Tribes Know Best
Some two million American Indians and Alaskan Natives in the United States are eligible to receive health care through tribal health programs. As a result, there are a great many opportunities for nurses to provide care for Indian patients living in tribal communities, in a wide variety of settings-from tribal clinics, Indian Health Service (IHS) facilities and tribally run health care institutions to reservations, tribal trust lands and urban clinics.
According to the most recent National Sample Survey of Registered Nurses, there are only about 13,000 American Indian/Alaskan Native (AI/ AN) nurses in the United States-not nearly enough to provide health care for the entire Indian population. As a result, tribal communities must depend on the collaborative efforts of both Indian and non-Indian nurses if they are to receive adequate, accessible and culturally competent nursing care.
But no matter what their race or ethnicity, all nurses who work with Indian populations in tribal settings must understand and appreciate the political and health history of AI/AN tribes if they are to truly provide effective, culturally sensitive care. Many nurses who work with tribal communities-even if they are Native Americans themselves-may not fully understand why Indians have different health resources than the general population, because they lack awareness of the political and historical issues involved and how these issues directly impact health care delivery.
There are over 550 federally recognized Indian tribes in the U.S. and each tribal government is set up differently. Many of these tribes are now managing their own health care programs; some tribes even have their own health insurance. Tribal governments frequently include health boards that make policy decisions affecting health care in general and nursing in particular.
Trust responsibility, tribal sovereignty, tribal politics and self-governance are all terms that are commonly used in Indian communities, including their health care programs. Both Indian and non-Indian nurses who want to work successfully in tribal settings need to understand what these concepts mean and how they affect their roles as nurses.
To understand why Native Americans have tribal health programs that are set apart from the rest of the U.S. health care system, nurses must understand that there is a trust responsibility, established by treaties, between the federal government and Indian tribes. In the 1830s, Chief Justice John Marshall coined the term “domestic dependent nations” to describe the fact that tribes are under the protection of the United States.
This promise by the federal government to provide for the tribes led to the creation of the Indian Health Service, an agency of the U.S. Department of Health and Human Services that is responsible for providing federal health programs to American Indians and Alaskan Natives. It is important for nurses to understand that by working in Indian health care programs, they are helping to fulfill the government’s trust responsibility toward the Indian nations under its care.
Tribal sovereignty means that Indian tribes have the status of independent nations, recognized as such by the federal government, with the inherent right to govern themselves. Today, 500 years after their first contact with Europeans, tribal nations remain distinct political entities. Although they function within the states in which they are located, each tribe operates internally as a sovereign government that deals with the federal system on a government-to-government basis.
The independence and power inherent in tribal sovereignty was strengthened during former President Clinton’s administration, when he decreed that tribal nations and the federal government must consult jointly on issues that directly affect tribes.Tribal sovereignty is an important part of Indian health care, because it is through these government-to-government relationships that tribal nations negotiate for federal health care funding. As the concept of tribal sovereignty has become better understood by the federal government, tribes have increasingly demanded and gained more control over the right to manage their own health care issues and programs-e.g., by taking over the management of former Indian Health Service facilities (see “Self-Governance”). In turn, the IHS has begun downsizing its structure and encouraging more Indian nations who receive federal funding to manage their tribal health programs directly.
Many tribes, such as the Chippewa Cree of Montana, have committees or boards that directly oversee health care issues and the dispersement of health care funds. An important role of nurses who work in tribal settings is to advise and educate tribal politicians about health issues that will affect the board’s decision-making on tribal health policies. In fact, nurses are often the politicians’ sole source of health-related information.
A notable example of this is the recent Supreme Court decision in which the Mille Lacs Band of the Ojibwa tribe regained their tribal rights for hunting and fishing on Indian lands. The influence of public health nurses who were working with the tribe to promote awareness of healthy lifestyles helped tribal leaders identify this as a health-related issue: By being able to hunt and fish, the Ojibwa people were able to return to a more traditional diet, which would help reduce the risk of diabetes in their community.
Self-governance, a tribal rights movement that emerged in the 1980s, refers to a tribe’s decision to manage its functions and programs itself, as opposed to having them managed by a federal agency or administrator, such as the Bureau of Indian Affairs. A group of 10 tribes, including the Cherokee Nation, took the lead in establishing themselves as self-governance tribes that would receive funding from the federal government but decide for themselves how to spend that money. Today, more than half of the nation’s tribes identify themselves as self-governance tribes.
The goals of the self-governance movement are to promote self-sufficiency, establish accountability, reduce bureaucratic red tape and change the roles of federal agencies as they relate to tribes. In the specific context of health care, self-governance means a tribe has exercised its right to run its own tribal health programs, rather than receive health services provided through the IHS.
Native and non-native nurses alike are needed to work in both tribally run and federally run Indian health programs. Tribes view nurses-and Indian nurses in particular-as knowledgeable health care professionals who can play a vital role in helping to direct and supervise tribal health care programs. Therefore, nurses who plan to work in tribal settings must understand that they may be expected to provide not only clinical patient care but also the management expertise needed to actually run clinics or other facilities.
Above all, nurses must understand that tribes know best when it comes to their own health care needs and how to allocate their resources and energies in the right direction. Armed with this insight and wisdom, nurses have the power to make unlimited contributions to improving the health of American Indians and Alaskan Natives.