Virtual Mentor. October 2009, Volume 11, Number 10: 793-798.
History of Medicine
The Indian Health Service and Traditional Indian Medicine
The Indian Health Service was created within the Department of Health and Human Services to integrate traditional Indian healing with Western biomedicine.
Everett R. Rhoades, MD
The federal government’s assumption of responsibility for American Indian health care brought together two fundamentally different systems: centuries-old traditional Indian medicine and modern Western medicine. Early physicians, while acknowledging extensive Indian use of herbal remedies and certain successful therapeutic procedures, generally regarded Indian healing as based primarily on superstition. Even so, recognition of Indian healing successes and patients’ insistence on being seen by a traditional healer sometimes resulted in a certain degree of cooperation between physicians and traditional healers . Systematic attention to Indian medicine, however, may be considered to have begun in the mid-20th century with two simultaneous occurrences: (1) the Many Farms Demonstration Project and (2) the 1955 transfer of Indian health services from the Department of Interior to the Department of Health, Education and Welfare (now Health and Human Services).
Learning Objective Learn about the development of the Indian Health Service within the Department of Health and Human Services and the efforts made to integrate traditional Indian healing with Western biomedicine.
The Many Farms Demonstration Project
The Many Farms Demonstration Project, a collaboration among the Public Health Service, Indian Health Service (IHS), Cornell University Medical School, the Navajo Nation, and the Many Farms Community, was designed to examine the feasibility of a comprehensive community-oriented system of care in a Navajo community . It was an outgrowth of earlier studies conducted by Cornell University physicians of the newly introduced isoniazid for the treatment of tuberculosis among Navajo Indians. Not surprisingly, the Many Farms Demonstration Project, with its inclusion of an anthropologist, examined the interface of traditional Indian healing and modern medicine. The project’s analysis of traditional Indian healing is perhaps the only semiquantitative approach to the subject and provides information that remains useful today. Part of the success of the program lay in the recognition that “First, it must be realized that this is not a situation of compromising alternatives. Rather, there is belief on the part of patients that both systems have something to offer, they both ‘work’” .
The Indian Health Service
Even before the Many Farms Project and the 1955 transfer referred to above, much of the care provided to Indian people had strong community emphasis, especially in preventive programs. The newly appointed IHS Director, Dr. James R. Shaw, built upon this community orientation and implemented a number of initiatives, one of which was attention to traditional Indian healing. Aware of the important role sometimes played by medicine men in improving community health programs, he recognized the value of inculcating traditional practices in the IHS . For example, he arranged for tours of IHS clinics and hospitals by medicine men, acquainting them with Western medical procedures and practices . This mark of respect for traditional healing set a positive tone for subsequent IHS policy. An illustration of IHS physicians’ calling on the assistance of a traditional healer is related by Dr. Shaw:
An intriguing bicultural aspect of this case is that the ceremony, apparently conducted in the laboratory, reached each patient room through use of the public address system. This case also illustrates that, in addition to specific individual healing procedures, cultural consultations are often important elements of successful therapeutic outcomes. I was once asked to consult (at a non-IHS hospital) on the case of an Indian patient who felt compelled, for rather complex and important tribal religious reasons, to leave the hospital against medical advice. The patient was able to relate the reasons for the need to me but not to his own physicians; the result was a successful outcome.
IHS efforts in the 1960s and early 1970s were given impetus by passage of the 1978 American Indian Religious Freedom Act, which, as the title indicates, was designed primarily to protect American Indian religions. Reflecting the importance of religious expression in much Indian healing, the IHS director issued the following policy statement:
The policy was explicit in regard to Indian patients:
In accord with this policy, in constructing new health care facilities, the IHS often sets aside a room or, in some instances, a building for use by traditional healers. The IHS also expanded efforts to support traditional Indian medicine through employment of a traditional healer, located in Headquarters West, Albuquerque, New Mexico. This individual served as a liaison with local communities and other traditional healers.
In 1992, the formal Traditional Medicine Program was established, also located in Headquarters West. Its primary purpose is to increase the interface between the two systems of care. A further advance occurred in 1994 with issuance of a policy statement introduced by the following memorandum from the IHS director:
This statement coincided with the establishment of the Traditional Cultural Advocacy Program (TCAP) as an important means of ensuring that traditional healing practices are respected by IHS employees in all our services and programs. During the next 2 years, roundtables were held throughout Indian country bringing together traditional Indian healers and IHS personnel to seek ways to foster cooperation and collaboration. In general, there were strong expressions that the IHS (and other government agencies) should do more to foster utilization of traditional healers. A number of suggestions were made, unfortunately many of them not clearly feasible within the federal system.
An important ancillary effort on the part of the IHS has been increased orientation of IHS personnel to respective local Indian customs and traditions. Efforts to make newly constructed facilities more attractive to Indian patients through attention to local cultural norms have also increased. As announced by the director in 2007:
Thus, efforts on the part of the IHS to support traditional healing continue. Presently, the most common interface between IHS practitioners and traditional medicine men and women is in the IHS Alcohol and Mental Health program. It is not uncommon, however, for IHS personnel to participate in certain healing activities such as the increasingly common “sweat” ceremonies used in several healing practices.
A relatively new development that will significantly influence incorporation of traditional healing is the assumption of management of health programs by the tribes themselves. Approximately one-half of health programs are now operated by the tribes through IHS self-determination or self-governance contracts. Notably, tribes are free of many bureaucratic requirements, such as personnel policies, with which the federal agency must comply. The extent to which various tribes incorporate traditional healing is not presently known, but anecdotal information indicates that a number provide for traditional healing.
Given the widely scattered nature of Indian communities and the highly individual nature of medical practice, it is not surprising that a given policy is sometimes unevenly implemented at the local level. In addition, inadequate funding and a number of practical and logistic requirements often pose barriers to full expression of a given policy. In the case of traditional Indian medicine, questions of credentialing, mechanisms of payment, and criteria for federal hiring or consultation by traditional healers as contractors have yet to be satisfactorily resolved. For example, if traditional healers are to become federal employees, they naturally will fall within the extensive civil-service requirements, which they may not be eager to accept. Tribes correctly assert that they are the ones who should designate (i.e., certify) traditional healers. While agreeing, the IHS is still faced with the dilemma of paying for such care, especially given the cumbersome and restrictive federal guidelines for the procurement of medical services, one element of which is the requirement for competitive bidding in the awarding of contracts. In fact, the IHS as a federal bureaucracy has a limited set of mechanisms that can be brought to bear on the subject. Notwithstanding the highest level of desire to be supportive, certain bureaucratic requirements will undoubtedly continue to pose challenges for some time.
Regardless of the several practical considerations, an underlying and fundamental question has not been completely resolved: whether the special sacred nature of much Indian healing might be injured by placing it within the IHS systems of care . As expressed by a young Indian woman to the Task Force on Health of the American Indian Policy Review Commission in 1976, “real traditional Indian healing should not even be talked about too publicly, it is too sacred for that” . Thus, one can appreciate the delicacy with which the IHS, as a federal bureaucracy, must proceed in efforts to provide for traditional Indian medicine. This delicacy is expressed in the 1978 policy noted above:
Each of these systems is affected by modern life and developments, but in different directions. While Western medicine continues dramatic growth, modern pressures are exerting a negative influence on the development of traditional healers and their work. A common concern expressed throughout Indian country is that the number of traditional healers continues to diminish.
It is not possible to predict the future, but it seems clear that support for traditional Indian medicine will continue to occupy the attention of both the IHS and tribal programs and efforts to accommodate each of the systems will continue to evolve. In the meantime, perhaps the most pertinent observation was made more than a half-century ago by the Many Farms leaders: “The two systems then, co-exist, but for any given illness there is no interaction. This situation is very unstable and one of the systems is likely to become dominant—but the outcome will be decided on political grounds, rather than on factors related to the relative efficacy of the two systems” .
Everett R. Rhoades, MD, is professor emeritus of medicine at the University of Oklahoma College of Medicine. A member of the Kiowa Tribe of Oklahoma, Dr. Rhoades is a senior consultant to the Center for American Indian Health Research of the University of Oklahoma College of Public Health and to the Strong Heart Study—a multicenter prospective study of cardiovascular disease and its associated risk factors among 13 Indian tribes. He is descended from a line of traditional healers and has personal experience with traditional Indian medicine. From 1982 to 1993, he served as the first American Indian director of the Indian Health Service.
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