What’s Really Behind the Native American Health Gap?

Growing up as a member of the Ojibwe tribe, Melissa Walls knew that that diabetes ran in her maternal family. “I’ve lost two very close family members, my great grandfather and an uncle, to complications related to type 2 diabetes,” she says. But it wasn’t until she began studying American Indian health in graduate school, at the suggestion of another uncle who served as a liaison between academics and local tribal communities, that she understood that her family’s plight was part of a much larger problem.

American Indian adults are more than twice as likely as white adults to be diagnosed with type 2 diabetes, according to the Office of Minority Health at the U.S. Department of Health and Human Services. Native American youth experience the highest and fastest-growing rate of the disease of any racial or ethnic group. But those statistics only scratch the surface of the kinds of health disparities that indigenous people face.

Nationally, the average life expectancy for a Native American person born today is 73 years—5.5 years below that for all other races. Members of this community, adolescents in particular, also experience much higher rates of depression, substance abuse, and suicide and suicidal behaviors. In fact, while the national suicide rate has gone up 33 percent since 1999, the rates for Native American women and men have jumped by an alarming 139 percent and 71 precent, respectively, according to a recent report from the Centers for Disease Control and Prevention.

“You could take almost any health outcome and find health inequity for tribes,” Walls says. “I mean, take your pick.”

The health statistics reflect a dire economic reality—1 in 4 Native Americans live in poverty, the highest rate compared to all other races—and the massive gap in medical resources available to this population. The Indian Health Service, which runs clinics and hospitals for Native Americans, spent $3,332 per person in 2017, compared to $9,207 spent on each person in the national health care system, according to a 2018 report on funding shortfalls by the U.S. Commission on Civil Rights.

Walls knows from experience: Like the majority of American Indians, she grew up outside a reservation. Her family lived in International Falls, Minnesota, a town of about 6,000 people—mostly white—near the Canadian border. But to access health services, her family had to go to the nearest reservation. “We drove an hour literally to go to the doctor, to go to the dentist, to get our eyes checked,” she says. “But when you grow up in that context, you don’t label it as an inequity or disparity. It’s just sort of your reality.”

More than two-thirds of Native Americans now live in urban areas, not reservations. That reflects 1950s-era federal policy designed to encourage American Indians living on reservations to urbanize, in the name of speeding “assimilation” (and freeing up tribal lands for federal exploitation). The Bureau of Indian Affairs’ Urban Relocation Program of 1952 and the federal Indian Relocation Act of 1956 offered promises of job training and housing for the new arrivals; the hope was that moving to cities like Chicago, Los Angeles, and Minneapolis would allow more Native Americans to participate in the postwar economic boom. But in practice the relocation policy was “essentially a one-way bus ticket from rural to urban poverty,” as former Indian Affairs Commissioner Philleo Nash admitted in the 1960s.

Walls is now the head of the new Great Lakes hub of Johns Hopkins University’s Center for American Indian Health in Duluth, Minnesota, the city of 86,000 located three hours south of where she grew up. Her team currently works with 11 different tribal communities to better understand the health inequities that Native Americans experience, and try to correct them. The hub is just a 15-minute drive from the Fond du Lac band of Ojibwe tribe, with whom Walls has been working closely on diabetes prevention. Among her research interests: how stress impacts can affect type 2 diabetes, and how culture and community can help to buffer the negative effects of modern lifestyles among Native Americans.

CityLab recently caught up with Walls to talk about possible solutions to health inequities among American Indians, and why the damage that government policies inflicted on this population has been so far-reaching. Our conversation has been edited and condensed.

Can you explain how government policy induced historical trauma in the indigenous population?

The historical trauma encompasses a lot of government actions like setting up reservations and marching people across the country. Then in the the 1950s and ’60s, the government started a relocation program to get [Native Americans] into urban areas, and give them job training programs. It failed miserably, like most of these things did, in part because the job training was woefully inadequate, and often [the jobs available] were temp work or summer employment, if anything.

People were taken out of their family support systems or cultural safety nets, thrown into these urban environments, and expected to survive. Certainly in some cities, native people have worked to try build those kinds of networks. But you are very much a minority in the urban context. I think the idea of not having access to not just your friends and your family, which we all need, but those particular aspects of cultural teachings of ceremony that creates a sense of spirituality, purpose, and belonging would be scary to anybody.

[The relocation policy] was rooted in this flawed idea that all people need to look and act like European Americans, and live the way they do. It’s shocking, if you go into some of these government records, just how blatantly plain the language is about how the goal was really to exterminate or assimilate.

That has impact on communities, and we see it play out in terms of mental health, substance abuse, suicide, and other chronic diseases.

You’ve been largely looking at diabetes—how does historical trauma fit into that story?

In the case of diabetes, one really tangible thing is what we call nutrition transition. In the Midwestern U.S., Ojibwe people once had a thing called a seasonal round, where with each season came new sources of food. In the springtime, you tap trees to get maple syrup. In the fall, you gather wild rice off the lake and you hunt deer. Every season had ways of getting [food] that burned a lot of calories.

Moving away from these ways of eating and getting your food, and suddenly relying on government-sponsored commodity programs [that included] flour, sugar, lard, butter, we start to see rates of obesity kind of going off the charts. And we continue to suffer the consequences.

And this trauma has affected multiple generations?

Some of the research we’ve done is really trying to link up negative health outcomes with specific policies. We’ve published a paper that demonstrates how families who’ve gone through those relocation programs have the worst health outcomes that we can track across three generations.

It’s based on survey data from members of eight tribal communities. We were able to track parents’ reports of their parents going through relocation. If they did, we saw a significant pathway where those [first-generation] parents might have had substance abuse issues, which led to substance abuse and depression in the [second-generation] parents. That led to them being not very good parents of their own kids—the third generation—who at the time were in adolescence. They had bad outcomes like delinquency and depression.

The article was published in 2012, but we continue to collect new data every year from that same cohort, so it’s an ongoing study.

Your research is mostly on communities that live within reservations, but what can you tell us about the current urban Native American population so far?

In our cohort study, the kids who grew up on the reservation, a good chunk of them now have moved on to cities, which is another thing that happens. People tend to migrate between cities and reservations. With our new data that’s being collected from that cohort, we’re going to be able to examine urban-rural differences.

What I do know is that the health issues that hit tribal people on reservations, some reports say they’re actually compounded and worse for people in the cities, for reasons like the lack of access to cultural protective factors and social networks. People are more likely to experience discrimination when they’re in an urban area. And there’s tons of research talking about how that hurts health.

What’s a common misconception about the indigenous community that you hope to dispel?

One of the big stories I’ve helped to push forward is that yes, we have these health inequities, but people on reservations and in urban areas also have really amazing positive stories. Like with positive mental health, when we started measuring it, our communities were off the charts compared to non-native people.

We found this measure created by a sociologist called Corey Keyes [that] assesses emotional well-being, psychological well-being, and social well-being across three domains using 14 different indicators. These items assess basically how much you’re flourishing or languishing in those domains. And the outcome was that the percentage of people in our sample who [reported] flourishing was much higher than what we had seen in other studies with non-Native samples.

So you can have these [inequity] issues, but also have vibrant and cultural richness, family centric [communities] with communal, take-care-of-one-another thinking.

And that has implications for all humans: that being embedded in your community is good for you, that being tied culturally to other people is good for you. It’s not just a dismal doom-and-gloom kind of story.

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What’s Behind the Barcelona Protests?

Barcelona erupted in protests yesterday, after courts handed out sentences of up to 13 years in prison to nine Catalan separatist leaders arrested for their role in staging a 2017 referendum on Catalan independence.

Protesters filled the streets across the Catalan capital, with an estimated 25,000 massing in the city center and an unconfirmed but substantial number at the airport. Employing a strategy most recently used by demonstrators in Hong Kong, they blocked train and metro access to the airport for several hours, causing over 100 flight cancellations.

The police response to the protesters was aggressive: After assaults with batons and foam bullets, 131 people required medical assistance, including one man who lost an eye.

The spark for the demonstrations was the sentencing of the Catalan leaders—among them, former Catalan Vice President Oriol Junqueras—who were responsible for organizing the region’s independence referendum in October 2017. The trial’s defendants maintained that the referendum was legal thanks to a law hustled quickly through Catalonia’s regional assembly, then overturned the following day by the country’s Constitutional Court. Judges rejected their argument and gave Junqueras and three other ministers 13 years apiece in prison for sedition and misuse of public funds. Former parliamentary speaker Carme Forcadell was given 11½ years, two other leaders nine years, and three further politicians were handed fines.

Notably absent from the trial: former Catalan President Carles Puigdemont, who is still evading trial by living in exile in Belgium. In a fiery op-ed published yesterday, Puigdemont insisted that the verdict yesterday will in the end “inevitably backfire on Spain.”

Things could have been worse for the defendants: They were also accused of the crime of rebellion—which carries a potential sentence of 25 years—but that charge was overturned because their moves came with no campaign of violence. As it stands, the long sentences they received are still intensely divisive. While many Spanish citizens support cracking down on the Catalan independence movement, doling out prison time to the region’s former administration can only compound the impression given to many in Catalonia that Spain seeks to maintain control of the semi-autonomous region by authoritarian means—in part to curry favor with voters elsewhere in the country who are happy to see the central government taking a firm, uncompromising hand in Catalonia.

Tension boiled over on the streets of Barcelona soon after the sentences were announced. Activist group Tsunami Democràtic put out calls on social media for protesters to congregate at the airport. Demonstrators started arriving (often by metro and train) in large numbers until by later afternoon, they filled terminal buildings and car parks. Meanwhile, beyond Barcelona itself, a further 25,000 protesters congregated in the nearby city of Girona, where they briefly blocked several highways to France before apparently removing the blockades themselves. The police response was equally swift, and again social media was flooded with images of street clashes. Coming two years after police beat Barcelonans trying to participate in the attempted independence referendum, images of this crackdown have only inflamed tensions more.

It would be a mistake, however, to assume that the clashes represent an uncomplicated publicity coup for pro-independence forces. While regional leaders have applauded the protests, they’re also responsible for directing some of the police conducting the crackdown.

As I explained earlier this year in this CityLab article, Barcelona has a complex—and some would say quasi-dysfunctional—policing situation in which responsibilities are divided between separate national, regional, and urban forces. The officers beating back protesters were thus not just from the Guardia Civil, which is under the control of Spain’s national government, but also from the Mossos D’Esquadra, the main force controlled by the pro-independence regional government. This might seem odd, but while the regional government might be in favor of independence, they are also responsible for public order. Placed in the perverse position of being obliged to police civil unrest fed by a cause they profess approval of, the authorities have tacitly put order first. So when Mossos officers fired foam projectiles at protesters, some opponents of the current regional administration—including figures from the city’s municipal government—have been quick to damn this as hypocritical cynicism.

This doesn’t look good. The regional government is in a very difficult position—they may ostensibly support the aims of the demonstrators, but, on a day when their erstwhile colleagues are behind bars, must nevertheless resist giving the impression that they are a chaotic anti-state force. This has led to a bizarre situation: Regional leaders have been applauding the protests on social media while simultaneously giving orders to break them up.

As of Tuesday, the unrest has died down (at least at time of publication), but with national elections coming up in early November—and no party with an unequivocal lead in the polls—this could all potentially just be chapter one.

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CityLab Daily: The Fears Behind the Bay Area’s Historic Power Outage

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What We’re Following

Candle in the wind: Much of the California Bay Area was blacked out yesterday, in a move that the state utility said would head off the risk that high winds could spark a deadly blaze. It’s being called a “preemptive blackout.” But what does that really mean? Pacific Gas and Electric Co. (PG&E) started shutting down parts of the electricity grid for safety purposes last year after its fragile and poorly maintained power lines helped ignite the deadly Camp Fire in Paradise, California. But this shutdown could last a while—as much as five days in some areas. An estimated 2.4 million people could be in the dark, although the most urbanized parts of the region should be left mostly untouched.

Elected officials and citizens are criticizing the utility for creating the conditions that made this shutdown necessary. PG&E is already under state investigation for last year’s wildfire, and the utility filed for bankruptcy in January, facing billions in liability and possible criminal charges related to its safety record. CityLab’s Sarah Holder has story: The Fears That Shut the Power Off in the Bay Area

Oops: We apologize for a typo in the subject line of yesterday’s newsletter. It should have read: “The Cities Where Emissions Are Already Falling.” You can still check out our story here.

Andrew Small


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