In 1990, 66 percent of American Indians and Alaska Natives 25 years old and over had graduated from high school or achieved a higher level of education; in contrast, only 56 percent had done so in 1980. Despite this advance, the figure was still below that for the U.S. population in general (75%). American Indians and Alaska Natives were not as likely as others in the United States to have completed a bachelor’s degree or higher (U.S. Census Bureau, 1993). Data suggest that Indian students achieve on a par with or beyond the performance of non-Indian students in elementary school and show a crossover or decline in performance between fourth and seventh grades (Barlow & Walkup, 1998). Explanations for this crossover vary. Indian children may have a culturally rooted way of learning at odds with teaching methods currently used in public education. Several researchers cite differences between Indian cognitive styles and Western teaching styles. For example, Indian children are primarily visual learners, rather than auditory or verbal learners. Indian youngsters tend to excel at nonverbal performance scales of development and fall below national averages on verbal scales (Yates, 1987). Verbal learners are favored by modes of mainstream public education and testing (Yates, 1987). Linguistic experts have observed that Native languages stress keen descriptive observation and form rather than the verbal or conceptual abstractions that are common in English, which may make learning in English-language schools difficult (Basso, 1996).

Regardless of the reasons for lower academic achievement, negative consequences often ensue. The academic crossover is paralleled by a similar trend in mental health status, as extrapolated from rates of child and adolescent outpatient treatment. Specifically, one study noted that Indian youth enter mental health treatment at a sharply increased rate during the same period, fourth to seventh grades, and that the rate dramatically exceeds their non-Indian counterparts, with a continuously widening gap into late adolescence (Beiser & Attneave, 1982). Subsequent work by Beiser and colleagues clearly underscores the contribution of cultural dynamics in the classroom to these outcomes (Beiser et al., 1998).

Income

Following the devastation of these once-thriving Indian nations, the social environments of Native people have remained plagued by economic disadvantage. Many American Indians and Alaska Natives are unemployed or hold low-paying jobs. Both men and women in this population were roughly twice as likely as whites to be unemployed in 1998 (Population Reference Bureau, 2000). From 1997 to 1999, about 26 percent of American Indians and Alaska Natives lived in poverty; this percentage compares with 13 percent for the United States as a whole and 8 percent for white Americans (U.S. Census Bureau, 1999b).

Physical Health Status

With some exceptions, the health of this ethnic minority group has begun to improve, and the gap in life expectancy rates between Native Americans and others has begun to close. For instance, the infant mortality rate of American Indians decreased from 22 per 1,000 live births in 1972–1974 to 13 in 1990 and 9 in 1997 (Indian Health Service, 1997). Still, American Indians and Alaska Natives have the second highest infant mortality rate in the Nation (National Center for Health Statistics, 1999) and the highest rate of sudden infant death syndrome (DHHS, 1998). The death rates among American Indians ages 15 to 24 are also higher than those for white persons in the same age group (Grant Makers in Health, 1998). American Indians and Alaska Natives are five times more likely to die of alcohol-related causes than are whites, but they are less likely to die from cancer and heart disease (Indian Health Service, 1997). The rate of diabetes for this population group is more than twice that for whites. In particular, the Pima tribe of Arizona has one of the highest rates of diabetes in the world. The incidence of end-stage renal disease, a known complication of diabetes, is higher among American Indians and Alaska Natives than for both whites and African Americans.

Nationally, one-third of American Indians and Alaska Natives do not have a usual source of health care, that is, a doctor or clinic that can provide regular preventive and medical care (Brown et al., 2000). In 1955, the U.S. Government established the Indian Health Service (IHS) within the Department of Health and Human Services (DHHS). The IHS mission is to provide a comprehensive health service delivery system for American Indians and Alaska Natives “… with opportunity for maximum Tribal involvement in developing and managing programs to meet their health needs” (IHS, 1996). The IHS is responsible for working to provide health delivery programs run by people who are cognizant of entitlements of Native people to all Federal, State, and local health programs, in addition to IHS and tribal services. The IHS also acts “as the principal Federal health advocate for the American Indian and Alaska Native people in the building of health coalitions, networks, and partnerships with Tribal nations and other government agencies as well as with non-Federal organizations [such as] academic medical centers and private foundations” (IHS, 1996).

Although the goal of the IHS is to provide health care for Native Americans, IHS clinics and hospitals are located mainly on reservations, giving only 20 percent of American Indians access to this care (Brown et al., 2000). Furthermore, IHS-eligible American Indians are less likely than others with private health insurance coverage to have obtained the minimum number of physician visits³ for their age and health status.

More than half of American Indians and Alaska Natives live in urban areas (U.S. Census Bureau, 1990). Title V of Public Law 94–437 of the Indian Health Care Improvement Act authorizes the appropriation of funds for urban Indian health programs. Presently, there are 34 such programs across 41 sites, independently operated through grants and contracts offered by the IHS. Though there is little data available regarding the health needs and access to care among urban Native Americans, the constellation of problems is similar to that of rural communities and includes serious mental illness, alcohol and substance abuse, alcohol and substance dependence, and suicidal ideation (Novins, 1999). An Urban Indian Epidemiology Center was recently funded by the IHS to address this important knowledge gap (Indian Health Service, 2001).

Even where the IHS is active, health service systems in general fail to meet the wide-ranging needs of indigenous populations, especially in remote and isolated regions of the United States. This includes rural, “bush” Alaska, which is divided into 12 Native regions that encompass several villages whose languages, dialects, and cultural connections are only somewhat similar (Reimer, 1999). For example, ethnographic studies in two Pacific Northwest Indian tribal communities document the lack of trust between American Indians and the IHS. Many community members felt they were not receiving appropriate care. Furthermore, holistic education programs to address health needs across the lifespan were considered lacking. Overall, many community members reported that they felt unheard and trapped in a system of care over which they have no control (Strickland, 1999).

Today, the IHS remains the primary entity responsible for the mental health care of American Indians and Alaska Natives. Until 1965, the delivery of mental health services was sporadic. That year, the first Office of Mental Health was opened on the Navajo Reservation. It remained severely understaffed and underfunded until its dissolution in 1977. Legislation to authorize comprehensive mental health services for tribes has been enacted and amended several times, but Congress consistently failed to appropriate funds for such initiatives (Nelson & Manson, 2000). Financial inadequacies have resulted in four IHS service areas without child or adolescent mental health professionals. Fragmented Federal, State, tribal, private foundation, and national nonprofit attempts to meet such obvious needs have led to isolation, difficult work conditions, cultural differences, and high turnover rates that dilute efforts to provide mental health services (Barlow & Walkup 1998; Novins, Fleming, et al., 2000).

³ Minimum number of visits set by the Kaiser Commission are at least one physician visit in the past year for children ages 0-5 and in the past two years for children ages 6-17 (as recommended by the American Academy of Pediatrics in Pediatrics, 96, 712), and in the past year for adults in fair or poor health and in the past two years for adults in good or excellent health (Kaiser Commission on Medicaid and the Uninsured, 2000).