The Persistence of American Indian Health Disparities · Indians continue to experience some of the worst health con-ditions in the United States. | David S. Jones, MD, PhD Disparities

PUBLIC HEALTH THEN AND NOW

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policy. European and Americanobservers have offered a diverserange of causes to explain Indiansusceptibility, from the providen-tial theories of Puritan coloniststo emphasis on environment, behavior, genetics, or socioeco-nomic status. How did AmericanIndians and their observers eval-uate these long lists of potentialcauses and determine whichwere most important or meaning-ful? Observers have offered asimilarly diverse range of re-sponses, from attempts that re-lieved disparities through healthcare to efforts that ignored oreven exacerbated them. How didpolitical and economic interestsshape their choices?

The history also raises ques-tions about the actual causes ofthe disparities. Health disparitieshave persisted, even as the un-derlying disease environment haschanged. Do American Indianshave intrinsic susceptibilities to

THE INDIAN HEALTH SERVICE(IHS) faced a daunting challengewhen it was established in 1955.Indian populations living in ruralpoverty suffered terribly fromdisease. Tuberculosis continuedto thrive, and infant mortalityreached 4 times the national average. During the past 50years, the IHS has improvedhealth conditions dramatically,but disparities persist—AmericanIndians continue to experiencesome of the worst health con-ditions in the United States.

| David S. Jones, MD, PhD

Disparities in health status between American Indians and other groups in the United States have persisted throughout the 500 yearssince Europeans arrived in the Americas. Colonists, traders, missionaries, soldiers, physicians, and government officials have strug-gled to explain these disparities, invoking a wide range of possible causes. American Indians joined these debates, often suggest-ing different explanations. Europeans and Americans also struggled to respond to the disparities, sometimes working to relievethem, sometimes taking advantage of the ill health of American Indians.

Economic and political interests have always affected both explanations of health disparities and responses to them, influencingwhich explanations were emphasized and which interventions were pursued. Tensions also appear in ongoing debates about the con-tributions of genetic and socioeconomic forces to the pervasive health disparities. Understanding how these economic and politicalforces have operated historically can explain both the persistence of the health disparities and the controversies that surround them.(Am J Public Health. 2006;96:2122–2134. doi:10.2105/AJPH.2004.054262)

Although this persistence is strik-ing, it is even more striking thatthe disparities have existed notfor 50 years but for 500 years.From the earliest years of colo-nization, American Indians havesuffered more severely whetherthe prevailing diseases weresmallpox, tuberculosis, alco-holism, or other chronic afflic-tions of modern society.

The history of these disparitiesprovides perspective on manyvexing problems of contempo-rary American Indian health

Health Disparities

The Persistence of

American Indian

A House-call on the NavajoReservation. As part of its effort toimprove health services forAmerican Indians in the 1950s,the Public Health Service fundeda series of innovative health careprojects. In one project, based atMany Farms, Arizona, physicians,nurses, anthropologists, and Navajohealth workers attempted to bringmodern medicine into Navajo homesand lives. Source. New York WeillCornell Medical Center Archives,Photograph Collection, NavajoProject, #2310.


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every disease for which dispari-ties have existed? Or does thehistory of disparity after disparitysuggest that social and economicconditions have played a morepowerful role in generating Indian vulnerability to disease?Understanding the histories ofhealth disparities may explainthe complex reactions they pro-voke and why efforts with thebest intentions have fallen short.

ENCOUNTERS AND EPIDEMICS

American Indians struggledwith ill health even before Euro-peans arrived. Although pre-Columbian populations werespared the ravages of smallpox,measles, influenza, and manyother infections, they did not in-habit a disease-free paradise.Careful analyses of skeletal re-mains have revealed many dis-eases, including tuberculosis andpneumonia.1 Whereas some pop-ulations, such as those of coastalGeorgia or Brazil, enjoyed excel-lent health, many American In-dian groups stretched their envi-ronments past the limits ofsustainability. From the aridsouthwest to the crowded urbancenters of Mexico and Peru, mal-nutrition, disease, and violencekept life expectancies below 25years of age. Health disparitiesalso existed within populations,such as the complex stratified so-cieties of Mesoamerica and theAndes.2 Moreover, paleoanthro-pologists have documented wide-spread evidence of worseningmalnutrition and disease duringthe years before Europeans ar-rived. Baseline ill health madeAmerican Indians vulnerable toEuropean diseases.3

Colonization made mattersworse. Mortality increased soonafter the arrival of Christopher

Columbus, and it quickly reachedcatastrophic proportions. Esti-mates of pre-contact Americanpopulations vary between 8 and112 million (2 to 12 million forNorth America), and estimates oftotal mortality range from 7 to100 million.4 Whatever the exactnumbers, the mortality was un-precedented and overwhelming.Hispaniola, the first region sub-jected to Spanish conquest, fore-told the fate of other areas: theArawak population decreasedfrom as many as 400000 in1496 to 125 in 1570.5 Everynew encounter brought new epi-demics. Smallpox, measles, in-fluenza, and malaria (and possiblyhepatitis, plague, chickenpox, anddiphtheria) spread into Mexicoand Peru during the 16th century,

New France and New Englandduring the 17th century, andthroughout North America andthe Pacific islands during the 18thand 19th centuries. Populationsoften decreased by more than90% during the first century aftercontact. As recently as the 1940sand 1960s, new highways andnew missionaries broughtpathogens to previously isolatedtribes in Alaska and Amazonia.6

News of the devastationreached Europe rapidly. In 1516,Peter Martyr condemned Spanishbrutality but acknowledged thatmany Indians died from “neweand straunge diseases.” The com-bined impact of abuse and dis-ease was horrifying: “They wereonce rekened to bee abovetwelve hundreth thousandeheades: But what they are nowe,I abhorre to rehearse.”7 The

English first encountered suchmortality during their early ef-forts to colonize North Carolinaand Maine. In 1585, ThomasHariot witnessed epidemicsamong the Roanok: wherever theEnglish visited, “the peoplebegan to die very fast.”8 In 1616,Richard Vines wintered with thePemaquid in Maine. The localtribes “were sore afflicted withthe Plague, for that the Countrywas in a manner left void of in-habitants.”9 Although its diagno-sis remains unclear (smallpox?chicken pox? hepatitis?), the epi-demic decimated the coast fromMaine to Cape Cod and allowedcolonists to move into aban-doned Indian villages.10 Anotherepidemic, likely smallpox, struckin 1633.11 Wherever the English

went, they saw evidence of mor-tality. According to William Brad-ford, the victims “not being ableto bury one another, their skullsand bones were found in manyplaces lying still above theground where their houses anddwellings had been, a very sadspectacle to behold.” Bradford es-timated overall mortality at95%.12 Others guessed it waseven higher.13

The mortality was not com-pletely one-sided. Half of the Ply-mouth colonists died during thefirst winter.14 Of 6000 colonistssent to Jamestown between 1607and 1624, only 1200 remainedin 1625.15 Despite their own mor-tality, explorers and colonists mar-veled at disparities in disease sus-ceptibility. When they remainedhealthy while the Roanok suc-cumbed, the English wondered

”“Understanding the histories of health disparities may explain the complex reactions they provoke and why efforts

with the best intentions have fallen short.


whether they should credit theodd epidemic to a recent comet,an eclipse, or a “speciall woorkeof God for our sakes.”16 AlthoughVines and his crew shared wintercabins with the dying Pemaquid,“(blessed be GOD for it) not oneof them ever felt their heads toake.”17 When English colonistsnursed American Indians suffer-ing from smallpox in Connecticutin 1633, “by the marvelous good-ness and providence of God, notone of the English was so muchas sick.”18 By the late 17th cen-tury, it was clear that Indian andEuropean populations had fol-lowed different trajectories. Whilethe English thrived, northeasternIndians declined, victims of dis-ease, displacement, and warfare.19

As a New York missionary de-scribed in 1705, “the English hereare a very thriving growing peo-ple, and ye Indians quite other-wise, they wast away & havedone ever since our first arrivalamong them (as they themselvessay) like Snow agt. ye Sun.”20

COLONIAL PRECEDENTS

The mortality amazed Euro-pean colonists. Their responsesillustrate many themes that oc-curred repeatedly as Europeans,and then Americans, witnessedthe ongoing health problemsamong American Indians. As al-ready seen, providential explana-tions came quickly to Puritanminds. John Winthrop, for exam-ple, wrote that “Gods hand hathso pursued them, as for 300miles space, the greatest parte ofthem are swept awaye by thesmall poxe.”21 But providence co-existed with many natural expla-nations. Although disparities inhealth status eventually con-tributed to the formation of mod-ern ideas of racial difference, thecolonists did not initially see anyintrinsic differences between En-glish and Indian bodies.22 PhilipVincent, a leader of the Englishforces during the Pequot War,concluded that “we had the samematter, the same mold. Only art

and grace have given us thatperfection which yet they want,but may perhaps be as capablethereof as we.”23 Believing thatEnglish and Indian bodies sharedthe same vulnerabilities, colonistsoften explained Indian epidemicsin the same ways that they ex-plained their own diseases. Theenvironment could support bothhealth and disease, with coldwinters causing aches and con-gestions and hot summers bring-ing fevers and fluxes. Starvationthreatened both groups. Newfoods were just as dangerous.William Wood observed thatwhen the Massachusett changed“their bare Indian commons forthe plenty of England’s fullerdiet, it is so contrary to theirstomachs that death or a desper-ate sickness immediately accrues,which makes so few of them de-sirous to see England.”24

During these initial years ofencounter between colonists andAmerican Indians, providentialand natural explanations ap-peared side by side. Early mod-ern writers experienced a worldin which all events had naturaland spiritual causes simultane-ously. This synergy of meaningand mechanism provided solacein a bewildering world, reassur-ing colonists that everything hap-pened according to God’s will.However, the different explana-tions often existed in tension.When fleeing Massachusett con-spirators died in 1623, theirleader, Ianough, feared that “theGod of the English was offendedwith them, and would destroythem in his anger.” EdwardWinslow had a more practical ex-planation: “Through fear they setlittle or no corn, which is the staffof life, and without which theycannot long preserve health andstrength.”25 Daniel Gookin de-scribed similar debates about

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Accomack [Plymouth Harbor] before the Plague. When Samuel deChamplain explored the coast ofMassachusetts in 1613, he foundthriving Indian communities, suchas Accomack, with its wigwamsand fields of corn. Three yearslater an epidemic devastated theMassachusett and Wampanogtribes. When English colonistsarrived in 1620, they foundAccomack abandoned. They builttheir first settlement, Plymouth, onits ruins. Source. Sameul deChamplain, Les Voyages du Sieurde Champlain Xaintongeois(Paris: 1613). By permission of theHoughton Library, HarvardUniversity.


the deaths of Indian students atHarvard College. Some “attrib-uted it unto the great changeupon their bodies, in respect oftheir diet, lodging, apparel, stud-ies; so much different from whatthey were inured to among theirown countrymen.” Others sawthe deaths as “severe dispensa-tions of God,” either because“God was not pleased yet tomake use of any of the Indians topreach the gospel” or becauseSatan “did use all his strategemsand endeavors to impede thespreading of the christian faith.”26

In these cases, the colonists didnot find integrated synergy ofprovidence and natural mecha-nism. Instead, they struggled tochoose between them.

These debates make a crucialpoint: providential explanationwas not simply the reflexive re-sponse of God-fearing colonists.Rather, colonial writers consid-ered many different explanations:providence, environment, nutri-tion, behavior, and physical differ-ences. Thus, they could empha-size the most meaningful or usefulexplanations. Their choices re-flected local economic and politi-cal pressures. English leaders, forinstance, had to justify their rightto settle lands already inhabitedby American Indians. King JamesI cited the epidemic-induced de-population: “Those large andgoodly Territoryes, deserted as itwere by their naturall Inhabitants,should be possessed and enjoyedby such of our Subjects and Peo-ple.”27 Many of Winthrop’s mostforceful statements of providentialinterpretation occurred when heargued in favor of English colo-nization. He believed smallpox“cleered our title to this place.”28

After all, “if God were not pleasedwith our inheriting these parts,why did he drive out the nativesbefore us? And why dothe he still

make roome for us, by demi-nishinge them as we increace?”29

The English used disparities inhealth status to convince them-selves that their mission in Amer-ica was righteous.

The English were not alone intrying to turn the epidemic dis-parities to political advantage.Many Indian groups, at least ac-cording to their English chroni-clers, were quick to see potentialbenefits. When the English didnot succumb to epidemics thatdevastated the Roanok, Ensenoreand other local elders concludedthat the English controlled dis-ease. Hoping to exploit thispower, they asked the English tounleash the disease against theirtribal enemies.30 Hobbamock, acounselor to Wampanoag ChiefMassasoit, made a similar requestof the Plymouth colonists: “Beingat varience with another Sachemborderinge upon his Territories,he came in solemne mannerand intreated the Governour,that he would let out the plagueto destroy the Sachem, and hismen who were his enemies.”31

Hobbamock and Ensenore hopedthat English control over diseasewould make them powerful allies.

Some Indians also used thedisparities in intratribal politics.Squanto, who learned to speakEnglish when he was kidnappedby English explorers in 1614, re-alized that he could become aninfluential translator and media-tor when the Plymouth colonistsarrived in 1620. Believing thathis position would be stronger ifthe Wampanoag feared the En-glish, he manipulated the tribe’sfear of disease. He told Hob-bamock that the English storedplague in barrels, which they“could send forth to what placeor people we would, and destroythem therewith, though westirred not from home.” When

Hobbamock confronted the En-glish about this, Squanto’s rusewas exposed. Massasoit nearlyhad him executed.32

In some cases, American Indi-ans engaged Europeans in de-bates about the etiologies of epi-demics. The Jesuits, for instance,introduced smallpox and other ill-defined fevers when they arrivedin Quebec in 1625. By 1637,50% of the Huron had died. TheHuron asked the Jesuits “why somany of them died, saying thatsince the coming of the Frenchtheir nation was going to destruc-tion.”33 The Jesuits, like the En-glish, attributed the epidemics toa range of factors, including thehardship of Huron lives, Huronreligious practices, and contagion.

The Huron, who were suspiciousof French intent, feared that theFrench “had a secret understand-ing with the disease” and couldspread disease by a “craftydemon” concealed in a musket,“bewitched” cloaks, or poisonedwater.34 Although the French de-nied Huron allegations of deliber-ate infection, they did admit theirculpability for the epidemics. AsHierosme Lalemant wrote,“Where we were most welcome,where we baptized most people,there it was in fact where theydied the most.”35 Within this firstgeneration of colonization inNorth America, both Indians andEuropeans struggled to under-stand the devastation. Theirresponses echoed their own per-spectives and interests.


”“The English were not alone in trying to

turn the epidemic disparities to political advantage. Many Indian groups, at least according to their English chroniclers,were quick to see potential benefits.



SMALLPOX AND THEMORAL LIFE

As European settlers movedinto the North American inte-rior, each new encounter trig-gered a new wave of epidemicdecimation. Smallpox struckagain and again throughout the17th and 18th centuries. Itreached the northwestern plainsby the 1780s and the PacificNorthwest by 1802.36 A particu-larly virulent outbreak struckthe upper Missouri valley in1837. It afflicted the tribes “withterror never before known, andhas converted the extensivehunting grounds, as well asthe peaceful settlements ofthose tribes, into desolate andboundless cemeteries.” Between10000 and 150000 Sioux,Mandan, Blackfeet, Arikara, andAssiniboine died. Abandonedvillages covered the plains: “Nosounds but the croaking of theraven and the howling of thewolf interrupt the fearful si-lence.”37 Although smallpoxdominates the accounts of In-dian mortality, observers alsodescribed alcoholism, syphilis,and many other fevers andfluxes.

Fur traders, soldiers, mission-aries, and settlers followed theirancestors’ lead and offered arange of explanations for theAmerican Indians’ susceptibilityto smallpox. Although lessprevalent, providence persisted.In 1764, Thomas Hutchinsonabandoned his usual skepticismof Puritan mythology: “Our an-cestors supposed an immediateinterposition of providence inthe great mortality among theIndians to make room for thesettlement of the English. I amnot inclined to credulity, butshould not we go into the con-trary extreme if we were to take

no notice of the extinction ofthis people in all parts of thecontinent.”38 Most observers,however, emphasized destruc-tive Indian behaviors: indiffer-ence to cleanliness, foreign diets,reckless use of sweat baths, andthe “vicious and dissolute life”caused by alcohol.39 Accordingto George Catlin, these factors,and not “some extraordinaryconstitutional susceptibility,” ex-plained the smallpox mortality.40

Amid the diversity of poten-tial explanations, the emphasison behavior played a usefulrole. Although less overtly theo-logical than providential expla-nations, behavioral theories hadclear moral utility: disease be-came a tool of moral exhorta-tion. According to missionaries,if vice brought disease to Amer-ican Indians, then acceptance ofChristian morality and lifestyleswould bring them health. Thesearguments targeted White audi-ences as well. It was, after all,Whites who had introducedAmerican Indians to alcoholand other sinful behaviors.Catlin warned his readers thatthe legacy of White influenceon Indian populations, “an un-requited account of sin andinjustice,” would haunt allAmericans on judgment day.41

American Indians shared thisanger. When an Ioway delega-tion visited London during the1840s, an English minister de-manded that the Ioway ac-knowledge smallpox as divinepunishment. Their war chiefhad a quick reply: “If the GreatSpirit sent the small pox intoour country to destroy us, webelieve it was to punish us forlistening to the false promises ofwhite men. It is a white man’sdisease, and no doubt it wassent among White people topunish them for their sins.”42

TUBERCULOSIS,EXTINCTION, AND THECIVILIZING PROCESS

Into the early 19th century,many European and Americanobservers dismissed Catlin’s con-cerns and argued that AmericanIndians had brought mortality onthemselves. This position becameincreasingly untenable during the19th century. As contact betweenWhite and American Indian soci-eties increased, it became obvi-ous that federal policies ad-versely affected Indian health.The reservation system, whichwas imposed between the 1830sand the 1870s, transformed pat-terns of morbidity and mortality.Smallpox, measles, cholera,malaria, venereal diseases, andalcoholism remained commonbut were reportedly mitigatedby government physicians withvaccination, fumigation, andquarantine.43

These problems, however,were dwarfed by tuberculosis.Consumption and scrofula hadbeen present but rare amongAmerican Indians for cen-turies.44 They quickly becamethe leading cause of death, espe-cially on the Dakota reserva-tions, where they dominated an-nual mortality reports, oftencausing half of all deaths.45

Physician Z. T. Daniel believedthat “it is practically the only dis-ease that causes their largedeath rate.”46 Although the bur-den of disease had shifted fromacute to chronic infections, thedisparities persisted. The sur-geon general reported that theconsumption hospitalization ratefor Indian soldiers in 1892 wasmore than 10 times the rate forWhite soldiers.47 Sioux mortalityfrom tuberculosis alone ex-ceeded the mortality rates fromall causes in most major cities.48

Observers had little difficultyexplaining the prevalence of tu-berculosis among the Sioux.Many blamed the reservationsystem and the terrible livingconditions imposed on the con-fined tribes. Damp, poorly venti-lated log cabins and inadequategovernment rations set the tribesup for disaster. However, as hadhappened before, they also werequick to blame the Sioux for

specific behaviors, from unhy-gienic cooking to religiousdances, pipe smoking, and ciga-rettes that made bad conditionsworse.49 O. M. Chapman statedthese punitive sentiments mostclearly: “The excessive mortalityis but the sum total of all theseinfluences combined—is the mea-sure of their transgressions.”50

A broad consensus acceptedthese problems as the proximatecauses of Sioux tuberculosis. Thecrucial debates of the late 19thcentury instead confronted the ul-timate causes of the disparities inhealth status, specifically the rolesof racial differences and socio-economic conditions. Ideas of

racial hierarchy were firmly en-trenched in the national con-sciousness. Influential works, suchas Josiah Nott and George Glid-don’s Types of Mankind, arguedthat although American Indianshad once thrived in America, theycould neither compete nor coexistwith “Caucasians”: “It is as clearas the sun at noon-day, that in afew generations more the last ofthese Red men will be numbered

with the dead.”51 Some doctorssaw these theories as compellingexplanations for the disparities inmortality. Daniel believed that In-dians could only be saved by mix-ing with other groups: they will“die everywhere they go, of tuber-culosis, until the race is so thor-oughly crossed by ‘foreign blood’that it will stamp out the tuberclebacillus, and when that is donethe Indian race in its original pu-rity will be no more.”52 For thosewho believed that extinction wasinevitable, the reservation systembecame little more than palliativecare for a dying race.53

Other observers rejected thesepessimistic visions and argued

that the outbreak of tuberculosiswas not the inevitable result ofhereditary inferiority. Rather, itwas the contingent product ofthe difficult transition from prim-itive life to civilization. Physi-cians who observed the Siouxbefore and after their confine-ment saw how quickly the nativehealth of the Sioux deteriorated.George Bushnell, for example,observed Sioux prisoners who

were brought to live amongSioux already settled on a reser-vation in 1881. He described“scrofulous youths from theAgency, their fleshless limbsfully clad, looking on wistfully atthe dances of the warriors in thesummer twilight … revealing inmany instances a magnificentphysique and a boundless vital-ity, which contrasted cruellywith the listless aspect of someof their spectators.”54

Although they knew thatreservations had fueled tubercu-losis, many physicians and offi-cials maintained their faith in thefundamental value of civilization.Tuberculosis existed not because



Ration Day on a Sioux Reservation.Between the 1830s and the 1870s,the federal government confinedmost American Indian groups ontoreservations. The Sioux encounteredterrible conditions as the govern-ment tried to transform them fromnomadic hunters to settled agricul-turalists. Many depended completelyon government rations for subsis-tence. These reservations providedideal conditions for tuberculosis.Source. By permission of theNational Anthropological Archives,Smithsonian Institution, 56 630.


the civilizing process was wrongbut because it had been imple-mented badly. Indians were “re-duced to the condition of pau-pers, without food, shelter,clothing, or any of those neces-saries of life which came fromthe buffalo; and without friends,except the harpies, who, underthe guise of friendship, feedupon them.”55 The governmenthad to intervene: “We have noright to assume that they are arace given over to God to de-struction, and we have less rightto doom them ourselves.”56

Health would be restored whenthe government enabled the In-dians to enjoy the full benefits ofWhite civilization.

PERSISTENT DISPARITIES

Faith that civilization wouldeventually bring health to theAmerican Indians prevailed inthe debate about the ultimatecauses of tuberculosis. Somegovernment officials committedthemselves to improving reser-vations through education, eco-nomic reform, and health care.However, their paternalisticpolicies, which were based onthe assumed superiority ofWhite culture and religion,rarely led to improvement andoften made matters worse. Med-ical campaigns, for example, suf-fered from inadequate funding.Commissioner of Indian Affairs

T. J. Morgan compared thesalaries paid to governmentphysicians in the Army, Navy,and IHS and divided thesesums by the populations served.He then calculated a crude esti-mate of how the governmentvalued people: $21.91 per sol-dier, $48.10 per sailor, and$1.25 per Indian.57

The enthusiasm of the Pro-gressive era brought new interestand new funding to the problemof Indian tuberculosis. Duringthe International Congress on Tu-berculosis in 1908, Commis-sioner of Indian Affairs FrancisE. Leupp identified tuberculosisas “the greatest single menace tothe Indian race.”58 PresidentWilliam Taft committed the gov-ernment to new action. Congressresponded in 1912 with an emer-gency appropriation of $12000.The Bureau of Indian Affairs(BIA) organized campaignsagainst tuberculosis, trachoma,infant mortality, house flies, alco-holism, and tooth decay.59 An-nual appropriations grew steadilyand reached $350000 by 1917.That year, for the first time inmore than 50 years, more Indi-ans were born than died. Physi-cian George Kober celebratedthe progress: “Thanks to theprogress of medical science andthe splendid humanitarian effortsof our Government, a noble raceof people has been snatchedfrom the very jaws of death.”60

The 1921 Snyder Act strength-ened the mandate for govern-ment action, and congressionalappropriations continued to grow:$596000 in 1925, $2980000in 1935, $5730000 in 1945,and $17800000 in 1955.61

Disparities, however, persisted.Tuberculosis mortality in 1925was 87/100000 among the gen-eral population, 603/100000among Indians overall, and1510/100000 among ArizonaIndians.62 During World War II,between 10% and 25% of Navajosoldiers and workers had to be re-turned to the reservation becauseof active tuberculosis.63 Postwarsurveys confirmed the problem:in 1947, tuberculosis mortalityamong Arizona Indians (302.4/100000) dwarfed both the rateamong Indians in general (200/100000) and the national popu-lation (30/100000).64 The prob-lem was not confined to tubercu-losis. Incidence among the Navajoexceeded that of the general pop-ulation by a factor of 15.8 for tu-berculosis, 101.6 for pneumonia,and 1163 for trachoma.65 TheNavajo also had the country’shighest infant mortality rate.66

Explanations for the persistenttuberculosis disparities followedthe framework of the late 19thcentury. Environmental theorieswere common; the new chal-lenge was to explain how tuber-culosis could thrive in the aridsouthwest, where the climate wasrecommended for many conva-lescing White patients. Physicianswho were still critical of Ameri-can Indian cultures found muchto blame in Navajo living condi-tions: “Benefits to health from anoutdoor life are over-balanced bythe ill effects of overcrowding,lack of sanitary provisions, andthe poverty which leads to apoor, inadequate supply offood.”67 They moved easily from


”“The problem was not confined to tuberculosis. Incidence among

the Navajo exceeded that of the general population by a factor of 15.8 for tuberculosis, 101.6 for pneumonia,

and 1163 for trachoma. The Navajo also had the country’s highest infant mortality rate.

blaming the conditions of pov-erty to emphasizing behaviorsthat the Navajo adopted whileliving in those conditions. Boththe healthy and the sick expecto-rated freely without disinfectingtheir sputum. The Navajo atemeals irregularly and preparedfood poorly. Intemperance, apa-thy, indolence, and hopelessnessall weakened the people. No onesought proper medical attention.As physician Sydney Tillim com-plained, they lacked “intelligencein all things medical.”68

The Navajo expressed both in-terest and skepticism in these ex-planations. When ManuelitoBegay, a prominent medicineman and a member of theNavajo Tribal Council, saw a mi-croscope slide of the tuberclebacillus, he was impressed butnot convinced of its relevance:“They tell me that it is inflictedby a person coughing in yourface—that is the way you get tu-berculosis in your system. Rightaway I disagree with it. A personshould not be that weak to besusceptible to a man’s cough.”69

Other Navajo also scoffed atmedical explanations of tubercu-losis. One woman argued that ifinfected sputum sowed tubercu-losis within Navajo homes, thenchickens, which constantlypecked at the infected dirt floors,should have been devastated bythe disease.70

White doctors shared Begay’spuzzlement about the specificcauses of Navajo susceptibility. Ill-defined genetic explanations re-mained popular. In 1923, theNew Mexico State Department ofHealth went so far as to assert anongoing process of natural selec-tion: “Resistant race has not beenbred as yet. Now undergoingprocess of weeding out the non-resistant strains.”71 Genetic expla-nations were used just as easily to

explain the surprisingly low inci-dence of noninfectious diseasesamong the Navajo, including hy-pertension, cancer, heart disease,and baldness.72 Most doctors,however, rejected genetic deter-minism. The National Tuberculo-sis Association argued in 1923that “tuberculosis attacks withoutany racial preference.”73 Studiesfound that “the character of tu-berculous lesions, as determinedroentgenologically, is not signifi-cantly different from that ob-served among the white popula-tion.”74 Although the reservationsclearly suffered severely from tu-berculosis, “identical” epidemicsexisted among populations “livingunder like conditions among peo-ple of the White and Yellowraces.”75 These writers believedthat socioeconomic conditions,when severe enough, could de-stroy the health of any population.

FIGHTING POVERTY WITHMEDICAL TECHNOLOGY

The different explanationshad clear implications forAmerican Indian health policy.Whereas New Mexico officialsseemed content to allow naturalselection to solve the tuberculo-sis problem, most governmentofficials accepted the causal roleof economic nondevelopmentand believed that health couldonly come from improvementsin socioeconomic conditions.This became especially clearwhen a postwar economic reces-sion struck the Navajo and Hopireservations. Congressional in-vestigators were shocked bywhat they found: “So long as theNavajos remain on the barrenwasteland on which they live,without communities, roads,water, sanitation, or the oppor-tunity to earn a living wage,they must continue to live in

squalor and disease.”76 Con-gress responded in 1950 with a$90000000 program for thelong-range rehabilitation of theNavajo and Hopi.77 This inten-sive program for the Navajo andHopi reservations paralleledpostwar political interest in in-ternational economic develop-ment. In each case, policymak-ers believed that the disparitiesin health status between devel-oped and developing popula-tions arose from disparities insocioeconomic conditions. Im-proved health could be achievedmost fundamentally by eco-nomic development.

Although economic develop-ment remained the ultimate goal,health officials realized that itcould not be achieved easily orquickly enough. They wanted tofind ways to improve the healthof underdeveloped populationsliving in rural poverty. One clearproblem, which was highlightedin a 1950 American Medical As-sociation report, was the inade-quacy of existing health serviceson the reservations.78 AnnieWauneka, who led the healthcommittee of the Navajo TribalCouncil, agreed during her testi-mony to Congress: “We thinkthere is no real health program.If there is, we haven’t heardabout it or seen it. And our sickpeople are paying for it.”79 Em-boldened by postwar optimismand by faith in new technologies,such as penicillin, isoniazid, andDDT, health officials believedthat they would be able to im-prove health conditions, even inthe absence of economicchanges. Walsh McDermott’s“Health Care Experiment atMany Farms” put this question tothe test.80 After choosing a re-mote area of the Navajo Reserva-tion, McDermott’s team of doc-tors, anthropologists, and social



scientists worked closely withWauneka and other Navajo lead-ers to reduce morbidity and mor-tality in the absence of socioeco-nomic reforms. They found thattheir treatment programs con-trolled tuberculosis but had littleimpact on the other leadingcauses of morbidity and mortal-ity, especially childhood diarrheaand pneumonia. These failuressurprised the researchers:“When one considers our pre-experiment expectations, soundlygrounded in the conventionalwisdom, these results wereclearly disappointing.”81 En-trenched disparities in health sta-tus did not yield easily to med-ical technology.

McDermott’s work was part ofa broader effort to reform healthcare on the reservations. Frus-trated by the continuing failuresof the BIA to relieve health dis-parities, Congress moved themedical services from the BIA tothe Public Health Service, thuscreating the Indian Health Ser-vice in 1955.82 The IHS con-ducted an initial health surveyand found wide disparities in

health status and health servicesbetween Indians and the generalpopulation. Among American In-dians, total mortality was 20%higher, infant mortality was 3times higher, life expectancy was10 years lower, and infectiousdiseases and accidents weremore prevalent; however, heartdisease and cancer were lesscommon.83

Health conditions remainedbad into the 1970s: life ex-pectancy was two thirds the na-tional average, and the incidenceof infant mortality (1.5 times),diabetes (2 times), suicide(3 times), accidents (4 times),tuberculosis (14 times), gastro-intestinal infections (27 times),dysentery (40 times), and rheu-matic fever (60 times) also wereabove the national average. As aresult, the Navajo Tribal Councilarticulated a new vision of Indianhealth self-determination and at-tempted to build its own medicalschool: “The day will arrivewhen a more effective health-care delivery system utilizing In-dian professionals will replacethe current system. The day will

arrive when the American Indianwill determine what his ownhealth standards and servicesshould be.”84 For Wauneka, the“paramount objective” was clear:“The care by Indians of our peo-ples’ health.”85

The Navajo did not succeed inobtaining funding to establish anindependent medical school.However, the IHS steadily in-creased the participation and theleadership of Indian health pro-fessionals within the IHS. It con-tinued to combat health dispari-ties, and by 1989, it claimedgreat success, arguing that its ef-forts since 1955 had reduced tu-berculosis by 96%, infant mortal-ity by 92%, pulmonary infectionsby 92%, and gastrointestinal in-fections by 93%. Although paritywith the general population hadnot been achieved, the gap hadbeen narrowed.86 However, asthey have done for centuries, thedisparities survived.

IHS data from the late 1990sshowed higher mortality ratesamong American Indians andAlaskan Natives compared withthe general population for mostleading causes of mortality: heartdisease (1.2 times), accidents (2.8times), diabetes (4.2 times), alco-hol (7.7 times), suicide (1.9times), and tuberculosis (7.5times). Only with cancer, the sec-ond leading cause of death, wasAmerican Indian mortality notgreater than that of the generalpopulation. Furthermore, thesedisparities all widened between1995 and 1998.87

Congress and the IHS con-tinue to work to improve condi-tions on the reservations. The1975 Indian Self-Determinationand Indian Assistance Act (PublicLaw 93-638) and the 1976 In-dian Health Care ImprovementAct renewed the government’scommitment to Indian health



The Satellite Clinic near Many Farms.Walsh McDermott’s team of cliniciansand researchers struggled to makebest use of the limited resourcesprovided for Indian health. Whentheir initial clinic at Many Farmsbecame overcrowded, they opened upa satellite clinic in the settlement atRough Rock, 22 miles away. Theyused a converted refrigerator car,donated by the Santa Fe Railroad:the car, which cooled off at night,remained cool during the hot Arizonadays. Source. Courtesy of New YorkWeill Cornell Medical CenterArchives, Photograph Collection,Navajo Project, #2302.


and gave the tribes more controlover their health care services.88

Working with an annual budgetof nearly $3000000000, theIHS now provides services to 1.6million people in 35 states.89

However, as has been true sincethe 19th century, per capita ex-penditures remain far belowthose in the general population:$1351 for Indians comparedwith $3766 for the general pop-ulation overall.90 Casinos havebrought wealth to a small num-ber of tribes, but Indian gamingcould prove to be catastrophicfor Indian health if public per-ception of American Indians asgambling moguls dissolves theobligation felt by Congress toprovide care for them.91

CONCLUSIONS

Disparities in health status be-tween American Indians and Eu-ropeans and Americans havebeen recognized for 5 centuries.Many observers have felt that theexistence of disparities is funda-mentally wrong. Such moral out-rage has motivated centuries ofattempts to relieve them. Howhave disparities been able to per-sist? How have they been al-lowed to persist? Several thingsare clear.

First, there are striking pat-terns in attempts to account forthe distribution of health and dis-ease. Explanations have spanneda remarkable range of possibleetiologies, including religion, diet,living conditions, climate, culturalpractices, racial differences, andsocioeconomic status. No singleexplanation has defined the phe-nomena of disease so clearly thatother explanations have beenprecluded. Many of the explana-tions have persisted throughoutthe centuries, although their spe-cific details and meanings have

changed. Invocations of provi-dence, for example, gave way togenetic determinism as the mostcommon argument for inevitabledisparity. Emphasis has alsoshifted, with religious explana-tions dominating initially butthen giving way to behavioral,genetic, and socioeconomic ex-planations. Such a trajectory,however, is only a coarse approx-imation. Far more striking hasbeen the persistence of the diver-sity of explanations over time.

Second, the enduring existenceof an abundance of possible ex-planations has allowed observersto emphasize the most meaning-ful or useful understandings ofdisease. Needing land, colonistssaw Massachusett depopulationas a gift of land. Wanting absolu-tion for the destruction of Indiansocieties, federal officials sawSioux tuberculosis as proof of In-dians’ inevitable demise. Thesechoices could have been con-strained by the plausibility of dif-ferent explanations. Instead, per-sistent inadequacies in healthdata for American Indians haveoften prevented the establish-ment of clear consensus aboutthe etiology of diseases and dis-parities. This has allowed ob-servers to exercise considerablediscretion in their assessmentsand has opened a large windowfor ideology to influence healthdata, theories, and policies.

Third, choices about explana-tions have reflected observers’ at-titudes about a fundamentalquestion: where should responsi-bility for disparities be assigned?Although some observersblamed personal choices, othersargued that Indian diseases werethe product of the disrupted so-cial conditions of colonization.Responsibility can fall on thesick (e.g., victims of genetic sus-ceptibility) or the healthy (e.g.,

misguided architects of the reser-vation system), or it can be trans-ferred to an outside authority(e.g., God’s providence). Theseassignments have crucial implica-tions for health policy.

Health disparities have beenseen as proof of a natural orderthat can be exploited for ob-servers’ benefit, and they havebeen seen as markers of socialinjustice that observers mustremedy. The shifting balance be-tween these ideological polescontributed to the enormous het-erogeneity of past federal Indianhealth policies. Furthermore, be-cause disparities in health statusparallel disparities in wealth andpower, responses necessarily in-volve decisions to deploy orwithhold economic and politicalresources. Policy makers havehad to balance Indian healthwith other priorities and obliga-tions of the federal government,including land acquisition, mili-tary needs, resource develop-ment, or questions about Indiansovereignty.

The tensions about responsi-bility and appropriate responseappear in current debates aboutthe genetics of health disparities.Researchers have proposed thatAmerican Indians have geneticsusceptibilities to many diseases,from alcoholism to virgin-soilepidemics or Pima diabetes.92

Despite this active research,genetic causes were notably ab-sent from a recent IHS report:“Lower life expectancy and thedisproportionate disease burdenexist perhaps because of inade-quate education, disproportion-ate poverty, discrimination in thedelivery of health services, andcultural differences.”93 Whatgenerates the controversy sur-rounding genetic theories ofhealth disparities? By focusingon biological origins, genetic

theories naturalize disparitiesand reduce the shame andstigma associated with behav-ioral or cultural explanations.But this can be problematic. Byintroducing an aura of inevitabil-ity, genetic arguments reducethe obligation to intervene andprevent or reduce disparities.More practical concerns alsocontribute. Current interest inmolecular genetics makes re-search into the genetics of dis-parities a safe bet for researchersin need of grants and publica-tions. In contrast, genetic expla-nations can be a dead end forpolicymakers, especially whencompared with the many inter-ventions suggested by explana-tions that emphasize socio-economic conditions or accessto health care.94

Debates about the genetic ori-gins of health disparities raise 1last question. Empowered by theHuman Genome Project, re-searchers hope to find genes forevery disease and disparity. How-ever, as more and more geneticlinks are proposed for AmericanIndian ill health, the overall argu-ment becomes harder to sustain.Disparities among American In-dians have existed whether theprevailing diseases were acute in-fections (e.g., smallpox andmeasles), chronic infections (e.g.,tuberculosis), or the endemic ail-ments of modern society (e.g.,heart disease, diabetes, alco-holism, and depression). Recenttrends suggest that disparities incancer might also emerge. Is itconceivable that American Indi-ans have genetic vulnerabilitiesto every class of human disease?

The existence of disparitiesregardless of the underlyingdisease environment is actuallya powerful argument againstthe belief that disparities reflectinherent susceptibilities of



American Indian populations.Instead, the disparities in healthstatus could arise from the dis-parities in wealth and powerthat have endured since colo-nization.95 Such awareness mustguide ongoing research and in-terventions if the disparities inhealth status between AmericanIndians and the general popula-tion are ever to be eradicated. ■

About the AuthorDavid S. Jones is with the Center for theStudy of Diversity in Science, Technology,and Medicine, Massachusetts Institute ofTechnology.

Requests for reprints should be sent toDavid S. Jones, MD, PhD, MassachusettsInstitute of Technology, 77 MassachusettsAve, E51–290, Cambridge, MA 02139(e-mail: [email protected]).

This article was accepted February 10,2005.

AcknowledgmentsThis research was supported in part by agrant from the Medical Scientist TrainingProgram, National Institutes of Health; theGraduate School of Arts and Sciences,Harvard University; and the Program inScience, Technology, and Society, Massa-chusetts Institute of Technology.

I would like to thank Allan Brandt,Arthur Kleinman, David Barnes,Stephen Kunitz, and Ted Brown for theirsuggestions. Adele Lerner and James L.Gehrlich provided invaluable assistanceat the NewYork Weill Cornell MedicalCenter Archives.

Endnotes1. Howard S. Russell, Indian New En-gland Before the Mayflower (Hanover,NH: University of New HampshirePress, 1980), 35, 104–105; Douglas H.Ubelaker, “Patterns of DemographicChange in the Americas,” Human Biol-ogy 64 (June 1992): 364; ClarkSpencer Larsen, “In the Wake ofColumbus: Native Population Biology inthe Postcontact Americas,” Yearbook ofPhysical Anthropology 37 (1994):109–154.

2. For discussions of the poor-healthof pre-Columbian populations, see themany excellent chapters in Richard S.Steckel and Jerome C. Rose, The Back-bone of History: Health and Nutrition inthe Western Hemisphere (Cambridge:Cambridge University Press, 2002). Fora detailed discussion of 1 urban popula-tion, see Rebecca Storey, Life and Death

in the Ancient City of Teotihuacan: AModern Paleodemographic Synthesis(Tuscaloosa: University of AlabamaPress, 1992), 253–266.

3. Larsen, “In the Wake of Colum-bus,” 109–154; Rebecca Storey, Lour-des Marquez Morfin, and Vernon Smith,“Social Disruption and the Maya Civi-lization of Mesoamerica: A Study ofHealth and Economy of the Last Thou-sand Years,” in Steckel and Rose, Back-bone of History, pp. 283–306; DouglasH. Ubelaker and Linda A. Newson, “Pat-terns of Health and Nutrition in Prehis-toric and Historic Ecuador,” in Steckeland Rose, Backbone of History, pp.343–375; S. Ryan Johansson and Dou-glas Owsley, “Welfare History on theGreat Plains: Mortality and SkeletalHealth, 1650 to 1900,” in Backbone ofHistory, ed. Steckel and Rose, pp.524–560; Steckel and Rose, “Patternsof Health in the Western Hemisphere,”in Backbone of History, pp. 563–579.

4. Henry F. Dobyns, “Estimating Abo-riginal American Population: An Ap-praisal of Techniques with a New Hemi-spheric Estimate,” Current Anthropology7 (October 1966): 395–416; Ubelaker,“Patterns of Demographic Change in theAmericas,” 361–379; Michael H. Craw-ford, The Origins of Native Americans:Evidence from Anthropological Genetics(Cambridge: Cambridge UniversityPress, 1998), 33–39; David Henige,Numbers from Nowhere: The American In-dian Contact Population Debate (Norman:University of Oklahoma Press, 1998).

5. “Estimates of the precontact popu-lation of Hispanola have ranged be-tween 60000 and nearly 8000000.”Noble David Cook, Born to Die: Diseaseand New World Conquest, 1492-1650(Cambridge: Cambridge UniversityPress, 1998), 22-23. The best availableevidence has narrowed the range to be-tween 100000 and 400000. MassimoLivi-Bacci, “Return to Hispanola: Re-assessing a Demographic Catastophe,”Hispanic American Historical Review 83(2003): 3-51.

6. Dean R. Snow and Kim M. Lan-phear, “European Contact and IndianDepopulation in the Northeast: TheTiming of the First Epidemics,” Ethno-history 35 (Winter 1988): 17; David E.Stannard, “Disease and Infertility: ANew Look at the Demographic Collapseof Native Populations in the Wake ofWestern Contact,” Journal of AmericanStudies 24 (1990): 325–350; John W.Verano and Douglas H. Ubelaker, ed.,Disease and Demography in the Americas(Washington, DC, 1992); Linda A. New-son, “The Demographic Collapse of Na-tive Peoples of the Americas, 1492-1650,” Proceedings of the BritishAcademy 81 (1993): 247–288;Stephen J. Kunitz, Disease and Social

Diversity: The European Impact on theHealth of Non-Europeans (New York: Ox-ford University Press, 1994); RobertMcCaa, “Spanish and Nahuatl Views onSmallpox and Demographic Catastrophein Mexico,” Journal of InterdisciplinaryHistory 25 (Winter 1995), 429; Craw-ford, The Origins of Native Americans,41–49.

7. Peter Martyr, The Decades of theNewe Worlde (1516), trans. RichardEden (1555), in The First Three EnglishBooks on America, ed. Edward Arber(Birmingham: 1885), 199, 172.

8. Thomas Hariot, A Briefe and TrueReport of the New Found Land of Virginia(1588; Ann Arbor: Edward Brothers,1931), F.

9. Ferdinando Gorges, A Briefe Nar-ration of the Originall Undertakings of theAdvancement of Plantations into the Partsof America (1658), in Sir FerdinandoGorges and his Province of Maine, ed.James Phinney Baxter, vol. 19 (1890;New York: Burt Franklin, 1967), 19.

10. Arthur E. Speiss and Bruce D.Speiss, “New England Pandemic of1616-1622: Cause and ArchaeologicalImplication,” Man in the Northeast 34(1987): 71–83; Timothy L. Bratton,“The Identity of the New England In-dian Epidemic of 1616–19,” Bulletin ofthe History of Medicine 62 (Fall 1988):351–383.

11. Sherburne F. Cook, “The Signifi-cance of Disease in the Extinction ofthe New England Indians,” Human Biol-ogy 45 (September 1973): 485–508;Ann F. Ramenofsky, Vectors of Death:The Archeology of European Contact (Al-buquerque: University of New MexicoPress, 1987); Dean R. Snow, “Mi-crochronology and Demographic Evi-dence Relating to the Size of Pre-Columbian North American IndianPopulations,” Science 268 (16 June1995): 1601–1604.

12. William Bradford, Of PlymouthPlantation, 1620–1647, ed. SamuelEliot Morison (New York: Alfred A.Knopf, 1979), 87, 270.

13. John White, for instance, wrotethat “the Contagion hath scarce leftalive one person in a hundred.” White,The Planters Plea (1630), in Tracts andOther Papers, ed. Peter Force, vol. 2(1836; New York: Peter Smith, 1947),14.

14. Bradford to Thomas Weston,1621, in Bradford, Of Plymouth Planta-tion, 95.

15. Karen Ordahl Kupperman, “Apathyand Death in Early Jamestown,” Journalof American History 66 (June 1979):24–40.

16. Hariot, A Briefe and True Report,F2.

17. Gorges, Briefe Narration, 19:19.

18. Bradford, Of Plymouth Plantation,271.

19. Cook, “The Significance of Dis-ease,” 485-508; James D. Drake, KingPhilip’s War: Civil War in New England,1675–1676 (Amherst: University ofMassachusetts Press, 1999), 169–174.

20. Mr. Moor to the Secretary of theSociety for the Propagation of theGospel in Foreign Parts, 13 Nov. 1705,quoted in John Duffy, “Smallpox andthe Indians in the American Colonies,”Bulletin of the History of Medicine 25(July–August 1951): 326.

21. John Winthrop to Simonds D’Ewes,21 July 1634, in Winthrop Papers, ed.Malcolm Freiberg, vol. 3 (Boston: Mass-achusetts Historical Society, 1943),171–172.

22. Compare Joyce Chaplin, “NaturalPhilosophy and an Early Racial Idiomin North America: Comparing Englishand Indian Bodies,” William and MaryQuarterly 54 (1997): 230, 244; Chap-lin, Subject Matter: Technology, the Body,and Science on the Anglo-American Fron-tier, 1500–1676 (Cambridge: HarvardUniversity Press, 2001), 8–9, 22–23,158–197, 244–276, 319–323; andDavid S. Jones, Rationalizing Epidemics:Meanings and Uses of American IndianMortality since 1600 (Cambridge: Har-vard University Press, 2004), 39,136–137.

23. Philip Vincent, A True Relation ofThe late Batell fought in New-England,between the English and the Pequet Sal-vages (1638), in Collections of the Massa-chusetts Historical Society, 3rd series,vol. 6 (Boston: American Stationers’Company, 1837), 34.

24. William Wood, New EnglandsProspect (1634), ed. Alden T. Vaughan(Amherst: University of MassachusettsPress, 1977), 82.

25. Edward Winslow, Good Newes fromNew England (1624), in Chronicles of thePilgrim Fathers of the Colony of Plymouth,from 1602 to 1625, ed. AlexanderYoung, 2nd ed. (Boston: Charles C. Lit-tle and James Brown, 1844), 346.

26. Daniel Gookin, Historical Collec-tions of the Indians in New England, c.1680 (1792; [n.p.]: Towtaid, 1970),53–54.

27. Quoted in Gorges, Briefe Narration,19:25–26n315.

28. Winthrop to D’Ewes, 21 July1634, 3:172.

29. Winthrop to John Endecott, 3 Jan-uary 1634, in Winthrop Papers, 3:149.

30. Hariot, A Briefe and True Report,F–F2.

31. Thomas Morton, New English



Canaan (1632), in Tracts and Other Pa-pers, ed. Peter Force, vol. 2 (1836; NewYork: Peter Smith, 1947), 71.

32. Winslow, Good Newes from NewEngland, 291-292; John Smith, TheGenerall History of Virginia, New-En-gland, the Summer Iles (1624), in TheComplete Works of Captain John Smith(1580-1631), ed. Philip L. Barbour(Chapel Hill: University of North Car-olina Press, 1986), 2:451; Bradford,Plymouth Plantation, 99; Morton, NewEnglish Canaan, 71.

33. For background, see Bruce G. Trig-ger, The Children of Aataentsic: A His-tory of the Huron People to 1660 (1976;Montreal: McGill-Queen’s UniversityPress, 1987). For Huron questioning,see Paul le Jeune, Relation of What Oc-curred in New France in 1637, 31 Au-gust 1637 (1638), in The Jesuit Relationsand Allied Documents: Travels and Explo-rations of the Jesuit Missionaries in NewFrance, 1610–1791, ed. Reuben GoldThwaites, 73 vols. (Cleveland: The Bur-rows Brothers Company, 1896–1901),11:193.

34. Hierosme Lalemant, “Relation ofWhat Occurred in the Mission of theHurons,” in Jesuit Relations, 19:93,19:97; Paul le Jeune, “Relation of WhatOccurred in New France in 1637,” inJesuit Relations, 12:87; le Jeune, “Letterto the Father Provincial,” 1637, in JesuitRelations, 12:237.

35. Lalemant, “Relation of 1640,”19:93.

36. John Duffy, “Smallpox and the In-dians in the American Colonies,” Bul-letin of the History of Medicine 25(July–Aug. 1951): 324–341; RussellThornton, American Indian Holocaustand Survival: A Population History Since1492 (Norman: University of OklahomaPress, 1987), 91–94.

37. “New Orleans, June 6, 1838,” inHannibal Evans Lloyd, “Translator’sPreface,” in Alexander Philip Maximil-ian, Travels in the Interior of NorthAmerica, in Early Western Travels,1748–1846, ed. Reuben GoldThwaites, 32 vols. (Cleveland: ArthurH. Clark Company, 1904-1906),22:33, 35. Mortality estimates: JohnJames Audubon, in Audubon and hisJournals, ed. Maria R. Audubon, 2 vols.(New York: Charles Scribner’s Sons,1897), 2:47; Henry R. Schoolcraft, In-formation Respecting the History, Condi-tion and Prospects of the Indian Tribes ofthe United States, 6 vols. (Philadelphia:Lippincott, Grambo & Company,1851–1857), 1:257–258, 6:486.

38. Thomas Hutchinson, The History ofthe Colony of Massachusetts-Bay,1628–1691 (Boston: Thomas & JohnFleet, 1764), 35n.

39. For one example, see John Heck-ewelder, An Account of the History,Manners, and Customs of the Indian Na-tions who once Inhabited Pennsylvaniaand the Neighbouring States (1819), re-vised ed. (Philadelphia: Historical Soci-ety of Pennsylvania, 1876), 221,221–223.

40. George Catlin, Illustrations of theManners, Customs, and Condition of theNorth American Indians, 10th ed. (Lon-don: Henry G. Bohn, 1866), 2:257.

41. Catlin, Illustrations of the Manners,Customs, and Condition, 2:256.

42. Quoted in George Catlin, Catlin’sNotes of Eight Years Travel and Resi-dence in Europe (London: Published bythe author, 1848), 2:41. Contempo-raries and historians have criticizedCatlin for his lack of objectivity. For ex-amples, see Audubon, in Audubon andhis Journals, 2:10, 2:27; Hiram MartinChittenden, American Fur Trade of theFar West (New York: Francis P. Harper,1902), 37.

43. For control of acute epidemics, seeJones, Rationalizing Epidemics, 119–121.For lists of other diseases, see James R.Doolittle, Conditions of the Indian Tribes(Washington: Government Printing Of-fice, 1867), 4–5; W. T. Hughes, in An-nual Report of the Commissioner of In-dian Affairs, 1877 (Washington:Government Printing Office, 1877), 74.

44. Ales Hrdlicka, Tuberculosis amongCertain Indian Tribes of the United States(Washington: Government Printing Of-fice, 1909); Hans L. Reider, “Tuberculo-sis Among American Indians of theContiguous United States,” Public HealthReports 104 (November–December1989): 654; Virginia Morell, “MummySettles TB Antiquity Debate,” Science263 (24 March 1994): 1686–1687.

45. For examples, T. M. Bridges, in An-nual Report of the Commissioner of In-dian Affairs, 1893 (Washington: Gov-ernment Printing Office, 1893): 286;James R. Walker, in Annual Report of theCommissioner of Indian Affairs, 1901(Washington: Government Printing Of-fice, 1902), 367; in O. M. Chapman, inAnnual Report of the Commissioner of In-dian Affairs, 1906 (Washington: Gov-ernment Printing Office, 1907), 364.

46. Z. T. Daniel, in Annual Report of theCommissioner of Indian Affairs, 1894(Washington: Government Printing Of-fice, 1895), 290.

47. Report of the Surgeon-General of theArmy to the Secretary of War, 1892(Washington: Government Printing Of-fice, 1892), 48.

48. T. M. Bridges, in Annual Report ofthe Commissioner of Indian Affairs, 1895(Washington: Government Printing Of-fice, 1896), 288.

49. Frederick Treon, “Medical WorkAmong the Sioux Indians,” Journal of theAmerican Medical Association 10 (25February 1888): 224-227; Treon,“Consumption Among the Sioux Indi-ans,” Cincinnati Lancet-Clinic 23 (10August 1889): 148-154; A. B. Holder,“Papers on Diseases Among Indians,”Medical Record (New York) 42 (13 Au-gust, 17 September, 24 September1892): 177–182, 329–331, 357–361);Z. T. Daniel, in Annual Report of theCommissioner of Indian Affairs, 1903(Washington: Government Printing Of-fice, 1904), 318.

50. O. M. Chapman, in Annual Reportof the Commissioner of Indian Affairs,1904 (Washington: Government Print-ing Office, 1905), 342.

51. J. C. Nott and George R. Gliddon,Types of Mankind (1854; Miami:Mnemosyne, 1969), 69.

52. Daniel, in Annual Report, 1894,290.

53. S. N. Clark, “Memoranda: Impor-tance of the Inquiry,” in “Are the Indi-ans Dying Out? Preliminary Observa-tions Relating to Indian Civilization andEducation,” in Annual Report of theCommissioner of Indian Affairs, 1877,494. See also George M. Fredrickson,The Black Image in the White Mind: TheDebate on Afro-American Character andDestiny, 1817–1914 (Hanover, NH: Uni-versity Press of New England for Wes-leyan University Press, 1971, 1987), 77,159, 220–255.

54. George E. Bushnell, A Study in theEpidemiology of Tuberculosis, with Espe-cial Reference to Tuberculosis of the Trop-ics and of the Negro Race (New York:William Wood and Company, 1920),159–160.

55. Richard Irving Dodge, Our WildIndians: Thirty-Three Years’ Personal Ex-perience among the Red Men of the GreatWest (1882; New York: Archer House,Inc., 1959), 296.

56. S. R. Riggs to John Eaton, 27 Au-gust 1877, quoted in Clark, “Memo-randa: Importance of the Inquiry,” 515.

57. T. J. Morgan, in Annual Report ofthe Commissioner of Indian Affairs, 1890(Washington: Government Printing Of-fice, 1890), xxi. For a parallel discussionof how the policies of the Canadiangovernment exacerbated the healthproblems of the aboriginal peoples ofCanada, see Mary-Ellen Kelm, Coloniz-ing Bodies: Aboriginal Health and Heal-ing in British Columbia, 1900-50 (Van-couver: UBC Press, 1998); Maureen K.Lux, Medicine that Walks: Disease, Medi-cine, and Canadian Plains Native People,1880–1940 (Toronto: University ofToronto Press, 2001).

58. Francis E. Leupp, quoted in Francis

Paul Prucha, The Great Father: TheUnited States Government and the Ameri-can Indians (Lincoln: University of Ne-braska Press, 1984), 2:848.

59. William H. Taft, “Special Messageto Congress,” in Annual Report of theCommissioner of Indian Affairs, 1912(Washington: Government Printing Of-fice, 1913), 17–19. See also DianeTherese Putney, “Fighting the Scourge:American Indian Morbidity and FederalPolicy, 1897-1928” (PhD Dissertation,Marquette University, 1980); FrancisPaul Prucha, The Great Father: TheUnited States Government and the Ameri-can Indians (Lincoln: University of Ne-braska Press, 1984), 2:850–855;Robert A. Trennert, White Man’s Medi-cine: Government Doctors and the Navajo,1863–1955 (Albuquerque: Universityof New Mexico Press, 1998), 74–75,136–138.

60. George M. Kober, George E. Bush-nell, Joseph A. Murphy, Albert B.Tonkin, William H. Baldwin, and HoytE. Dearholt, in Tuberculosis Among theNorth American Indians (Washington:Government Printing Office, 1923), 42.

61. US Public Health Service, HealthServices for American Indians, PublicHealth Service Publication No. 531(Washington: Government Printing Of-fice, 1957), 90–92; US Public HealthService, The Indian Health Program ofthe U.S. Public Health Service (Washing-ton: US Department of Health, Educa-tion, and Welfare, 1966), 18–19; JeffHenderson, “Native American HealthPolicy: From US Territorial Expansionto Legal Obligation,” JAMA 265 (1 May1991): 2272; Abraham B. Bergman,David C. Grossman, Angela M. Erdich,John G. Todd, and Ralph Forquera, “APolitical History of the Indian HealthService,” Milbank Quarterly 77 (1999):591.

62. Herbert A. Burns, “Tuberculosis inthe Indian,” American Review of Tubercu-losis 26 (July–December 1932):498–499.

63. James R. Shaw, quoted in Bergmanand others, “A Political History of theIndian Health Service,” 577–578.

64. Fred T. Foard, “Health Services forthe North American Indians,” MedicalWoman’s Journal 571 (November1950): 12.

65. J. Nixon Hadley, “Health Condi-tions Among Navajo Indians,” PublicHealth Reports 70 (September 1955):835.

66. J. A. Krug, The Navajo: A LongRange Program for Navajo Rehabilitation(Washington: US Government PrintingOffice, 1948), 6.

67. Sydney J. Tillim, “Medical Annalsof Arizona: Health Among the Navajos,”



Southwestern Medicine 20 (August1936): 277.

68. Tillim, “Medical Annals of Arizona:Health Among the Navajos,” Southwest-ern Medicine 20 (October 1936): 391.For other examples, see Isaac W.Brewer, “Tuberculosis Among the Indi-ans of Arizona and New Mexico,” NewYork Medical Journal 84 (1906):981–982; Kober and others, Tuberculo-sis Among the North American Indians,29-37; Ralph M. Alley, “TuberculosisAmong Indians,” Diseases of the Chest 6(February 1940): 45.

69. Manuelito Begay, quoted in “Min-utes of the Navajo Tribal Council,” 12Febrary 1954, Walsh McDermott Pa-pers, NewYork Weill Cornell MedicalCenter Archives, Box 11, Folder 7, p.10; see also Kurt Deuschle, “Tuberculo-sis Among the Navajo: Research inCross-Cultural Technologic Develop-ment in Health,” American Review ofRespiratory Diseases 80 (1959): 201.

70. Deuschle, “Tuberculosis Amongthe Navajo,” 201.

71. New Mexico State Department ofHealth, quoted in Kober and others, Tu-berculosis Among the North American In-dians, 31.

72. For example, see Irvine H. Page,Lena A. Lewis, and Harvey Gilbert,“Plasma Lipids and Proteins and theirRelationship to Coronary Diseaseamong Navajo Indians,” Circulation 13(May 1956): 675–679.

73. Kober and others, TuberculosisAmong the North American Indians, 4.

74. J. G. Townsend, Joseph D. Aronson,Robert Saylor, and Irma Parr, “Tubercu-losis Control among the North Ameri-can Indians,” American Review of Tuber-culosis 45 (1942): 46.

75. J. Arthur Myers, “Editorial: Tuber-culosis Among American Indians,” Dis-eases of the Chest 16 (1949): 248.

76. Frank S. French, James R. Shaw,and Joseph O. Dean, “The NavajoHealth Problem, Its Genesis, Propor-tions and a Plan for Its Solution,” Mili-tary Medicine 116 (June 1955): 453.

77. “An Act to Promote the Rehabili-tation of the Navajo and Hopi Tribes ofIndians and a Better Utilization of theResources of the Navajo and Hopi In-dian Reservations, and for Other Pur-poses,” Public Law 474, United StatesCode, 81st Cong., 2nd sess., 1950, pp.44–45. See also Stephen J. Kunitz, Dis-ease Change and the Role of Medicine:The Navajo Experience (Berkeley: Uni-versity of California Press, 1983),26–43.

78. Lewis J. Moorman, “Tuberculosison the Navaho Reservation,” AmericanReview of Tuberculosis 61 (1950): 589.

79. Annie Wauneka, Written State-ment, 2 November 1953, read in theUS Senate, in “Hearings on HR 303:An Act to Transfer the Maintenanceand Operation of Hospital and HealthFacilities for Indians to the PublicHealth Service,” 28–29 May 1954, inCongressional Hearings, Senate, Interiorand Insular Affairs, 83rd Cong., 2ndsess., 1953–1954, vol. 14, 83S1085–10, p. 43.

80. Walsh McDermott, Kurt Deuschle,John Adair, Hugh Fulmer, and BerniceLoughlin, “Introducing Modern Medi-cine in a Navajo Community: Physiciansand anthropologists are cooperating inthis study of changing patterns of cul-ture and disease,” Science 131 (22 Janu-ary 1960): 197–205, 280–287; JohnAdair and Kurt Deuschle, The People’sHealth: Medicine and Anthropology in aNavajo Community (New York: MeredithCorporation, 1970); Walsh McDermott,Kurt Deuschle, and Clifford R. Barnett,“Health Care Experiment at ManyFarms,” Science 175 (7 January 1972):23–31.

81. McDermott, “Draft of Chapter II,”undated, in Walsh McDermott Papers,Box 11, Folder 6, p. 12. See also Mc-Dermott and others, “Health Care Ex-periment at Many Farms,” 25–27; JohnAdair, Kurt Deuschle, and Clifford Bar-nett, with a chapter by Barnett andDavid L. Rabin, The People’s Health:Medicine and Anthropology in a NavajoCommunity, 2nd ed. (Albuquerque: Uni-versity of New Mexico Press, 1988),157-159. See also David S. Jones, “TheHealth Care Experiment at ManyFarms: The Navajo, Tuberculosis, andthe Limits of Modern Medicine,1952–1962,” Bulletin of the History ofMedicine 76 (Winter 2002): 749–790.

82. “An Act to Transfer the Mainte-nance and Operation of Hospital andHealth Facilities for Indians to the Pub-lic Health Service, and for Other Pur-poses,” Public Law 568, United StatesCode, 83rd Cong., 2nd sess., 1954;Stephen J. Kunitz, “The History and Pol-itics of US Health Care Policy for Amer-ican Indians and Alaskan Natives,”American Journal of Public Health 86(October 1996): 1465.

83. USPHS, Health Services for Ameri-can Indians, 39–57, 230–232.

84. Navajo Health Authority, “PositionPaper,” Walsh McDermott Papers, Box11, Folder 1, p. 5.

85. Wauneka to Elliot Richardson,1 July 1971, in Navajo Health Author-ity, “Capsules of Navajo Health His-tory,” in “Summary of Program Com-ponents,” c. 1974, Walsh McDermottPapers, Box 11, Folder 1, p. 19. Seealso Jones, Rationalizing Epidemics,218–222. For the political background,

see Bergman and others, “A PoliticalHistory of the Indian Health Service,”575, 588.

86. US Public Health Service, IndianHealth Service: A Comprehensive HealthCare Program for American Indians andAlaska Natives (Washington DC: US De-partment of Health and Human Ser-vices, 1989), v, 16–22.

87. Indian Health Service, “Facts onIndian Health Disparities,” September2002, downloaded from http://info.ihs.gov/health/health_index.asp.

88. Jeff Henderson, “Native AmericanHealth Policy: From US Territorial Ex-pansion to Legal Obligation,” JAMA265 (1 May 1991): 2272–2273;Kunitz, “US Health Care Policy forAmerican Indians,” 1464–1473; JosephG. Jorgensen, “Comment: Recent Twistsand Turns in American Indian HealthCare,” American Journal of Public Health86 (October 1996): 1362–1364.

89. IHS, “Facts on Indian HealthDisparities.”

90. Indian Health Service, “Year 2001Profile,” at http://www.ihs.gov/publicinfo/publicaffairs/pressreleases/press_release_2001/fy%202001%20ihs%20profile.pdf.

91. Joan Stephenson, “For Some Amer-ican Indians, Casino Profits Are a GoodBet for Improving Health Care,” JAMA275 (19 June 1996): 1783–1785; Mar-sha F. Goldsmith, “First Americans FaceTheir Latest Challenge: Indian HealthCare Meets State Medicaid Reform,”JAMA 275 (19 June 1996): 1786-1788; “Special Report: Indian Casinos,”Time Magazine 160 (8 December2002): 44–58.

92. For alcohol, see Peter C. Mancall,Deadly Medicine: Indians and Alcohol inEarly America (Ithaca: Cornell Univer-sity Press, 1995), 1-10; James B. Wal-dram, Revenge of the Windigo: The Con-struction of the Mind and Mental Healthof North American Aboriginal Peoples(Toronto: University of Toronto Press,2004), 134–143, 165–166. For virginsoil epidemics, see Alfred W. Crosby,“Virgin Soil Epidemics as a Factor inthe Aboriginal Depopulation in Amer-ica,” William and Mary Quarterly 33(April 1976): 289–299; David S. Jones,“Virgin Soils Revisited,” William andMary Quarterly 60 (October 2003):703–742. For Pima diabetes, seehttp://diabetes.niddk.nih.gov/dm/pubs/pima/index.htm.

93. IHS, “Facts on Indian Health Dis-parities.”

94. Stephen J. Kunitz, “The evolutionof disease and the devolution of healthcare for American Indians,” in TheChanging Face of Disease: Implications forSociety, ed. N. Mascie-Taylor, J. Peters,

and S.T. McGarvey (New York: CRCPress, 2004), 153–169.

95. For the connections betweenwealth disparities and health disparities,see: “Health and Wealth,” Daedalus 123(Fall 1994), 1–216; Robert G. Evans,Morris L. Barer, and Theodore R. Mar-mor, ed., Why are Some People Healthyand Others Not? The Determinants ofHealth of Populations (New York: Aldinede Gruyter, 1994); Richard Wilkinson,Unhealthy Societies: The Afflictions of In-equality (London: Routledge, 1996);Norman Daniels, Bruce Kennedy, andIchiro Kawachi, eds., Is Inequality Badfor Our Health? (Boston: Beacon Press,2000).
