Child Trends’ president, Carol Emig, submitted the following comments to the National Academies of Sciences, Engineering, and Medicine’s Ad Hoc Committee on Racial and Ethnic Health Inequities, along with a short letter to introduce the comment authors:
“On behalf of Child Trends, I am proud to submit the enclosed response to the Ad Hoc Committee’s request for input on federal policies that contribute to racial and ethnic health inequities. The response is authored by Child Trends researchers Heather Sauyaq Jean Gordon, PhD, Deana Around Him, DrPH, and Elizabeth Jordan, JD, and is fully endorsed and supported by Child Trends. Thank you for your efforts to promote health equity and for the opportunity to provide input to your work.”
Dear Committee of the National Academies of Sciences, Engineering, and Medicine:
We are grateful for this opportunity to provide examples of how federal policies contribute to racial and ethnic health inequities for Indigenous children and families. As we describe below, due to Federal Indian Law, Indigenous communities have faced unique traumas and challenges from a history of colonization and genocide; however, they also bring incredible strengths and protective factors that could be better supported through federal policy. We believe the federal government has a key role to play in reducing disparities for Indigenous communities through changes to federal policies that currently foster inequities in the health and well-being of Indigenous children and families.
Throughout these comments, we use the terms Indigenous Peoples, Indigenous Nations, and Indigenous communities to refer to Alaska Natives (Indigenous Peoples from lands presently known as Alaska), American Indians (Indigenous Peoples from lands presently known as the contiguous 48 states), Native Hawaiians (Indigenous Peoples from lands presently known as Hawaii), Other Pacific Islanders (Indigenous Peoples from lands presently known as the Pacific Islands), and descendants of the Taino (living primarily in lands presently known as Puerto Rico). These are Peoples who existed in the United States (U.S.) and U.S. territories prior to European/Russian colonization beginning in the late 1400s.
Child Trends is a highly respected, nonpartisan research organization focused exclusively on improving the lives and prospects of children, youth, and their families. Our researchers and evaluators have decades of experience providing research support and technical assistance to a variety of leaders, including Tribal Nations, programs serving Indigenous children and families, early childhood programs, and states. We also provide research, analysis, and technical assistance services through grants and contracts from several federal offices, including the Administration for Children and Families (ACF).
Our research experience and academic credentials show our commitment to working with Indigenous communities to achieve community well-being. Our researchers’ close collaborations with Indigenous communities have included teaching, supporting and leading research projects, providing capacity building to communities and researchers, and supporting relationship building between Indigenous communities and researchers to create mutually beneficial research. We have backgrounds in the social determinants of health and the life course approach to health, training in maternal and child health, and experience working with Indigenous communities to develop and adapt interventions, build public health research and evaluation capacity, and strengthen knowledge and infrastructure in the areas of research oversight and ethics. We also have experience with participatory approaches to research, including community-based participatory research (CBPR) or community-led approaches with Indigenous communities. Our recent Comments on Technical Assistance Needs and Priorities on Implementation and Coordination of Early Childhood Development Programs in American Indian and Alaska Native Communities provide extensive information on how to work with Indigenous Peoples—insights that will be vital in addressing federal policy changes.
Our research team also includes a prior employee of the Administration for Native Americans who worked closely with prospective grantees, helping them develop rigorous evaluation plans for their projects; these plans included clearly defined objectives, goals, and steps to accomplish goals. In that role, this researcher also worked with the Native Youth Initiative for Leadership, Empowerment, and Development (I-LEAD) grantees, sharing strategies on engaging youth through photovoice (a participatory research method that asks youth to take photos of their communities to more authentically document and reflect on reality), talking about culture as a protective factor, and reviewing futures scenarios to help Indigenous youth reach an optimistic future and have positive outlooks. They also advised ACF on the missing and murdered Native Americans crisis and on methods for research and evaluation with Indigenous Peoples.
Much of federal policy, statute, and case law (especially Federal Indian Law and past and present policies) affects the health of Indigenous Nations, Peoples, and communities in the United States and U.S. territories. Colonization, which is ongoing and pervasive in federal policy, continues to negatively affect the health of Indigenous Peoples and communities. Relationships between Indigenous Peoples and foreign governments began with treaties (many which have since been broken) and continue today in case law, statute, and policy. This body of policy, also known as Federal Indian Law, directly impacts the health of Indigenous communities (Image 1). Research demonstrates a loss of both sovereignty and the ability for Indigenous Peoples to practice their self-determination (defined by the United Nations Declaration on the Rights of Indigenous Peoples as the right of Peoples to “freely determine their political status and freely pursue their economic, social and cultural development”) in Indigenous communities.
Figure 1: Adverse Outcomes of Federal Indian Law
Image source: Hoss, A. (2019). Federal Indian law as a structural determinant of health. Journal of Law, Medicine & Ethics, 47(S4), 34-42.
Indigenous Nations are inherently sovereign based on their governments’ existence prior to colonization; however, Federal Indian Law places “practical” limits on Tribal sovereignty, in that the U.S. government provides their own interpretation of how it can exist. The U.S. federal government only recognizes the sovereignty of 574 Tribal Nations. Dozens more Tribes are unrecognized by the federal government and may be working toward recognition, including some Tribes that lost recognition during the Termination Era (1945-1960)—when the federal government took away federal recognition and land in an attempt to dissolve Tribal governments and assimilate their populations (Native Hawaiians, Other Pacific Islanders, and Taino descendants do not have any federal recognition of their sovereignty).
Earlier case law also aimed to take land. Three U.S. Supreme Court cases known as the Marshall Trilogy (Johnson v. McIntosh in 1823, Cherokee Nation v. Georgia in 1831, and Worcester v. Georgia in 1832) took Indigenous lands through the Doctrine of Discovery. The cases limited who Tribes could sell or cede land to (only the federal government); characterized Tribes as “domestic dependent nations” and related them to the United States as a “ward to his guardian,” such that the United States had trustee responsibilities to protect their resources and well-being and provide educational services; and determined that, although considered “dependent” on the U.S. government, Tribes have the “right to self-government.” While these cases restricted the external powers of Indigenous Peoples, they also recognized limited but persistent Tribal sovereignty over Tribal lands and members. In 1886, the U.S. Supreme Court decided United States v. Kagama, which gave the U.S. Congress “plenary power” to extinguish Tribal sovereignty (in the practical sense) at any time.
Beyond limiting sovereignty, federal policy has also caused great harm to Indigenous Peoples’ health and well-being through warfare, disease, deceitful treaties, slavery, and forced relocation—practices considered justified by the Doctrine of Discovery. The Indian Removal Act of 1830 forced tens of thousands of American Indians from their homelands in the southeastern United States to lands roughly 1,000 miles away. Thousands died from disease, winter weather, and starvation along what is now described as the Trail of Tears. The 1887 Dawes Act further disrupted Indigenous communities when it deliberately broke up reservation land and sold it to non-Native people. In 1968, Congress passed the Indian Civil Rights Act (ICRA), which described the limited governmental powers Indigenous Nations are allowed to possess, according to their colonizer, the U.S. government.
The United States purchased Alaska from Russia in the 1867 Russian-U.S. Treaty of Cession, even though Alaska Natives did not recognize Russia as the owners of Alaska. The United States annexed Hawaii in the 1898 Newlands Resolution, claiming ownership of all islands of Hawaii without the consent of the Hawaiian sovereign government. Territories with Indigenous populations were acquired through the 1898 Treaty of Paris (Guam, Puerto Rico); the 1900 and 1904 cessions of the islands of Tutulia and Manu’a, respectively, and a 1925 act of the U.S. Congress relating to Swain Island (American Samoa); and the 1947 United Nations Trust Territory of the Pacific Islands (Commonwealth of the Northern Mariana Islands). Most Indigenous Peoples in the United States and its territories have had most, if not all, of their land taken by the United States. Kimmerer explains, “To the settler mind, land was property, real estate, capital, or natural resources. But to our people, it was everything: identity, our connection to the ancestors, the home of non-human kinfolk, our pharmacy, our grocery store, our library, the source of everything that sustained us.”
Further assimilation practices have also led to loss of life, cultures, and languages. These include forced and coercive attendance at government and missionary boarding schools beginning in the 1800s, which did not allow Indigenous cultures or languages; restrictions on spiritual practices through the Religious Crimes Code in 1883, which were not lifted until the U.S. Constitution’s First Amendment rights were granted to Indigenous Peoples in the American Indian Religious Freedom Act of 1978 (even though their U.S. citizenship had been established in the 1924 Indian Citizenship Act); sterilization of American Indian women without their consent by the U.S. Indian Health Service; and disconnection fostered by the 1940s and 1950s Indian Relocation Program, which decreased funding to reservations and moved Native people from reservations to cities with little preparation or support.
Federal policy efforts that attempt to address race equity and health for Indigenous Peoples and communities should emphasize decolonization. Health inequities experienced by Indigenous Peoples are directly linked to their colonization through treaties, case law, statutes, and policies, which over time have included genocide through wars and massacres; diseases; forced removal from their homelands; boarding schools and related assimilation policies; racism; and legislation suppressing cultures, religions, and languages. Colonization is not over: There has never been decolonization or an overhaul of Federal Indian Law and the policies, case law, and legislation that continue colonization of Indigenous Peoples.
Colonization results in historical trauma, which is the cumulative emotional and psychological wounding that Indigenous people experience over their lifespans and across generations. Historical trauma impacts the well-being of Indigenous individuals, families, and communities. Increased cumulative stress from historical trauma can have direct, negative impacts on health and drive the adoption of unhealthy behaviors, resulting in adverse mental, behavioral, physical, social, and relational health; high rates of suicide, substance misuse, adverse childhood experiences, poverty, maternal morbidity and mortality, food insecurity, rape, assault, and homicide; overrepresentation in the criminal justice system; environmental injustice; and more. These disparities are maintained by colonizing federal policies, case law, and statutes (Image 2).
Figure 2: Logic Model Linking Federal Indian Law to Adverse Health Outcomes
Image source: Hoss, A. (2019). Federal Indian law as a structural determinant of health. Journal of Law, Medicine & Ethics, 47(S4), 34-42.
Federal policies should promote and support Indigenous cultures, which serve as a preventive and protective factor against colonization and historical trauma for Indigenous children and families and build Indigenous community resilience against adverse health outcomes. Federal policies should reflect what Indigenous Knowledge has known for millennia and what a growing body of research tells us—that an asset-based approach that recognizes culture as a protective and preventive factor improves Indigenous child and family well-being. There are six primary areas of Indigenous cultures linked to protective and preventive results, including 1) enculturation and Indigenous identity formation; 2) traditional activities and games; 3) relationships with the land, including subsistence and traditional foods; 4) social connectedness among family, across generations and with Elders, and with community; 5) Indigenous languages; and 6) spirituality and ceremonies.
Indigenous health and well-being are tied to Indigenous relational perspectives on the natural world, traditional healthy foods, and passing on cultural practices. Subsistence is an important aspect of well-being for Indigenous Peoples and means more than just hunting, fishing, and gathering food. Indigenous Peoples see subsistence as part of spirituality and way of life, and as a way to relate to the natural world and steward it as protectors and keepers while it provides food for survival. Subsistence is intricately related to Indigenous Peoples’ overall sense of well-being, and passing on subsistence practices gives younger generations grounding in their culture (which, in turn, is protective).
Federal Indian Law is an extensive amassing of case law, statues, and policies that legalize past and present colonization and genocidal practices. It is directly tied to health disparities as a structural determinant of health through termination of Tribes, hyperregulation of Indigenous Peoples and citizenship through blood quantum, and removal of Indigenous ownership and access to ancestral sacred lands and waters. At present, Federal Indian Law sustains the U.S. government as a guardian of Indigenous Peoples—able to use plenary power, break treaties, and dictate consultation (a trust responsibility established by treaties)—leading to decisions that inhibit Tribal jurisdiction over their lands and citizens.
Until the harm caused by Federal Indian Law is addressed, it will continue the genocide of Indigenous Peoples in the United States and its territories. From 1492 to now, it’s estimated that 13 million Indigenous people have died on present-day U.S. lands. As defined by Polish lawyer Raphael Lemkin, “genocide does not necessarily mean the immediate destruction of a nation, except when accomplished by mass killings of all members of a nation. It is intended rather to signify a coordinated plan of different actions aiming at the destruction of essential foundations of the life of national groups, with the aim of annihilating the groups themselves. The objectives of such a plan would be the disintegration of the political and social institutions, of culture, language, national feelings, religion, and the economic existence of national groups, and the destruction of the personal security, liberty, health, dignity, and even the lives of the individuals belonging to such groups.”
In this section, we outline five ways in which federal policies create health inequities for Indigenous Peoples and negatively impact the community and cultural context for Indigenous children and families. Although we do not provide a comprehensive accounting of all Federal Indian Law, the categories are helpful for organizing the overarching policy issues.
First, policies that diminish Indigenous sovereignty and self-determination create health inequities for Indigenous children, families, and communities. Past and present colonization by the United States suppresses the freedom of Indigenous Nations to be self-determining. As Dr. Darlene Sambo Dorough (Iñupiaq Indigenous rights advocate) explained, when “self-determination is denied, the repercussions are felt by its individual members and overall Indigenous communities are destroyed or become vulnerable to destruction.” Self-determination is a right outlined in the United Nations Declaration on the Rights of Indigenous Peoples. Makau W. Mutua, JD emphasized that “The most fundamental of all human rights is that of self-determination … Without this group or individual right, no other human right could be secured, since the group would be unable to determine for its individual members under what political, social, cultural, economic and legal order they would live.”
Self-determination is a freedom required for well-being and survival, and Indigenous Nations practice it through self-government, subsistence, fate control, freedom, and cultural regeneration and maintenance. When Indigenous Peoples are removed from their traditional lands and food sources, stripped of their identity through assimilation practices, and have their sovereignty limited, these practices lead to a lack of wellness. The well-being of Indigenous children and families is directly impacted by policies that limit self-determination and impede Indigenous Peoples’ access to protective cultural practices (e.g., healthy traditional foods) and ability to provide safe homes and communities. A recent study found that putting decision-making power in the hands of Indigenous Nations to address their own lives is the best way to deal with colonialism, especially as Indigenous Peoples may hold values different from the majority population. Example policy areas in which Indigenous sovereignty and self-determination are diminished include:
Second, policies that erode Indigenous rights to land stewardship and subsistence damage the relationship between Indigenous Peoples and the natural world and create health inequities by harming food security, the ability to pass on protective cultural ways, and access to healthy traditional foods. Examples of specific policies that erode Indigenous rights to land stewardship and subsistence include:
Third, policies that reinforce blood quantum are a codification of race and prevent Indigenous people from having unified communities and passing protective cultural ways to future generations. Indigenous people do not see themselves as being a “percentage” Indigenous. This type of external classification conflicts with Indigenous cultures, causes community stratification, and damages well-being. However, federal policies promote or reinforce this idea in many ways. For example:
Fourth, health care for Indigenous people (part of the federal trust responsibility, codified in the Snyder Act) is chronically underfunded, lacks adequate infrastructure, and is difficult to access, all of which perpetuate grave health inequities for Indigenous children, families, and communities. For example:
Fifth, chronic underfunding of education (part of the federal trust responsibility)—as well as barriers to federal funding for infrastructure and other services—perpetuate social and economic inequities that contribute to health inequities for Indigenous communities. For example:
Since the 1970s Self-Determination policy era, Congress has passed a number of federal statutes that promote Tribal self-determination and self-government. Many of these laws were passed due to strong advocacy by Indigenous Nations and people. For example, the 1975 Indian Self-Determination and Education Assistance Act created opportunities for Indigenous Nations to engage in more self-governance. With greater attention to their full implementation, many other federal policies and practices can also promote Indigenous health equity.
First, government acts and policies written specifically to improve the well-being of Indigenous populations are vulnerable to being rescinded, or are being implemented in ways that are detrimental to the health of Indigenous children and families.
Second, despite increasing federal investments in programs and services for Indigenous Peoples that can reduce disparities, resources are inadequate to meet federal obligations and inaccessible to many communities. The following circumstances create environments wherein Indigenous Nations may not feel appropriately consulted or qualified to apply for funding, or feel that their specific needs are being met regarding issues related to the well-being of their children, families, and communities.
Third, many current federal policies and initiatives limit participation to federally recognized Tribes, reducing their ability to correct existing health inequities. For example:
Fourth, U.S. laws and policies do not adequately protect resources and rights foundational to human health within Indigenous communities. There are many instances in which environmental regulatory practices within or near Indigenous communities are not enforced, are insufficient, or fail, resulting in environmental injustices (e.g., poisoned lands and waters that increase toxic exposures through everyday activities and traditional food and medicinal sources). For example:
Much work has been done by Indigenous Peoples and the federal government to understand the ways in which policies contribute to health inequities and to develop potential policy solutions. With that existing work in place, we recommend the Committee look to two additional resources to understand some of the key federal policy gaps and areas for necessary implementation support. The first is the National Congress of American Indians’ (NCAI) annual and mid-year resolutions—“one of the policy mechanisms utilized by NCAI to express the consensus positions of member tribes on tribal, federal, state, and/or local legislation, litigation, or policy matters that affect the welfare and rights of American Indian and Alaska Native governments or communities.” Resolutions go into detail on improving implementation of federal grant programs and funding for Tribes (e.g., Calling on Centers for Medicare and Medicaid Services to Permanently Expand Telehealth, Calling on Federal Agencies to Expedite Grant Review and Award Processing for Critical 2022 Tribal Infrastructure Projects, Particularly in Areas with Limited Construction Windows, and In Support Of Expanding Access to Impact Aid for Tribally Controlled Schools), providing federal strategies for supporting Tribal sovereignty and self-determination (e.g., Calling Upon Congress to Recognize a Right of Indigenous Economy and Calling on the Federal Communications Commission [FCC] to Respect Tribal Data Sovereignty Regarding Broadband Data in the Broadband Data Collection Portal), describing the ways in which Indigenous culture may both support and be supported by federal policy (e.g., Supporting Tribal Nations’ Innovative Solutions to Drought in the West and Declaring Native American Languages in a State of Emergency and Support for an Executive Order on Native American Language Revitalization), and elevating unique needs and historical injustices of Indigenous children, families, and communities (e.g., Support for a National Native Youth Suicide Prevention Initiative and Entreating a United States Proclamation that a Genocide was Committed on Native Children, Families, and Nation).
In addition to NCAI’s resolutions, the U.S. Commission on Civil Rights published a 2004 report, Broken Promises: Evaluating the Native American Health Care System, which was later updated and expanded in 2018. Many of the recommended changes to federal policy within both reports remain unfulfilled and may be informative to the Committee. In addition to describing the strong connection between the federal government’s broken treaty obligations and Indigenous Peoples’ health, both reports describe how health equity could be supported through federal investments in housing, public safety, education, economic development, core infrastructure, and technical assistance. In particular, the 2018 report provides comprehensive descriptions of the health disparities experienced by Indigenous people, such as lower life expectancies and higher infant mortality and suicide rates, and describes the ways in which federal health care programs fail to fully support the needs of these communities.
We hope the Committee’s analysis considers how federal policies that do not acknowledge and respect Indigenous sovereignty, Knowledge, self-determination, histories, and needs lead to health inequities for Indigenous Peoples. We conclude with the following considerations when prioritizing action regarding federal policies to advance health:
Gordon, H. S. J., Around Him, D., & Jordan, E. (2022). Federal policies that contribute to racial and ethnic health inequities and potential solutions for Indigenous children, families, and communities. Comments to the National Academy of Sciences Ad Hoc Committee on Racial and Ethnic Health Inequities. Child Trends. https://doi.org/10.56417/9136x1024u
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