Situated along the banks of the Rio Grande in New Mexico, halfway between Albuquerque and Santa Fe, is the reservation of the Santo Domingo Pueblo people. Archeologists estimate that the Pueblo people have been living off the same land and in the same adobe structures anywhere from 10,000 to 30,000 years.
They've survived European conquests, wars and the encroachment of Western society, holding fast to their traditional culture and centuries-old way of life.
Like so many other American Indian and Alaskan Native peoples, though, the Santo Domingo Pueblo disproportionately suffer from a lack of access to quality health care, the provision of which legally and constitutionally rests upon the United States government.
"The U.S. has promised much in the way of health care to the American Indian people," says Michael Bird, a social worker and member of the Santo Domingo Pueblo, referring to various treaties, legislation and executive orders. Bird, a past president of the American Public Health Association, calls them empty promises. "Just look at how they fund the Indian Health Service."
The IHS, an agency within the U.S. Department of Health and Human Services that serves as the principal federal health care provider and health advocate for approximately 1.9 million of the nation's estimated 3.3 million American Indians, is notorious for being severely underfunded and understaffed; even its new director, Yvette Roubideaux, M.D., a member of the Rosebud Sioux Tribe of South Dakota, admits as much.
"It is clear that we face enormous challenges as we consider how to change and improve Indian Health Service and how to address the health issues of the population we serve," Roubideaux said at her June 29, 2009, swearing-in ceremony.
Those health issues are myriad. In fact, American Indians as a group fare worse than all other minorities in terms of health disparities. For example, according to the IHS, American Indians born today have a life expectancy that is 4.6 years less than the rest of the U.S. population (72.3 years to 76.9 years, respectively).
Also, they die at higher rates than other Americans from tuberculosis (750 percent higher), alcoholism (550 percent higher), diabetes (190 percent higher), unintentional injuries (150 percent higher), homicide (100 percent higher) and suicide (70 percent higher).
But things are changing, or so American Indians have been promised once again.
President Barack Obama, who himself was adopted into the Crow Nation in Montana during the 2008 presidential campaign and bestowed the name "One Who Helps People Throughout the Land," repeatedly has said his administration is committed to regular and meaningful consultation and collaboration with tribal officials in policy decisions that have tribal implications.
On Nov. 5, Obama hosted the largest and most widely attended gathering of tribal leaders ever for what the president billed as the first annual White House Tribal Nations Conference. At the conference, Obama called for a comprehensive strategy to address the needs of American Indians, including health care.
"We know that as long as Native Americans die of illnesses like tuberculosis, alcoholism, diabetes, pneumonia and influenza at far greater rates than the rest of the population, then we're going to have to do more to address disparities in health care delivery," the president said.
Obama has directed each federal agency to create detailed plans to consult and collaborate more with tribal leaders in the development of policies that have tribal implications. Those plans are due in February.
Already the Obama administration, through the American Recovery and Reinvestment Act, has invested half a billion dollars in revamping the IHS. Nelrene Yellowbird, Minot (N.D.) State University assistant professor of social work and NASW board member, says this money is badly needed because of the gross disparities in health care for American Indians.
Yellowbird, a member of the Three Affiliated Tribes — the Mandan, Hidatsa and Arikara, says because of the infusion of dollars from the Recovery Act, her reservation is finally going to get the health care facility it's been promised ever since a flood in the 1950s destroyed the original building.
Still, much more funding is needed to realize the mission of the IHS: to raise the physical, mental, social and spiritual health of American Indians and Alaskan Natives to the highest level.
"This is probably the first time that an administration has made an apology over how the American Indians have been treated over the years," says Yellowbird. "It is the first administration I can remember to really stop and listen to the Indian people, and that gives them hope."
Though it's hard for him not to be skeptical, Michael Bird also thinks there's been a sea change. He and a delegation representing the Santo Domingo Pueblo in October left a meeting with IHS Director Roubideaux feeling very hopeful.
"The meeting went extremely well," recalls Bird. "We had a very constructive dialogue where [Roubideaux] heard what we had to say and recognized the validity of our issues. And, she said she was committed to tribal consultation, which historically has not been the case."
Things are happening in Congress that also give the American Indian people hope. After more than a decade of failed attempts to do so, Congress was poised at this story's deadline to reauthorize the Indian Health Care Improvement Act. First enacted in 1976, the IHCIA is the primary legal framework for funding IHS programs.
The U.S. House of Representatives in November passed the Indian Health Care Improvement Reauthorization and Extension Act as part of the Affordable Health Care for America Act, H.R. 3962.
"It has been a long time coming and it is a moral responsibility that we carry a healthy nation in the country and one that develops with the participation of our tribal leaders to what works best on health care in Indian Country," House Speaker Nancy Pelosi, D-Calif., told tribal leaders at a meeting just days before passage of the AHCAA.
Reauthorization faces two more hurdles, however: The Senate must vote on its version of health care reform legislation, which may or may not contain the IHCIA reauthorization, and then the House and Senate bills need to be merged into a final bill that both houses of Congress must vote on. At this story's deadline, the Senate had yet to vote on its health care reform bill.
Bird says passage of the act is critical. "People in my community literally are dying, there is such a long wait for IHS care because of the lack of resources."
The situation among the Santo Domin-go Pueblo hardly is unique. "IHS has always operated in the red and run out of money before the fiscal year ends, and a lot of people get put on a waiting list and some die waiting for care," says Yellowbird. "That's just how it is."
Among other things, the IHCIA reauthorization legislation would appropriate funding for grant and scholarship programs to increase the recruitment and retention of health care professionals, including social workers. It also would establish mental and behavioral health programs beyond alcohol and substance abuse, such as fetal alcohol spectrum disorders and child sexual abuse and domestic violence prevention programs.
"There is a great need for social workers who can work with American Indians, not just on the reservations but in urban areas as well," says Yellowbird. "This legislation would help."
Yellowbird points out that it would be advantageous for those social workers to be American Indian themselves because they know the customs, traditions and cultural aspects of that group, but she says all social workers should be trained to work in the American Indian community.
"Unfortunately, however, the dominant culture in the U.S. doesn't know our history," Yellowbird says. "To be an effective social worker it's extremely important to be able to build a rapport with one's clients and establish credibility. We've grown in that sense as a profession, to be more culturally sensitive, but I think training definitely could be enhanced."
The social work curriculum today is largely academic and theoretical, Bird says. "Students just don't know what's really happening on a reservation," he says.
Yellowbird says she'd like to see less emphasis on the historical problems plaguing the American Indian community and a greater emphasis on contemporary issues. "Social workers need to have the tools to be able to deal with the problems communities currently face."
Both Bird and Yellowbird say the persistence of certain stereotypes has been a major barrier to getting more social workers to be involved in the American Indian community. Bird says many people simply are afraid to go to a reservation because of their preconceived notions, and still others "cherry pick" certain communities to work in because they're not as difficult to deal with. Yellowbird laughs, "They think there's going to be tepees there!"
Another misconception, Bird points out, is that the American Indian community is monolithic. "For example," he says, "the general public thinks all Indians are benefiting from casinos and that's not the case. Some tribes do have casinos, which have improved their way of life, but that's not the case with my tribe. We don't operate a casino, so we don't have that kind of revenue stream."
Yet another major barrier to getting more social workers involved in the American Indian community is that many reservations are in remote, hard to reach areas of the country.
But information technology is helping to bridge the divide. The Minot State University social work program reaches out to surrounding rural communities and reservations using distance learning technology.
Yellowbird says more American Indians are graduating from the social work program and are able to remain on the reservation as a result. "And their caseloads are already overloaded," she says.