroke. Native American women have double the rate of stroke of white women. About 3.6% of Native American and Alaska Native men and women over 18 have a stroke.[33] The stroke death rate of Native Americans and Alaska Natives is 14 percent greater than among all races.[34]

Combating disease and epidemics[edit]

Many initiatives have been put in place to combat Native American disease and improve the overall health of this demographic. One primary example of such initiative by the government is the Indian Health Service which works "to assure that comprehensive, culturally acceptable personal and public health services are available and accessible to American Indian and Alaska Native people."[35] There are many other governmental divisions and funding for health care programs relating to Native American diseases, as well as a multitude of programs administered by tribes themselves.

Diabetes programs[edit]

Eagle books are a book series produced by the CDC to inform Native American children about healthy lifestyles in order to prevent diabetes.

As diabetes is one of the utmost concerns of the Native American population, many programs have been initiated to combat this disease.

Governmental programs[edit]

One such initviative has been developed by the Centers for Disease Control and Prevention (CDC). Termed the "Native Diabetes Wellness Program", this program began in 2004 with the vision of an "Indian Country free of the devastation of diabetes."[36] To realize this vision, the program works with Native American communities, governmental health institutions, other divisions of the CDC, and additional outside partners. Together they develop health programs and community efforts to combat health inequalities and in turn prevent diabetes. The four main goals of the Native Diabetes Wellness Program are to promote general health in Native communities (physical activity, traditional foods), spread narratives of traditional health and survival in all aspects of life, utilize and evaluate health programs and education, and promote productive interaction with the state and federal governments.[36]

Funding for these efforts are provided by the Balance Budget Act of 1997, Public Law 105-33, and the Indian Health Service. One successful effort of this program is the Eagle Books series, which are books using animals as characters to depict a healthy lifestyle that prevents diabetes, including embracing physical activity and healthy food. Other successful efforts include Diabetes Talking Circles to address diabetes and share a healthy living message and education in schools. The Native Diabetes Wellness Program also has worked with tribes to establish food programs that support the "use of traditional foods and sustainable ecological approaches"[36] to prevent diabetes.

The Indian Health Service has also worked to control the diabetes prevalence among Native Americans. The IHS National Diabetes Program was created in 1979 in order to combat the escalating diabetes epidemic.[37] A sector of the service is the Division of Diabetes Treatment and Prevention, which "is responsible for developing, documenting, and sustaining clinical and public health efforts to treat and prevent diabetes in American Indians and Alaska Natives."[37]

This division contains the Special Diabetes Program for Indians, as created by 1997 Congressional legislation. This program receives $150 million a year in order to work on "Community-Directed Diabetes Programs, Demonstration Projects, and strengthening the diabetes data infrastructure."[37] The Community-Directed Diabetes Programs are programs designed specifically for Native American community needs to intervene in order to prevent and treat diabetes. Demonstration Projects "use the latest scientific findings and demonstrate new approaches to address diabetes prevention and cardiovascular risk reduction."[37] Strengthening the diabetes data infrastructure is an effort to attain a greater base of health information, specifically for the IHS Electronic Health Record.[37]

In addition to the Special Diabetes Program for Indians, the IHS combats diabetes with Model Diabetes Programs and the Integrated Diabetes Education Recognition Program. There are 19 Model Diabetes Programs which work to "develop effective approaches to diabetes care, provide diabetes education, and translate and develop new approaches to diabetes control."[37] The Integrated Diabetes Education Recognition Program is an IHS program that works towards high quality diabetes education programs by utilizing a three-staged accreditation scale. Native American programs in health care facilities can receive accreditation and guidance to effectively educate the community concerning diabetes self-management.[37]

Tribal Programs[edit]

Many tribes themselves have begun programs to address the diabetes epidemic, which can be specifically designed to address the concerns of the specific tribe. The Te-Moak Tribe of Western Shoshone have created their own diabetes program. With this program, they hope to promote healthly lifestyles with exercise and modified eating and behavior. The means of achieving these ends including "a Walking Club, 5 a Day Fruits and Vegetable, Nutrition teaching, Exercise focusing, 28 day to Diabetes Control, and Children's Cookbook."[38] Additionally, the Te-Moak tribe has constructed facilities to promote healthy lifestyles, such as a center to house the diabetes program and a park with a playground to promote active living.[38]

The Meskwaki Tribe of the Mississippi has also formed diabetes program to provide for the tribe's people. The Meskwaki Tribe facilitates their program in order to eliminate diabetes as a health concern through prevention and control of complications. The program has a team mentality, as community, education and clinical services are all involved as well as community organizations and members.[39]

There are many facets of this diabetes program, which include the distribution of diabetes information. This is achieved through bi-weekly articles in the Meskwaki Times educating the population about diabetes prevention and happenings in the program and additional educational materials available about diabetes topics. Other educational is spread through nutrition and diabetes classes, such as the Diabetes Prevention Intensive Lifestyle Curriculum Classes, and events like health fairs and walks. Medical care is also available. This includes bi-weekly diabetes clinics, screenings for diabetes and related health concerns and basic supplied.[39]

HIV-AIDS Programs[edit]

This is the official seal of the National Native HIV/AIDS Awareness Day.

Multiple programs exist to address the HIV and AIDS concerns for Native Americans. Within the Indian Health Service, an HIV/AIDS Principal Consultant heads a vast HIV/AIDS Program. This program involves many different areas to address "treatment, prevention, policy, advocacy, monitoring, evaluation, and research."[40] They work through many social outputs to prevent the masses from the epidemic and enlist the help of many facilities to spread this message.[40]

The Indian Health Service also works with Minority AIDS Initiative to use funding to establish AIDS projects. Recently, this funding has been used to create testing, chronic care, and quality care initiatives as well as training and camps.[41] The Minority AIDS Initiative operates through the Ryan White HIV/AIDS Program, under the Public Health Service Act. This is in recognition of the disproportionate impact of HIV/AIDS on racial and ethnic minorities.[42]

There has also been a National Native HIV/AIDS Awareness Day held on March 20 for American Indians, Alaska Natives, and Native Hawaiians, with 2009 marking its third year. This day is held to:

  1. encourage Native people to get educated and to learn more about HIV/AIDS and its impact in their community;
  2. work together to encourage testing options and HIV counseling in Native communities; and
  3. help decrease the stigma associated with HIV/AIDS.[43]

This day takes place across the United States with many groups working in coordination, such as the CDC and the National Native Capacity Building Assistance Network. By putting out press releases, displaying posters, and holding community events, these groups hope to raise awareness of the HIV/AIDS epidemic.[43]

Heart disease and stroke programs[edit]

The United States CDC contains a Division for Heart Disease and Stroke Prevention, and collects data and specifically releases information to form policy for Native Americans. They have identified many areas in which lifestyles of Native Americans need to be changed in order to greatly decrease the prevalence of heart disease and stroke.[34] One major concern to prevent is diabetes, which directly relates to the presence of heart disease. Many general health concerns also need to be addressed, according to the CDC's observations, including moderating alcohol use, eliminating tobacco use, maintaining health body weight, regularizing physical activity, diet, and nutrition, preventing and controlling high blood cholesterol, and preventing and controlling high blood pressure.[34]

The Indian Health Service works in collaboration with the University of Arizona College of Medicine to maintain the Native American Cardiology Program. This is a program that acknowledges the changes in lifestyle and economics in the recent past which have ultimately increased the prevalence of heart attacks, coronary disease, and cardiac deaths. The Native American Cardiology Program prides itself in its cultural understanding, which allows it to tailor health care for its patients.[44]

The Program has many bases but has placed an emphasis on providing care to remote, rural areas in order for more to be cared for. One of the more unique aspects of the Native American Cardiology Program is its telemedicine component. This branch also allows for health care to be made more accessible to Native Americans. This includes interpreting medical tests, offering specialist input and providing triage over the phone. The Native American Cardiology Program also has educational programs, such as lectures on cardiovascular disease and its impact, and outreach programs.[44]

See also[edit]

General:

References[edit]

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  2. ^ Francis, John M. (2005). Iberia and the Americas culture, politics, and history: A Multidisciplinary Encyclopedia. Santa Barbara, California: ABC-CLIO. 
  3. ^ Marshall, Joseph (2005). The Journey of Crazy Horse, A Lakota History. Penguin Books. 
  4. ^ a b c Waldman, Carl (2009). Atlas of the North American Indian. New York: Checkmark Books. p. 206. 
  5. ^ Marshall, Joseph (2005). The Journey of Crazy Horse, A Lakota History. Penguin Books. 
  6. ^ Cowley, Geoffrey (1991). The Great Disease Migration. NewsWeek. 
  7. ^ Robertson, R. G. (2001). Rotting Face Smallpox and the American Indian. New York: Caxton. 
  8. ^ Watts, Sheldon (1999). Epidemics and History: Disease, Power and Imperialism. Yale University Press. ISBN 978-0-300-08087-2. 
  9. ^ Lyon, William S. (1998). Encyclopedia of Native American Healing. W. W. Norton and Company. 
  10. ^ a b c d Ewald, Paul W. (2000). Plague Time: How Stealth Infections Cause Cancer, Heart Disease, and Other Deadly Ailments. New York: Free. 
  11. ^ Brown, Thomas Did the U.S. Army Distribute Smallpox Blankets to Indians? Fabrication and Falsification in Ward Churchill's Genocide Rhetoric. Ann Arbor, MI: MPublishing, University of Michigan Library 2006
  12. ^ Dowd, Gregory Evans (2004). War under Heaven: Pontiac, the Indian Nations, and the British Empire. New York: The Johns Hopkins University Press. 
  13. ^ a b "American Indian & Alaska Native (AI/AN) Populations". Office of Minority Health and Health Disparities, Centers for Disease Control and Prevention. November 30, 2010. Retrieved December 4, 2013. 
  14. ^ Barnes, P.M., P.F. Adams, and E. Powell-Griner. (2010). Health Characteristics of the American Indian or Alaska Native Adult Population: United States, 2004-2008. Hyattsville, MD: U.S. Dept. of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics.
  15. ^ a b c d "American Indian/Alaska Native Profile – The Office of Minority Health." Home Page – The Office of Minority Health. 31 July 2009. Web. 01 Oct. 2009. <http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=52>
  16. ^ Young, T. Kue (1997). "Recent Health Trends in the Native Americans' Population". Population Research and Policy Review 16: 147–67. 
  17. ^ Young, T. Kue (1997). "Recent Health Trends in the Native Americans' Population". Population Research and Policy Review 16: 147–67. 
  18. ^ Barnes, Patricia M. (2005). Vital and Health Statistics: Health Characteristics of the American Indian and Alaska Native Adult Population (356th ed. ed.). Centers for Disease Control and Prevention. 
  19. ^ "Division for Heart Disease and Stroke Prevention – AIAN Fact Sheet". Centers for Disease Control and Prevention. October 9, 2009. 
  20. ^ Duyff, Roberta Larson (2006). American Dietetic Association Complete Food and Nutrition Guide. New York: Wiley. 
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  22. ^ "Cancer and American Indians/Alaska Natives". United States Department of Health and Human Services: Office of Minority Health. June 13, 2012. Retrieved September 7, 2012. 
  23. ^ "Cancer and American Indians/Alaska Natives". United States Department of Health and Human Services: Office of Minority Health. June 13, 2012. Retrieved September 7, 2012. 
  24. ^ a b "Division of Diabetes Treatment and Prevention". Indian Health Service. Retrieved October 8, 2009. 
  25. ^ a b c Joslin, Elliott P. (2005). Joslin's diabetes mellitus. Philadelphia: Lippincott Williams & Willkins. 
  26. ^ Mogensen, Carl Erik (2000). The Kidney and Hypertension in Diabetes Mellitus. New York: Springer. 
  27. ^ a b c d Ekoé, Jean-Marie; Zimmet, Paul; Williams, Rhys, eds. (2001). The Epidemiology of Diabetes Mellitus: An International Perspective. New York: Wiley. 
  28. ^ Sandefur, Gary D (1996). Changing numbers, Changing needs: American Indian demography and public health. National Academy Press. ISBN 978-0-309-17529-6. 
  29. ^ Crawford, Michael H. (2001). The Origins of Native Americans Evidence from Anthropological Genetics. New York: Cambridge University Press. 
  30. ^ Fan, Hung (2004). AIDS Science and Society, Fourth Edition. Jones and Bartlett Series in Biology. New York: Jones and Bartlett. 
  31. ^ a b "The Indian Health Service Fact Sheets". Retrieved October 11, 2009. 
  32. ^ a b "HIV/AIDS among American Indians and Alaska Natives — Factsheets". Centers for Disease Control and Prevention. Retrieved October 6, 2009. 
  33. ^ "Stroke and American Indians/Alaska Natives". Office of Minority Health. Retrieved October 11, 2009. 
  34. ^ a b c "Division for Heart Disease and Stroke Prevention – AIAN Fact Sheet". Centers for Disease Control and Prevention. Retrieved October 11, 2009. 
  35. ^ "Introduction to IHS by Dr Yvette Roubideaux". Indian Health Service. Retrieved October 9, 2009. 
  36. ^ a b c "National Diabetes Wellness Program". Centers for Disease Control and Prevention. Retrieved October 9, 2009. 
  37. ^ a b c d e f g "Division of Diabetes Treatment and Prevention". Indian Health Service. Retrieved October 9, 2009. 
  38. ^ a b "Special Diabetes Program". Te-Moak Tribe of Western Shoshone. Retrieved October 13, 2009. 
  39. ^ a b "Sac & Fox Tribe – Diabetes & Wellness Program". Official Site of the Meskwaki Nation. Retrieved October 13, 2009. 
  40. ^ a b "IHS HIV/AIDS Program". Indian Health Service. Retrieved October 11, 2009. 
  41. ^ "IHS HIV/AIDS Program Minority AIDS Initiative". Indian Health Service. Retrieved October 11, 2009. 
  42. ^ "HRSA – Part F Minority AIDS Initiative". Health Resources and Services Administration. Retrieved October 11, 2009. 
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  44. ^ a b "Native American Cardiology Program at UMC". University Medical Center Tucson, Arizona. Retrieved October 14, 2009. 

External links[edit]