University of North Carolina Chapel Hill MHCH/PUBH Understanding and Addressing Health Disparities in the US “Raising Awareness of American Indian/Alaska

University of North Carolina Chapel Hill

MHCH/PUBH

Understanding and Addressing Health Disparities in the US

“Raising Awareness of American Indian/Alaska

Native Health Issues”

Dean S. Seneca, MPH, MCURPHealth Scientist Policy, Tribal Portfolio

Portfolio Management ProgramOffice of the Chief of Public Health Practice Centers for Disease Control and Prevention

American Indian/Alaska Native Health Disparities

The American Indian and Alaska Native people have long experienced lower health status when compared with other Americans. Lower life expectancy and the disproportionate disease burden exist because of inadequate education, disproportionate poverty, discrimination in the delivery of health services, and cultural differences. These are broad quality of life issues rooted in economic adversity and poor social conditions.


American Indians and Alaska Natives born today have a life expectancy that is 2.4 years less than the U.S. all races population (74.5 years to 76.9 years, respectively; 1999-2001 rates), and American Indian and Alaska Native infants die at a rate of nearly 12 per every 1,000 live births, as compared to 7 per 1,000 for the U.S. all races population (2002-2004 rates).


American Indians and Alaska Natives die at higher rates than other Americans from tuberculosis (750% higher), alcoholism (550% higher), diabetes (190% higher), unintentional injuries (150% higher), homicide (100% higher) and suicide (70% higher).

(Rates adjusted for misreporting of Indian race on state death certificates; 2002-2004 rates. )


Given the higher health status enjoyed by most Americans, the lingering health disparities of American Indians and Alaska Natives are troubling. In trying to account for the disparities, health care experts, policymakers, and Tribal Leaders are looking at many factors that impact upon the health of Indian people, including the adequacy of funding for the Indian health care delivery system.

Who is an Indian?

Tribes establish criteria for membership1/4 tribal blood, BIA Standarda descendant of a tribal memberor a person recognized by the tribal members as

a member.

Alaska Native: The term collectively refers to Eskimos, Aleuts, and American Indians who are indigenous to Alaska.

American Indian: This includes enrolled members of Federal and/or State recognized tribes as well as people who are self-identified as “American Indian” on the U.S. Census and other similar reports.

What is an Indian Tribe?

Any Indian tribe, band, Nation, rancheria, Pueblo, or other organized group or community, including any Alaska Native village, group, regional, or village corporation as defined in or established by the Alaska Native Claims Settlement Act, and is recognized as eligible for the special programs and services provided by the United States to Indians through government to government relationships, specifically treaties. A tribe may be federally recognized, state recognized, or self-recognized.

What is a Reservation?

The geographic area reserved by treaty or other law for a federally recognized Indian tribe.

Navajo Nation -

1492Arrival of Columbus

1790ForcedInland

1830IndianCountry

1860ImmigrationStampede

1890Vanquished

2090Indian Country?

= Reservation Lands

Tribal Sovereignty

Treaty Tribes have a Nation to Nation

relationship with the US. Government

Tribes are Sovereign Nations

States do not have jurisdiction on tribal

lands

Movement towards Tribal Self-Governance

Tribes make and enforce your own Laws

Federal Indian Policy

• 1608-1830, “Treaties” – The Marshall Trilogy historic cases Johnson v. McIntosh, Cherokee Nation v. Georgia, and Worcester v. Georgia all recognized Indian Nations as Sovereign Entities. The Supreme Court found that Tribes were no longer territorially separate from the United States. Tribes (a) could not transfer lands to or sign treaties with any other colonizing power and (b) had placed themselves under the protection of the United States.

Federal Indian Policy Continued

• 1830-1850, “Removal Policy” – Indian Removal Act policies moved the Tribes west of the Mississippi into the Louisiana and Northwest Territories.

• 1850-1871, “Removal Shifts to Reservation System” – Over 100 treaties created moving Tribes to new, smaller territories or confined them to smaller territories reserved from their aboriginal territory.

Federal Indian Policy Continued 1871-1928, “Assimilation and Allotment Era” – The

United States sold or gave Indian Land to non Indians to make Indians Assimilate into non-Indian communities. Resulted in (a) the loss of 90 out of 138 million acres of land and (b) the displacement of thousands of Indians.

“Indian Reorganization Act of 1934” – The Act reaffirmed that tribal governments had inherent powers.

1943 – 1968, “Termination” – Reversed many of the reforms made in the 1930’s by terminating many federal state tribal relationships. Promoted assimilation of Indians into mainstream society.

Federal Indian Policy Continued

1968 – Present – “Self Determination” – In 1968, PL 280 was amended to require the consent of Indian Nations before state could assume jurisdiction. This era of various presidential policy statements and legislative acts that benefited Indians, strengthened tribal governments, reaffirmed tribal sovereignty and ended the termination period.

Reservation Boarding School System Existed between 1870-1928

Movement attributed to Manifest Destiny philosophy Mission: to educate Indian children and assimilate them

into the European language and culture. Allow the Indian people to become self-sufficient, and therefore reduce government spending.

“Social Evolution” of the Indian expectations included: - Speaking English - Learning a vocation - Practicing farming Founded to expand the land available to the Europeans

and confine the Indian people. Result-assimilation failed and Indian culture survived, but

Native children suffered serious repercussions

Fort Simcoe, Washington

Apache Children at Carlisle Indian School

Apache Children at Carlisle Indian School 4 months later

American Indian Facts

Data According to the U.S. Census 2000 Population Data of AI/AN in United States: -4.1 million Geographic Distribution: -West (43%) -Midwest (17%) -South (31%) -Northeast (9%)

U.S.Natives All Races

24 yrs. 33 yrs.

$19,900 $30,000

32% 13%

66% 75%

Median Age

Median Income

Below Poverty

High School

Demographics, 1990 Census

U.S.Natives All Races

28 yrs. 35.3 yrs.

$31,799 $42,148

25.9% 11.3%

70.9% 80.4%

Median Age

Median Income

Poverty Rate

High School

Demographics, 2000 Census

Public Law 93-638• To Provide maximum Indian Participation in the Government

and education of Indian People.

To provide for the full participation of Indian Tribes in programs and services conducted by the federal government.

After Careful review Congress finds:(1) The prolonged federal domination of Indian service

programs has served to retard rather than enhance the progress of Indian people and their communities by depriving Indians of full opportunity to develop leadership skills crucial to the realization of self-government

(2) The Indian people will never surrender their desire to control their relationships both among themselves and with non-Indian governments, organizations and persons

Public Law 93-638 Cont.

Contracting: allows the Tribes to take over planning and implementation of any or all federal services. Tribes can requests permission from the IHS to redesign those parts of the health care system they are responsible to address.

Compacting: Tribes enter into funding agreements where they assume control over the planning, and delivery of some or all federal services. Tribes can do what ever they want with the funding as long as it is intend for the desired purpose.

Direct Service: The Federal government provides a service directly to the tribe.

Sharing and generosity Allegiance to family, community and tribe Respect for Elders Non-Interference Orientation to present time Harmony with Nature Respect for status of the Woman and the

Child

Common Values Among Natives

Common Beliefs Related to Spirituality

A belief in an unseen power, Great Mystery

or Creator

All things in the universe are related

Worship reinforces bonds between the

individual, family and community (our

relatedness)

Spirituality is intimately connected to our

health

Respective Core Values

Traditional Native Main Stream Society, U.S.

Cooperative Competitive

Group/Tribal Emphasis Freedom, Progress, Efficiency

Extended Family Important Individualism

Modesty Sexy

Patience/Passive (SW) “Getting Ahead in Life”

Generous/Non-Materialistic Material Comfort

Respect for Age Youth

Spirituality External Conformity

Indirect Criticism Direct Criticism

Harmony with Nature Conquest of Nature

Presidential Memorandum on Government-to-Government Relations

with AI/AN Tribal Governments Operate within a government-to-government relationship with

federally-recognized Tribes Consult, to the greatest extent practicable and to the extent

permitted by law, with Indian tribal governments before taking actions that affect federally recognized tribes.

Assess the impact of executive department and agency activities on tribal trust resources and assure that tribal rights and concerns are considered.

Take appropriate steps to remove procedural impediments to working directly and effectively with tribal governments on activities that affect the trust responsibility and/or governmental rights of tribes.

Executive Order 13175 of November 6, 2000“Consultation and Coordination with Indian

Tribal Governments”

Funding Principles

Policy Making Criteria

Consultation

Increasing Flexibility for Indian Tribal Waivers

AI/AN Public Health:Challenges/Obstacles

• Few AI/AN public health professionals• Limited familiarity with AI/AN policies• Complexities/logistics – over 500 tribes• Public health legislation/legal

foundations• Lack of public health infrastructure• Funding issues

AI/AN (1992-1994) Age-Adjusted Death Rates Compared to U.S. All Races (1993)

Source: Trends in Indian Health, 1997IHS Epidemiology

1.1

1.6

1.7

3.1

3.3

4.4

5.3

0 1 2 3 4 5 6

Cardiovascular Diseases

Pneumonia & Influenza

Suicide

Accidents

Diabetes Mellitus

Chron. Liver Disease & Cirrhosis

Tuberculosis, All Forms

Ratio

Albuquerque82,818

Portland158,892

Billings58,794

California132,740 Phoenix

150,540

Oklahoma318,691

Nashville78,745

Navajo223,029

Tucson28,980

Alaska109,780

Aberdeen102,758

2001 IHS Service Population* by AreaTotal Population: 1,540,129

*Projected from 1990 CensusIHS Epidemiology

Bemidji94,362

Ten Leading Causes of Death for American Indians/Alaska Natives in

U.S.,2003

1. Heart disease2. Cancer3. Unintentional injuries4. Diabetes5. Stroke6. Chronic liver disease and Cirrhosis7. Chronic lower respiratory diseases8. Suicide9. Influenza and Pneumonia10. Nephritis, Nephrotic Syndrome, &

NephrosisSource: Health, United States, 2005, Table 31.

http://www.cdc.gov/NCHS/data/hus/hus05.pdf#summary

Ten Leading Causes of Death in the U.S. in 2004 for AI/AN as Compared to the Nation

AI/AN1. Heart disease2. Cancer3. Unintentional injuries4. Diabetes5. Stroke 6. Chronic liver disease &

Cirrhosis7. Chronic lower respiratory

diseases8. Suicide9. Influenza and Pneumonia10. Nephritis, Nephrotic

Syndrome, & Nephrosis

Source: Health, United States, 2005, Table 31.http://www.cdc.gov/NCHS/data/hus/hus05.pdf#summary

U.S.

Heart disease Cancer Stroke Chronic lower respiratory

diseases Unintentional injuries Diabetes Alzheimer’s Disease Influenza and Pneumonia Nephritis, Nephrotic Syndrome, &

Nephrosis Septicemia

Age-Adjusted Death Rate Per 100,000 Persons By Race & Hispanic Origin For All Causes U.S.,

2004

800.8 786.3

1027.3

650.0

443.9

586.7

0

200

400

600

800

1000

1200

All Races White AfricanAmerican

AmericanIndian/Alaska

Native

Asian/PacificIslander

Hispanic

Ag

e-A

dju

ste

d D

ea

th R

ate

pe

r 1

00

,00

0 P

ers

on

s


Age-Adjusted Death Rates per 100,000 Persons by Race

for All Causes: U.S. & IHS Service Area - 1997

479.1456.5 465.3

620.7

715.2

0

150

300

450

600

750

All Races (HUS) White (HUS) American Indian/Alaska Native AI/AN

(HUS)

AI/AN UnAdjustedIHS Service Area

(IHS)

AI/AN Adjusted * IHSService Area (IHS)

Ag

e-A

dju

sted

Dea

th R

ate

per

100

,000

Per

son

s

Source: Health, United States, 2005, Table 31. And IHS Trends in Indian Healthhttp://www.cdc.gov/NCHS/data/hus/hus05.pdf#summary

Source:IHS Trends in Indian Health, 2000-2001, Table 4.11, p.69.

0

250

500

750

1,000

1972-74 (1973) 1983-85 (1984) 1994-96 (1995) 1996-98 (1997)

Calendar Year(s)

Age-Adjusted Death Rate

Rate Per 1,000 PopulationAmerican Indians & Alaska Natives, Actual (3-Year)

U.S. White (1-Year)

U.S. All Races (1-Year)

American Indians & Alaska Natives, Adjusted (3-Year)

Deaths by Age and Race

0

5

10

15

20

25

30

35

Under 1

1 to

4

5 to

14

15 to

24

25 to

34

35 to

44

45 to

54

55 to

64

65 to

74

75 to

84

85 &

Ove

r

Age

AI/AN, 1996-1998 AdjustedU.S. All, 1997U.S. Black, 1997U.S. White, 1997

Percent Distribution


Age-Adjusted Death Rates per 100,000 Persons by Race

for Cerebrovascular Diseases: U.S. & IHS Service Area - 1997

25.9

24.0

19.9

26.7

29.5

0

5

10

15

20

25

30


(HUS)


(IHS)


Ag

e-A

dju

sted

Dea

th R

ate

per

100

,000

Per

son

s


60

80

100

120

140

Age-Adjusted Malignant NeoplasmDeath Rates, 1973-1997

Rate Per 100,000 Population

1973 1975 1980 1985 1990 1995 1997

Calendar Year

American Indians & Alaska Natives, Actual

U.S. All Races

American Indians & Alaska Natives, Adjusted


0

10

20

30

40

Age-Adjusted Lung Cancer Death Rates

Per 100,000 Population

1973 1975 1980 1985 1990 1995 1997

Calendar Year

American Indians & Alaska Natives, Actual

U.S. All Races

American Indians & Alaska Natives, Adjusted


Age–Adjusted Death Rates Per 100,000 Persons By Race & Hispanic Origin

For Unintentional Injuries: U.S.

37.7 38.836.3

53.1

16.7

29.8

0

10

20

30

40

50

60



Native


Hispanic

Ag

e-A

dju

ste

d D

ea

th R

ate

pe

r 1

00

,00

0 P

ers

on

s


Age-Adjusted Death Rates per 100,000 Persons by Race for Unintentional Injuries: U.S.

& IHS Service Area - 1997

30.1 29.6

58.5

82.2

94.7

0

10

20

30

40

50

60

70

80

90

100


(HUS)


(IHS)


Ag

e-A

dju

sted

Dea

th R

ate

per

100

,000

Per

son

s

Unintentional Injuries Age-Adjusted Death Rates, per 100,000 Persons

U.S. and Selected States, 1995-1997

30.336.7

33.029.8 30.0

33.736.7

0.0

33.5

57.4

133.1

11.016.4

0.0

17.8

28.8

0.0

31.4

0

20

40

60

80

100

120

140

US SD TX

Age

-Adj

uste

d D

eath

Rat

es p

er 1

00,0

00 P

erso

ns

TotalWhiteBlackAI/ANAsian/PIHispanic

Source: Health, United States, 2007,

Unintentional Injuries Age-Adjusted Death Rates per 100,000 Persons U.S. and Selected States 1995-

1997

30.3

51.4

23.0

29.8

48.2

22.2

36.731.1

26.8

57.4

99.1

0.0

16.4

0.0

13.1

28.8

60.4

9.0

0

20

40

60

80

100

120

US NM MD

Age

-Adj

uste

d D

eath

Rat

es p

er 1

00,0

00 P

erso

ns

TotalWhiteBlackAI/ANAsian/PIHispanic

Source: Health, United States, 2007

Age Adjusted Death Rates Per 100,000 Persons By Race & Hispanic Origin For Motor

Vehicle-Related Injuries: U.S.,2004

15.2 15.614.8

26.0

7.8

14.4

0

5

10

15

20

25

30



Native


Hispanic

Ag

e-A

dju

ste

d D

ea

th R

ate

pe

r 1

00

,00

0 P

ers

on

s


Age-Adjusted Death Rates per 100,000 Persons by Race for Motor Vehicle-related Injuries:

U.S. & IHS Service Area - 1997

15.9 15.9

32.3

46.6

54.8

0

10

20

30

40

50

60


(HUS)


(IHS)


Ag

e-A

dju

sted

Dea

th R

ate

per

100

,000

Per

son

s

Age-Adjusted Mortality Rates Per 100,000 Persons By Race/Ethnicity for Suicide: U.S.,

2004.

10.912.0

5.3

12.2

5.8 5.9

0

5

10

15

20

25

All Races White African American AmericanIndian/Alaska

Native


Hispanic

Age

-Adj

uste

d D

eath

Rat

e pe

r 10

0,00

0 Per

sons


Age-Adjusted Death Rates per 100,000 Persons by Race for Suicide:


10.611.3

12.9

17.6

20.2

0

5

10

15

20

25


(HUS)


(IHS)


Ag

e-A

dju

sted

Dea

th R

ate

per

100

,000

Per

son

s

Source: Health, United States, 2007, Table 29.http://www.cdc.gov/NCHS/data/hus/hus05.pdf#summary and IHS Trends AI/AN Health

Suicide Death Rates for Males Ages 15-24 Per 100,000 Persons by Racial/Ethnic Group

1990-2004

0

10

20

30

40

50

60

1990

2000

2002

2003

2004

Age

-Ad

just

ed D

eath

Rat

e p

er 1

00,0

00 P

erso

ns

Total

White

Black

AI/AN

Asian/PI

Hispanic

Source: Health, United States, 2007 http://www.cdc.gov/NCHS/data/hus/hus05.pdf#summary Table 46.

CDC, ADMH, GHR

Age-Adjusted Death Rates Per 100,000 Persons By Race and Hispanic Origin

For Diabetes Mellitus: U.S., 2004.

24.522.3

48.0

39.2

16.6

32.1

0

5

10

15

20

25

30

35

40

45

50



Native


Hispanic

Ag

e-A

dju

ste

d D

ea

th R

ate

pe

r 1

00

,00

0 P

ers

on

s


Age-Adjusted Death Rates per 100,000 Persons by Race for Diabetes Mellitus:


13.511.9

30.4

44.4

52.8

0

10

20

30

40

50

60


(HUS)


(IHS)


Ag

e-A

dju

sted

Dea

th R

ate

per

100

,000

Per

son

s

Source: Health, United States, 2007, Table 29.http://www.cdc.gov/NCHS/data/hus/hus05.pdf#summary and IHS Trends in AI/AN Health

0 25 50 75 100 125 150 175 200

Tucson

Bemidji

Albuquerque

Phoenix

Aberdeen

Billings

Nashville

Navajo

Oklahoma

Portland

California

Alaska

Rate per 100,000 Population

Actual

Adjusted

Age-Adjusted Diabetes Mellitus Death RatesCY 1996-1998

IHS Adjusted Total - All Areas = 52.8

U.S. All Races (1997) = 13.5

IHS Regional Differences in Indian Health 2000-2001, Table 4.24, p 67.

AGE-ADJUSTED DIABETES DEATH RATES American Indians and Alaska Natives, IHS Service Area

0

10

20

30

40

50

60

70

1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999

Per 100,000 population (single-year rates)

Calendar Year

U.S. All Races

American Indians and Alaska Natives, Actual

American Indians and Alaska Natives, Adjusted

IHS Trends in Indian Health

Age-Adjusted Death Rate Per 100,000 Persons By Race & Hispanic Origin For Chronic Liver

Disease and Cirrhosis: U.S., 2004.

9.0 9.27.9

22.7

3.2

14.0

0

5

10

15

20

25



Native


Hispanic

Ag

e-A

dju

ste

d D

ea

th R

ate

pe

r 1

00

,00

0 P

ers

on

s


Age-Adjusted Death Rates per 100,000 Persons by Race for Chronic Liver Disease and

Cirrhosis:U.S. & IHS Service Area - 1997

7.4 7.3

20.6

31.7

36.4

0

5

10

15

20

25

30

35

40


(HUS)


(IHS)


Ag

e-A

dju

sted

Dea

th R

ate

per

100

,000

Per

son

s

Source: Health, United States, 2007, Table 29.

and IHS Trends in AI/AN Health ttp://www.cdc.gov/NCHS/data/hus/hus05.pdf#summary

Age-Adjusted Death Rates per 100,000 Persons by Race or Influenza & Pneumonia:


12.9 12.413.4

19.8

21.5

0

5

10

15

20

25


(HUS)


(IHS)


Ag

e-A

dju

sted

Dea

th R

ate

per

100

,000

Per

son

s

Source: Health, United States, 2007, Table 29. and IHS Trends in AI/AN Health ttp://www.cdc.gov/NCHS/data/hus/hus05.pdf#summary

Age Adjusted Death Rate Per 100,000 Persons By Race & Hispanic Origin for Human

Immunodeficiency Virus (HIV) Disease : U.S., 2004.

4.5

2.3

20.4

2.9

0.7

5.3

0

5

10

15

20

25



Native


Hispanic

Ag

e-A

dju

ste

d D

ea

th R

ate

pe

r 1

00

,00

0 P

ers

on

s

Source: Health, United States, 2007, Table 29. ttp://www.cdc.gov/NCHS/data/hus/hus05.pdf#summary

IHS Appropriations Per Capita Compared to Other Federal Health Expenditure Benchmarks

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

Medicare

Expenditures

per Enrollee

Medical Care

for Veterans

Administration

Users

US Per Capita

Expenditures

for Personal

Medical

Services

Acute Medical

Care for

Medicaid

Enrollees

Medical Care

for Federal

Prison Inmates

FEHB Medical

Care

Benchmark per

IHS User

IHS

Appropriations

& Collections

Per User

5,915

1999

5,214

5,065

1999

3,879

1998

3,803

1999

3,725

1999 1,914

619Med

IHS2002

2001

Non-Med

IHS Per Capita Appropriations

American Indian/Alaska Native Elderly Issues, Social

Poorer Older Less Educated Less Likely to be Married Chronic Disease occur earlier among American

Indians/Alaska Natives Functional Limitations High rates of Disability Low rates of service for which they are eligible

American Indian/Alaska Native Elderly Issues, Behavioral cont.

Smoking Physical inactivity Obesity Diabetes Greater behavioral risk Access barriers Chronic Disease will increase as the number of elders

grows from approximately 310,000 to 459,000 in 2010 (1990 -2000 increase 23%)

American Indian/Alaska Native Elderly Issues, Health Status

20% more like to experience arthritis 49% more likely to experience congestive health

failure 18% more likely to have heart failure 18% more likely to have high blood pressure 18% more likely to have a stroke 44% more likely to asthma 173 % more likely to be afflicted with diabetes

Source IHS Directors Statement

American Indian/Alaska Native Elderly Issues Cultural cont.

Culture, Language and Resources The Seventh Generation Gate Keepers to Knowledge, Customs and

Traditions Respected source in the community The health of the elders is a measure of the

health of our culture and communities.

Total Enrollment of Minorities in Schoolsfor Selected Health Occupations: Nursing, Registered

According to Detailed Race, and Hispanic Origin: U.S. 2001-2002

100.0

78.4

11.8

1.1 3.8 4.9

0

10

20

30

40

50

60

70

80

90

100

All Races White Non-Hispanic

AfricanAmerican

Non-Hispanic

AmericanIndian

Asian Hispanic /Latino

Pe

rce

nt

Dis

trib

uti

on

of

Stu

de

nts

Total Enrollment of Minorities in Schoolsfor Selected Health Occupations: DentistryAccording to Detailed Race, and Hispanic

Origin: U.S. 2004-2005

100.0

66.1

5.40.5

22.1

5.8

0

10

20

30

40

50

60

70

80

90

100


AfricanAmerican

Non-Hispanic

AmericanIndian


Pe

rce

nt

Dis

trib

uti

on

of

Stu

de

nts

Total Enrollment of Minorities in Schoolsfor Selected Health Occupations: Medicine (Allopathic)According to Detailed Race, and Hispanic Origin: U.S.

2004-2005

100.0

63.3

7.40.9

20.7

6.7

0

10

20

30

40

50

60

70

80

90

100


AfricanAmerican

Non-Hispanic

AmericanIndian


Pe

rce

nt

Dis

trib

uti

on

of

Stu

de

nts

Total Enrollment of Minorities in Schoolsfor Selected Health Occupations:

Medicine (Osteopathic) According to Detailed Race, and Hispanic Origin: U.S. 2004-2005

100.0

73.5

3.70.7

15.7

3.8

0

10

20

30

40

50

60

70

80

90

100


AfricanAmerican

Non-Hispanic

AmericanIndian


Pe

rce

nt

Dis

trib

uti

on

of

Stu

de

nts

Percent Distribution of Enrollment of Minorities

in Medical and Dental Schoolsby Race/Ethnicity 2004-2005

63.366.1

73.5

7.45.4 3.7

0.9 0.5 0.7

20.7 22.1

15.7

6.7 5.8 3.8

0

10

20

30

40

50

60

70

80

Medicine (Allopathic) Dentistry Medicine (Osteopathic)

White

Black

AI/AN

Asian

Hispanic

Thought Provoking

Treat all men alike. Give

them all the same law. Give

them all an even chance to

live and grow. All men were

made by the same Great

Spirit Chief. They are all

brothers. The earth is the

mother of all people, and all

people have equal rights

upon it.

Chief Joseph, Nez

Perce

Documents

University of North Carolina Chapel Hill MHCH/PUBH Understanding and Addressing Health Disparities in the US “Raising Awareness of American Indian/Alaska