摘要：Mortality rates for American Indians (including Alaska Natives) declined for much of the 20th century, but data published by the Indian Health Service indicate that since the mid-1980s, age-adjusted deaths for this population have increased both in absolute terms and compared with rates for the White American population. This increase appears to be primarily because of the direct and indirect effects of type 2 diabetes. Despite increasing appropriations for the Special Diabetes Program for Indians, per capita expenditures for Indian health, including third-party reimbursements, remain substantially lower than those for other Americans and, when adjusted for inflation, have been essentially unchanged since the early 1990s. I argue that inadequate funding for health services has contributed significantly to the increased death rate. OVER THE PAST CENTURY, mortality among American Indians (including Alaska Natives) declined roughly in parallel with that of the rest of the US population, although rates continue to be higher than for White Americans. The decline, which persisted for most of the 20th century despite the vicissitudes of federal policies, practices, and appropriations, is an example of the epidemiological transition from a regime characterized by infectious diseases to one characterized by noninfectious, chronic diseases. 1 It is generally assumed that in advanced economies this progression is more or less inevitable; infectious diseases recede and are replaced in relative importance by noninfectious diseases, but total mortality continues to fall. The collapse of the Soviet Union and the catastrophic reversal of declining mortality in its former republics and elsewhere in Eastern Europe show that such progress is not inevitable. 2 There are other cases of reversal or, at the very least, stagnation of declining mortality in advanced economies. For example, the life expectancy of Aboriginal Australians has been largely stagnant for several decades, 3 and recent changes in the mortality rates of American Indians indicate something similar. I use published data to examine recent changes in age-adjusted mortality of American Indians in general and of Navajos in particular. Navajo data are included for several reasons: (1) the Navajos, as the largest tribe living on a reservation in the United States, have an important impact on overall rates; (2) during the period under consideration, Navajo health services were provided by the Indian Health Service (IHS) and not by tribally managed programs; and (3) historical data on Navajo health services and mortality are more readily available than for other, smaller American Indian populations. Causes of death are classified as either amenable or not amenable to interventions by the health care system. This classification is usually traced to the work of David Rutstein et al. in the mid-1970s. 4 As Holland has said, Here medical care is defined in its broadest sense, that is prevention, cure and care, including the application of all relevant medical knowledge, the services of all medical and allied personnel, the resources of governmental, voluntary, and social agencies, and the co-operation of the individual himself. An excessive number of such unnecessary events serves as a warning signal of possible shortcomings in the health care system, and should be investigated further. 5 (p1) Avoidable deaths, which are described in more detail in the following section, may thus arise for a variety of reasons, including unusual genetic and epidemiological characteristics of particular populations, inadequate funding, inaccessible services or populations, incompetent staff, uninformed populations, and noncompliant patients. Although all of these factors may be contributory, the fact that some populations have higher rates than others is an indication that adequate health services responsive to the unique needs of particular populations may not be available. 6 I briefly consider 2 other issues. The first has to do with the impact of devolution of responsibility for services to American Indian tribal governments or other entities. Self-determination in American Indian affairs has been federal policy since 1974, and some attempts have been made to examine the impact, if any, on health of changes in management. 7 The second has to do with a question debated in public health since the early years of the 20th century: the degree to which programs should be vertical or horizontal. The former refers to programs aimed at the eradication or control of a particular disease. The latter refers to programs covering a broad range of services. 8 – 11
