Challenges Abound for Indigenous Peoples of North America

Our world, our nation, our communities, and our specialty have struggled with access to health care and issues related to diversity, equity, and inclusion. The COVID-19 pandemic laid bare many more inequities that were “hidden” in plain view, and struggles for racial justice and fair treatment of all people remain ubiquitous. The ASA Monitor has featured a number of issues focusing on diversity (February 2023), global engagement (April 2023), rural anesthesia (September 2023), advocacy (October 2023), and equity (December 2023), and now we focus on Indigenous Peoples of North America.

One of the most gratifying aspects of practice as an anesthesiologist is the privilege of being involved in some of the most significant moments in the lives of patients and their families. Often, these are moments where we can see life from someone else’s perspective.

Over my more than three decades of practice as an anesthesiologist, I have been privileged to meet and interact with students and trainees at all levels and with thousands of other medical professionals. I often have reason to ask medical students what sparked their interest in medicine and anesthesia trainees what introduced them to the field of anesthesiology. More often than not, the spark turns out to be an individual or an experience where the future anesthesiologist met someone who motivated them, who encouraged them, who helped them learn about something they didn’t know existed. This is mentorship at its best, and watching someone learn about and come to love your profession is an amazing experience. Most of us can think back to people who inspired and motivated us.

On October 8, 2021, I attended the 35^th Annual Meeting of the Society for Pediatric Anesthesia (SPA). This was the first in-person meeting I attended after the onset of COVID-19. I had limited my own travel and was cautious about attending the SPA meeting and the 2021 ASA annual meeting. During a SPA session titled “COVID and Society,” I heard an amazing talk by Delbert Lamb, MD, about the impact of COVID-19 on Native American communities. His talk and follow-up article for the ASA Monitor, “From White Horse to Boston Children’s,” opened my eyes to a world I only vaguely knew about (ASA Monitor 2022;86:16). I knew very little about the Indigenous People of the United States, and my understanding was inaccurate, incomplete, and mostly wrong.

I am a late student of history; somehow there was never time to add this to my course list, and my poor knowledge of history and geography is a weakness of mine. In my journey to understand and make an impact in “Global Health,” I have come to understand that I come from a position of privilege, and I have been trying to be deliberate about educating myself about how others experience health and health care. Part of the amazing benefit of traveling around the world and in meeting people from different cultures, societies, and even other U.S. cities is learning about and from them. Truly, “global” means “local” and “local” means “global,” and there is tremendous value in global engagement.

After listening to Dr. Lamb’s presentation about Native American communities and initiatives to increase the numbers of Native Americans in medicine, I began to learn so much more, and that has been the inspiration for this special section of the ASA Monitor.

American Indian and Alaska Native (AI/AN) communities have poor access to quality health care, shorter life expectancies, and higher rates of many disease states compared to White populations (asamonitor.pub/46hkaft; asamonitor.pub/3R9h7ip). There are limited opportunities for Native Americans to pursue careers in health care and few role models in medicine and anesthesiology. Recent data show that just over 0.25% of U.S. anesthesiologists are American Indian or Alaska Native (and fewer than 20% of those are women), and only 0.7% of anesthesiology residents are AI/AN (JAMA Netw Open 2022;5:e2143398). Equitable representation of AI/ANs in the physician workforce will take over 100 years without systemic change (Lancet Reg Health Am 2023;26:100588).

Inequities in health care impact children as well. One need not look far to read about adverse childhood experiences or the incidence of RSV in American Indian youth (Pediatrics 2023;152:e2023062207; Pediatrics 2023;152:e2022060435).

Indigenous peoples are poorly represented in government. In November 2023, for the first time, a Native Hawaiian woman was confirmed as a federal judge in the U.S. Only three Pacific Islander people, five Native American people, and 70 Asian American people have served lifetime judicial appointments in the 234 years since the federal judiciary was established (asamonitor.pub/41hZtxO).

In 1990, President George H.W. Bush declared the month of November to be Native American Heritage Month (asamonitor.pub/47H3xtV). Coordinating this special issue during November made me even more aware of the many resources available to understand and appreciate Native American culture.

Efforts to celebrate Indigenous Peoples’ Day have grown in the last few years (asamonitor.pub/3NhkR06). President Joe Biden became the first sitting president to issue an official proclamation of Indigenous Peoples’ Day and said in his 2021 Indigenous Peoples’ Day proclamation (asamonitor.pub/3GurUyX):

Space does not permit an in-depth review of medical challenges for Native Hawaiians or the First Nations, Inuit, and Métis Peoples of Canada (Indigenous Canadians), but they face the same unacceptable health disparities (asamonitor.pub/4a2xmGV; asamonitor.pub/3Gx3zZi).

Alika Lafontaine, MD (@AlikaMD), an anesthesiologist with Anishinaabe, Cree, Métis, and Pacific Islander ancestry, and who is Immediate Past President of the Canadian Medical Association, has embarked on a reconciliation process to improve patient outcomes for Indigenous people (asamonitor.pub/3tfH8Vg). The Canadian Medical Association is convening a Guiding Circle to advance equitable health care in allyship with First Nations, Inuit, and Métis Peoples (asamonitor.pub/3Nf4IIP). Jason McVicar, MD (@jaymcv), an anesthesiologist in Ottawa, has studied disparities in postoperative outcomes for Indigenous people in Canada (CMAJ 2021;193:E713-22; CMAJ Open 2022;10:E304-12).

In this special issue, you will learn from:

• Thomas Locke, MD, MPH, about “Tribal Self-Governance and Foundational Public Health Services.”
• Samuel Percy, MD, et al., on “Strengthening Anesthesia Care on Navajo Nation.”
• Chermiqua Tsosie, who recounts “A Native American Girl’s Continuing Journey to Becoming a Physician.”
• Delbert Lamb, MD, on “Mentorship Matters.”

There is much work to do to increase the quality of and access to health care for Indigenous communities in North America and around the world. There is much work to do to increase the numbers of Native Americans in health care, in medicine, and in anesthesiology. These articles can only scratch the surface, but I hope they spark an interest in many of you to educate yourself and learn more.