Code Talkers, Boarding Schools, & Approaches to Healthcare for Native American Patients
7-9 Minute Read
Author: Judy Bolstad-Hanrahan, JD, MA
Purpose
To introduce clinical educators to evidence-based approaches to providing effective healthcare to Native American patients and to historical reasons for potential mistrust of western medical institutions.
Learning Objectives
Identify two evidence-based approaches to providing effective healthcare to Native American patients; and
Describe one historical reason that Native American people might have distrust in western medical institutions.
Native American people have served in the American armed forces since the Revolutionary War, and continue to serve at per capita rates higher than any other racial/ethnic group in the United States.(1,2) During World War I soldiers from various American Indian tribes used their native languages to transmit secure military communications (3) while at the same time the United States government was actively trying to eradicate the historical, cultural, and linguistic traditions of Native American communities across the country by targeting native children in off-reservation boarding schools.(4)
The boarding school movement arose after the American Civil War as part of the federal government’s plan toward making a “permanent peace” with Native American peoples across the country. President Ulysses S. Grant articulated an assimilationist agenda to incorporate native people by stripping them of their culture, land, language, and overall lifeways.(4 p.17) Col Richard Pratt, who founded the first off-reservation boarding school for Native American children in 1879 (4 p.1), explained the thought process behind assimilation versus outright murder of indigenous people,
A great general has said that the only good Indian is a dead one, and that high sanction of his destruction has been an enormous factor in promoting Indian massacres. In a sense, I agree with the sentiment, but only in this: that all the Indian there is in the race should be dead. Kill the Indian in him, and save the man.(5)
According to historian Samantha Williams, the assimilationist endeavor involved eliminating both the outward appearance of being Native American, including cutting hair, adopting western attire, and banning the use of native languages and attempting to instill western values such as preference for private versus communal property, individualism, and agricultural rather than nomadic living.(4)
Some have called this process of forced assimilation ‘cultural genocide,'(6 as cited by 7) but genocide scholar Patrick Wolfe argues that, “the imposition on a people of the procedures and techniques that are generally glossed as ‘cultural genocide’ is certainly going to have a direct impact on that people’s capacity to stay alive (even apart from their qualitative immiseration while they do so).”(7 pp.398-99) Wolfe points to health disparities including a life expectancy for Aboriginal Australians 25% lower than non-indigenous Australians, and asks, “What species of sophistry does it take to separate a quarter ‘part’ of the life of a group from the history of their elimination?”(7 p.399)
The history of genocide against Native Americans continues today in assimilationist practices and structures that continue to marginalize, dominate, or eradicate indigenous knowledge, culture, familial bonds, and health/healing practices. Western medicine and its institutions are associated with this history of genocide in several ways including 1. as yet another supremacist institution that believes its way of knowing is superior to indigenous ways of knowing, 2. as failing to recognize that its ways of knowing were developed within the same societies that caused many of the worst health issues for Native American people, 3. as rooted in western values–for example, individualism rather than community, and 4. as fundamentally assimilationist rather than integrationist. Considering the traumatic history of things like forced sterilization of Native American women Melissa Lewis notes,
There is some mistrust of medical providers by Native people. I believe that some basic education of medical providers can help reduce the mistrust. If you don’t understand your patients’ health beliefs or decision making, you need to learn more about where they come from.(8)
Medical and nursing school curricula teach undergraduate medical and nursing students several evidence-based approaches to providing effective healthcare for Native American patients including 1. Cultural Humility, 2. Strengths-Based Approach to Healthcare, and 3. Incorporation of Native Health and Healing Practices.(9-11) Consider including these practices in your own medical practice and reinforce them with students who rotate with you.
Cultural Humility
The importance of trying to understand the lived experience, including the historical context, of one’s patient population cannot be understated. While it would be nearly impossible for any single practitioner to know the full history and traditions of every ethnic, cultural, religious, or other minority or minoritized group, all practitioners can engage in the “process of self-reflection to understand personal and systemic biases and to develop and maintain respectful processes and relationships based on mutual trust.”(11) The Canadian First Nations Health Authority explains, “Cultural humility involves humbly acknowledging oneself as a learner when it comes to understanding another’s experience.”(12)
Remember you are coming from a medical culture with its own customs, norms, and values–make it your standard practice to have genuine curiosity with your patients about their own customs, norms, and values.
Strengths-Based Care Approach
The strengths-based approach to health emerged in response to calls from indigenous peoples globally to center Indigenous knowledge, culture, and social structures when discussing health disparities and solutions rather than focusing on individual or community deficit or utilizing language of despair.(13) “Healthcare and health professions education informed by such frameworks aim for health equity through the use of Indigenous perspectives on well-being, human dignity, capacity building, agency, and resilience.”(13) What this means in a patient encounter is highly dependent on whether the practitioner is themselves indigenous and, when they are not, their level of knowledge of and involvement with local indigenous communities. A practitioner who is indigenous may be best suited to both direct the patient towards cultural and social resources and to engage the patient in a dialogue to elicit their individual, cultural, and social resources. All practitioners, regardless of their level of engagement with the Native American community, can, and arguably should, engage in a dialogue to elicit patients’ individual, cultural, and social resources. This approach can be used for patients from any cultural background, but it particularly resonates for Native American patients because it values and works with patients’ often deeply important cultural, spiritual, and community resources.
Incorporation of Native Health and Healing Practices
Incorporation of Native health and healing practices is increasingly encouraged for intrinsic and instrumental reasons. Intrinsically, mounting scientific evidence supports the efficacy of these practices, and instrumentally, it aids the physician patient relationship. The US Veteran’s Administration uses and supports the use of the Navajo Enemy Way Ceremony for Native American soldiers returning from war.(14) Incorporating native health and healing practices could range from connecting with local indigenous health advocates or healers to develop culturally specific health interventions, resources, or support systems to finding and connecting Native American patients to local native cooking classes–for nutrition, sobriety resources–for substance use issues, or dance classes or running groups–for exercise options or it could merely be urging your patients to look to their local community for these kinds of resources.■
References
United States of America Department of Veterans Affairs. American Indian and Alaska Native Veterans: 2017. National Center for Veterans Analysis and Statistics; 2022:28. Accessed November 4, 2022. https://www.va.gov/vetdata/docs/SpecialReports/AIAN.pdf
National Indian Council on Aging. American Indian Veterans Have Highest Record of Military Service. NICOA.org. Accessed November 4, 2022. https://www.nicoa.org/american-indian-veterans-have-highest-record-of-military-service/
National Museum of the American Indian. Native Words, Native Warriors. americanindian.si.edu. Accessed November 4, 2022. https://americanindian.si.edu/nk360/code-talkers/
Williams SM. Assimilation, Resilience, and Survival: A History of the Stewart Indian School, 1890-2020. University of Nebraska Press; 2022.
Kliewer A, Mahmud M, Wayland B. “Kill the Indian, save the man”: Remembering the stories of Indian boarding schools. The University of Oklahoma. Accessed November 7, 2022. https://www.ou.edu/gaylord/exiled-to-indian-country/content/remembering-the-stories-of-indian-boarding-schools
Lemkin R. Axis Rule in Occupied Europe: Laws of Occupation, Analysis of Government, Proposals for Redress. 2nd ed. Lawbook Exchange, Ltd; 2008.
Wolfe P. Settler colonialism and the elimination of the native. Journal of Genocide Research. 2006;8(4):387-409. doi:10.1080/14623520601056240
Weiner S. Culture and Cures: Healing Native American Health. AAMC News. (September 2017). Accessed October 20, 2022. https://www.aamc.org/news-insights/culture-and-cures-healing-native-american-health
Lewis M, Prunuske A. The Development of an Indigenous Health Curriculum for Medical Students. Academic Medicine. 2017;92(5):641-648. doi:10.1097/ACM.0000000000001482
Gelt J. The Healing Power of Ceremony the Integrative Health Benefits of Diné Cleansing Practice. Published online July 2017. Accessed October 20, 2022. https://www.nursing.arizona.edu/news/healing-power-ceremony-integrative-health-benefits-din%C3%A9-cleansing-practice
Kennedy A, Sehgal A, Szabo J, et al. Indigenous strengths-based approaches to healthcare and health professions education – Recognising the value of Elders’ teachings. Health Education Journal. 2022;81(4):423-438. doi:10.1177/00178969221088921
First Nations Health Authority. Cultural Safety and Humility. Accessed November 20, 2022. https://www.fnha.ca/wellness/wellness-and-the-first-nations-health-authority/cultural-safety-and-humility
Askew DA, Brady K, Mukandi B, et al. Closing the gap between rhetoric and practice in strengths‐based approaches to Indigenous public health: a qualitative study. Australian and New Zealand Journal of Public Health. 2020;44(2):102-105. doi:10.1111/1753-6405.12953
National Library of Medicine. Traditions Preserved and Renewed: The Talkers’ Code of Silence. Accessed November 3, 2022. https://www.nlm.nih.gov/nativevoices/exhibition/healing-ways/native-heritage/navajo-code-talkers.html