Globalization, states, and the health of indigenous peoples.

The consequences of globalization are mixed, and for the indigenous peoples of poor countries globalization has potentially important benefits. These are the result not of participation in the global economy but of participation in global networks of other indigenous peoples, environmental activists, and nongovernmental organizations. Since World War II, nonstate actors such as these have gained standing in international forums. It is indigenous peoples' growing visibility and ability to mobilize international support against the policies of their own national governments that has contributed in some important instances to their improved chances of survival.

Risk factors for conduct disorder among Navajo Indian men and women.

OBJECTIVES: To describe the risk factors for conduct disorder before age 15 among Navajo Indians. METHODS: The study was based on a survey of a stratified random sample of adult Navajo Indians between the ages of 21 and 65 living on and adjacent to two different areas of the Navajo Reservation. There were 531 male and 203 female respondents. The average age (SD) of the men was 38.7 (10.5) years and of the women 35.5 (9.0) years. Conduct disorder was diagnosed retrospectively using the Diagnostic Interview Schedule first developed for the Epidemiological Catchment Area study. The responses were combined into a continuous scale. RESULTS: Significant risk factors for increased scores on the conduct disorder scale were: histories of physical and sexual abuse in childhood; abusive maternal drinking; a small number of households per camp; younger age; and being male rather than female. Measures of social status and religion in which subjects were raised were not significant. CONCLUSIONS: Many of the risk factors that are associated with conduct disorder in other populations are also risk factors in the Navajo population. There is suggestive evidence that some of these risk factors have become more common since World War II, raising the possibility that conduct disorder has become more prevalent, as is thought to be the case nationwide.

Alcohol dependence and conduct disorder among Navajo Indians.

OBJECTIVE: The purpose of this study is to examine the association between conduct disorder before age 15 and subsequent alcohol dependence, and to describe the lifetime prevalence of alcohol dependence among Navajo Indian women and men. METHOD: This was a case-control design which included both men (n = 735) and women (n = 351) and in which the Diagnostic Interview Schedule was used for the diagnosis of the lifetime history of alcohol dependence and conduct disorder. Alcohol dependent cases were selected from inpatient and outpatient treatment programs (204 men, 148 women). Whenever possible, controls were matched for age, sex and community of residence and were randomly selected and interviewed until a nonalcohol dependent individual was found. Among the men, there were 374 alcohol dependent controls and 157 nonalcohol dependent controls. Among the women, the figures were 60 and 143, respectively. When combined, the controls comprise samples of the adult male and female populations from which estimates of lifetime prevalence of alcohol dependence, and of the amount of alcohol dependence in the population attributable to conduct disorder, may be inferred. RESULTS: Conduct disorder is a risk factor for alcohol dependence among both men and women. Lifetime prevalence of alcohol dependence in this population is high (70.4% for men and 29.6% for women), but the amount of alcohol dependence in the population attributable to conduct disorder is low. On the other hand, among the alcohol dependent, those with conduct disorder had the most severe alcohol- and nonalcohol-related problems. CONCLUSIONS: The potential limitations of the study are those common to case-control designs, especially biased recall by cases. There are also potential sampling biases among the controls. It is shown that none of the potential biases invalidate the findings, which support the hypothesis that in this population conduct disorder is a risk for alcohol dependence. The implications for primary prevention of alcohol dependence are discussed.

Boarding and public schools: Navajo educational attainment, conduct disorder, and alcohol dependency.

Many critics of United States government operated boarding schools for American Indians have asserted that the boarding school experience has lasting deleterious effects on personality development. Specifically, it has been suggested that a boarding school education is likely to lead to problems with alcohol in adulthood. To examine that assertion, data from interviews with over 1000 Navajos are analyzed concerning schooling, conduct disorder and the history of alcohol use. Consistent with data on the U.S. population generally, Navajo high school dropouts reported greater problems with alcohol than did graduates. Contrary to expectations, Navajos with a history of alcohol dependency were no more likely to have attended boarding schools than those who did not report patterns of alcohol dependency.

Alcohol dependence and domestic violence as sequelae of abuse and conduct disorder in childhood.

OBJECTIVES: To examine in the Navajo population: (1) the importance of childhood abuse as a risk factor for conduct disorder; (2) the importance of each form of abuse and conduct disorder as risk factors for alcohol dependence; and (3) the relative importance of each form of abuse, conduct disorder, and alcohol dependence as risk factors for being a perpetrator and/or victim of domestic violence. METHOD: The study is based on a case-control design. Cases (204 men and 148 women) between the ages of 21 and 65 were interviewed in alcohol treatment program and matched to community controls. There were two groups of controls: alcohol dependent (374 men, 60 women) and nonalcohol dependent (157 men, 143 women). When adjusted for stratification by age, community of residence, and sex, the combined control groups comprise a representative sample of the Navajo male and female population 21-65 years of age. RESULTS: The prevalence of physical and sexual abuse before age 15 is within limits observed in other populations. Each form of abuse is a risk factor for conduct disorder. Along with conduct disorder, physical abuse is a risk factor for alcohol dependence. Physical abuse and alcohol dependence are independent risk factors for being involved in domestic violence as both perpetrator and victim. There appears to have been no secular trend in the incidence of childhood abuse over the past several generations, but there is suggestive evidence that domestic violence has become more common. CONCLUSIONS: Physical abuse is a significant risk factor for alcohol dependence as well as for domestic violence independent of the effects of alcohol abuse. The effects of sexual abuse with regard to both domestic violence and alcohol dependence do not appear to be significant.

Metropolitan governance, residential segregation, and mortality among African Americans.

OBJECTIVES: This study tested the hypothesis that the degree to which local government is metropolitanized is associated with mortality rates for African Americans and with residential segregation, which has itself previously been shown to be positively associated with mortality among African Americans. METHODS: One hundred fourteen US standard metropolitan statistical areas were examined. The primary dependent variable was the age-adjusted, race- and sex-specific all-cause mortality rate, averaged for 1990 and 1991. The 2 primary independent variables were residential segregation, as measured by the index of dissimilarity, and metropolitanization of government, as measured by the central city's elasticity score. RESULTS: Mortality rates for male and female African Americans were lower in metropolitan statistical areas with more metropolitanized local governments and lower levels of residential segregation. Mortality for male and female Whites was not associated in either direction with residential segregation. White male mortality showed no association with level of metropolitanization, but lower White female mortality rates were associated with less metropolitanization. CONCLUSIONS: This study suggests the need for further research into whether policy changes in areas not traditionally thought of as "health policy" areas can improve the health of urban minorities.

PIP: The relationship between metropolitanization and mortality among African Americans in the United States is analyzed using data from 114 standard metropolitan statistical areas for 1991-1992 taken from the NCHS Mortality Detail Files and the census. The results confirm the finding that segregation is positively associated with mortality among adult African Americans. The results also indicate that less metropolitanization is associated with more segregation.

The history and politics of US health care policy for American Indians and Alaskan Natives.

This paper traces the development of the US federal government's program to provide personal and public health services to American Indians and Alaska Natives since the 1940s. Minimal services had been provided since the mid 19th century through the Bureau of Indian Affairs of the Department of the Interior. As a result of attempts by western congressmen to weaken and destroy the bureau during the 1940s, responsibility for health services was placed with the US Public Health Service. The transfer thus created the only US national health program for civilians, providing virtually the full range of personal and public health services to a defined population at relatively low cost. Policy changes since the 1970s have led to an emphasis on self-determination that did not exist during the 1950s and 1960s. Programs administered by tribal governments tend to be more expensive than those provided by the Indian Health Service, but appropriations have not risen to meet the rising costs, nor are the appropriated funds distributed equitably among Indian Health Service regions. The result is likely to be an unequal deterioration in accessibility and quality of care.

What Yugoslavia means: progress, nationalism, and health.

Theories of modernization have assumed that the creation of nation-states involved the breakdown of parochial ethnic boundaries and increasing secularism, all of which resulted in a demographic transition from high to low fertility and mortality. Recent experiences suggests, however, that in some circumstances nation-states may be highly unstable as ethnic minorities assert their rights to self-determination. Under such conditions, converging patterns of mortality may begin to diverge as growing inequalities appear between newly independent region of once unified states. The recent history of Yugoslavia is described to provide an example of how this process might occur and what the results might be.

Health care policy for aboriginal Australians: the relevance of the American Indian experience.

This paper discusses and compares the systems for the delivery of health care services to indigenous peoples in the United States and Australia; both are poor minorities in wealthy countries and many live in remote locations. Three necessary conditions that have shaped the relative success of the Indian Health Service in the United States are relevant to the Australian situation: federal government administration; the separation of the Indian Health Service from other Indian affairs; and the provision of an integrated health service. Ironically, recent policy changes in the United States by the Clinton administration are reducing the federal bureaucracy, and along with it, Indian Health Service funding. In Australia, the states have had responsibility for service delivery to Aboriginal people, there have been no treaties formalising the relationship between indigenous people and the federal government, and Aboriginal health has been switched between different departments while remaining primarily within the Aboriginal affairs (rather than the health) portfolio. Since 1993, there has been pressure to return Aboriginal health to the health portfolio, and in July 1995, funding and administration of Aboriginal health services were moved from the Aboriginal and Torres Strait Islander Commission to the Department of Human Services and Health.

Health of populations in northern Queensland aboriginal communities: change and continuity.

We show that Australian Aborigines living in North Queensland have had an impressive decline in infant mortality over the past 50 years. Since the early 1970s, much of the decline can be attributed to preventive and curative medical services. On the other hand, the growth trajectory of infants and children has improved only slightly since the early 1970s, and mean and median weights are still well below international standards. In addition, there is no evidence that life expectancy at birth has improved significantly since the early 1970s. The pattern of declining infant mortality and stagnant life expectancy is accounted for by unchanging mortality at older ages. The major contributing causes are heart disease and accidents and violence. We suggest that the decline of infant mortality is the result of specific policy decisions made by the providers of preventive health services that infant health would be the focus of their efforts. The result was that many other aspects of health were not dealt with and adult mortality stagnated. We also suggest tentatively that the reduction in infant mortality coupled with persistent high rates of low birth weight and low weight for age at 1 year may be related to the high rates of young adult deaths from ischemic heart disease observed in Aboriginal populations.

Medical education change: a detailed study of six medical schools.

This article reports a comparative case study of six selected USA medical schools, undertaken to identify factors that facilitate or obstruct innovation in medical education. The findings suggest that the culture of each medical school results from a combination of intra-institutional and external factors. Together these forces influence substantially the fate of educational innovations. The institutional culture influences critical elements such as educational philosophy, leadership and resources provided in support of innovation. Equally important, the culture shapes the level and type of change a school considers and implements. The findings also suggest that the availability of resources and the creative impetus present in schools giving priority to research can benefit the educational goals and facilitate educational change.

A prospective study of isolation and mortality in a cohort of elderly Navajo Indians.

The prospective association between social isolation and mortality in a sample of 271 elderly Navajo Indian men and women living on their reservation in northern Arizona is reported. The follow-up period averaged three years from the time of interview in 1982-3. Self-reported level of physical functioning was predictive of mortality. Of the psycho-social measures, only marital status among men was predictive of increased risk of death, with the unmarried being at higher risk than the married. These results are attributed to the fact that Navajo society is traditionally matrilineal and matrilocal, with the mother-daughter bond being especially significant and with men being relatively more peripheral than their wives to the kin group. Thus unmarried men are far more likely to be isolated from kin than unmarried women and married people of either sex.

A suicide prevention program for Hopi youth.

In recent years, Hopi Indians have been concerned about what they believe are rising suicide rates especially among teenagers and young adults. A review of 30 years of Hopi suicides reveals that: (a) although it is possible that rates are rising, it is more likely that they are relatively stable; (b) high age specific rates for those between 15 and 34 years of age is not a recent phenomenon; (c) the individuals at risk for suicide and for alcohol abuse are the children of parents who made traditionally disapproved marriages, i.e. intertribal, intermesa, and between clans of disparate social status. By labeling the parents as deviant the community creates 'primary' deviance in the second generation. To be successful, a suicide program must not be designed specifically for troubled adolescents. Nor can it identify the problem as caused by either acculturation or traditional culture. The proposed program and constraints placed upon its implementation are discussed.

Infant mortality and economic instability in Yugoslavia.

Efforts to manage Yugoslavia's debt crisis beginning in 1979 led to economic policies which resulted in declining real income in subsequent years. This has been associated with a slowing of the rate at which infant mortality has declined. There is no evidence, however, that populations in poor parts of the country experienced a more dramatic impact on infant mortality than did populations in more favored regions. The lack of difference is attributed to redistributive social policies among and within republics.

The prevalence of hypertension among elderly Navajos: a test of the acculturative stress hypothesis.

This is a study of the prevalence of hypertension among a sample of Navajo Indians 65 years of age and above. It is not clear whether prevalence has increased over the past generation in this age group. When men and women are compared, conventional measures of "acculturation" are related to hypertension among women but not among men. The differences between men and women seem most probably related to differences in the situation of men and women within both Navajo and Anglo-American society. Several alternative explanations are discussed as well.

Alcohol use among migrant laborers in western New York.

A survey of alcohol use among 217 Black and Haitian migrant agricultural workers was conducted in 13 camps in three counties of upstate New York. The orienting hypothesis stated that older, unattached men account for much of the drinking on migrant camps and that older, unattached men have experienced a variety of personal troubles as a result of their drinking. The results of the survey were found to support the initial hypothesis. In camps composed primarily of family groups, social control mechanisms were found to be more highly developed than in camps composed primarily of unattached, isolated men. It was also found that this difference in degree of social control was reflected in differences of drinking behavior. It is suggested that the mechanization of agriculture has become a self-reinforcing process that results in a proportional increase in the use of the homeless and troubled as a source of low-cost agricultural labor.