North Carolina has the largest number of American Indian residents of any state in the Eastern United States,a represented by eight state- or federally recognized tribes. There are a number of academic, tribal, and community organizations focused on health issues in this population. There are limited data available on the health of American Indians in our state, but data that are available indicate significant disparities in health outcomes relative to other racial/ethnic groups. These disparities are largely driven by adverse social determinants of health, such as poverty, limited formal education, limited access to care, and disability. This issue of the North Carolina Medical Journal brings together leading researchers, policy makers, and health care providers from academic, governmental, and private organizations across the state to elucidate health and health care issues that affect American Indian communities and families. Key themes include the need to increase the number of culturally competent health care providers serving in American Indian communities; the lack of quality health care and outcomes data, particularly at the tribal level; the concern that tribal leaders have for health disparities in their communities; and the importance of language and culture in delivering quality health care. Efforts are needed to collaboratively develop and implement culturally appropriate, evidence-based public health interventions to address disparities and achieve health equity.
Introduction
As a lifelong resident of North Carolina and an enrolled member of the Lumbee Tribe of Robeson County, one thing I appreciate about living here (outside of having great options for barbecue), is our rich racial and ethnic diversity across the state. Many people are not aware that North Carolina has the largest number of residents who self-identify as American Indianb of any state in the Eastern United States [1]. This population is represented by eight state-recognized tribes, including the Eastern Band of Cherokee Indians (also the only federally recognized tribe in the state), the Lumbee, the Sappony, the Meherrin, the Waccamaw-Siouan, the Haliwa-Saponi, the Coharie, and the Occaneechi Band of Saponi (Figure 1).
North Carolina Tribal and Urban Communities
See a full-color version of this figure on page 370. Source. North Carolina Commission of Indian Affairs.
Our tribes are also fortunate to be served at the state level by the North Carolina Commission on Indian Affairs and the North Carolina American Indian Health Board (NC AIHB), and in our major cities by four Urban Indian Organizations (the Triangle Native American Society, the Metrolina Native American Association, the Guilford Native American Association, and the Cumberland County Association for Indian People). Three of our state’s higher education institutions have centers focused on American Indians, including the Center for Native Health (Western Carolina), the American Indian Center (UNC-Chapel Hill), and the American Indian Heritage Center (UNC-Pembroke). I am proud to serve as chair of the NC AIHB, which focuses on research, education, and advocacy with the goal of improving the health of American Indian families and communities in our state.
Unfortunately, most of the data available to us indicate that this population has significant and persistent health disparities. According to the “2018 Health Equity Report” from the North Carolina Office of Minority Health and Health Disparities, American Indians experience significant disparities compared to non-Hispanic Whites in infant mortality (70% higher) and child and adolescent mortality (30% higher); health conditions such as diabetes (140% higher), kidney disease (50% higher), and prostate cancer (70% higher); homicide (440% higher); and unintentional motor vehicle injuries (100% higher), just to name a few [2]. These disparities are largely driven by social determinants of health, such as lower levels of formal education, unemployment and poverty, limited access to health care, and disability.
Health risk factors and outcomes data that specify American Indian race are relatively new phenomena. Early in my academic career, the best I could hope for when looking for American Indian health data in our state was data broken down by “White/non-White” or “White/minority.” Even now, when data are available, they are unreliable (due to a number of factors) or of questionable quality. This presents many challenges in getting a full picture of the health status of American Indians in North Carolina, as is pointed out in the article in this issue by Greg Richardson, our esteemed executive director of the North Carolina Commission on Indian Affairs [3].
This issue of the North Carolina Medical Journal features leaders from across the state who are on the front lines of our efforts to develop a better understanding of the health disparities that exist for North Carolina’s American Indian population, and who recommend strategies for addressing these disparities to achieve health equity. It is our hope that the content of this issue will be enlightening and, if you aren’t already with us, that you join us in this bold mission.
Two articles focus on important issues related to American Indian child health. The first, by Dr. Joseph Bell, a member of the Lumbee tribe and medical director of Children’s Health of Pembroke (and my older and more popular brother), draws on his 30+ years of experience in North Carolina and across the country to illuminate the cultural nuances of caring for our precious Native children [4]. While there are significant issues that impact these children even before birth, it is critical to recognize the importance of delivering culturally competent care to these families, and the need to train more American Indian providers to serve in these communities. The second such article, by Dr. Alice Ammerman, professor in the Gillings School of Global Public Health and director of the Center for Health Promotion and Disease Prevention at UNC-Chapel Hill, and Miranda Freeman, a member of the Lumbee Tribe and a medical student at ECU, draws attention to the impact of adverse childhood experiences (ACEs) on Native health throughout the lifespan [5]. Ammerman and Freeman provide examples of how models of resilience for families and communities can help mitigate the negative effects of ACEs.
In addition to the focus in the article by Dr. Bell on the importance of training American Indian providers, two other articles focus on this topic. Dr. Linwood Watson, a member of the Haliwa-Saponi Tribe and a Family Medicine physician, provides some historical perspective for the meanings that Native people place on health [6]. One key to understanding the health of this population, as noted by Dr. Watson, is that the homelands of our tribes are in rural parts of the state, meaning that access to health care is challenging. Dr. Watson also speaks to the importance of tribal community, and the ways in which Native people care for themselves and others in their community through tribal traditions. He also provides a warning that tribal membership can lead to harmful stereotypes that can impact the delivery of health care, and speaks to the need to break down those barriers. Dr. Cherry Beasley, a member of the Lumbee Tribe and the Belk Distinguished Professor of Nursing at UNC-Pembroke, also writes about the importance of training the next generation of health care providers to deliver culturally competent care [7]. Particularly important are symbols, language, and tribal connectedness. Dr. Beasley proposes a stepwise process for cultural competency development, including self-reflection, intentional engagement, and refinement.
American Indians’ focus on history, language, and culture is also highlighted in the article by Dr. Lisa Lefler, professor in the College of Health and Human Sciences at Western Carolina University and director of the Center for Native Health. Dr. Lefler brings a wealth of knowledge from her experience working with the Eastern Band of Cherokee Indians. She speaks to the importance of expressing humility, learning about the community, recognizing historical trauma, and spending time in and engaging with individuals as ways for non-Natives to effectively partner with tribal communities in addressing health disparities [8].
Three articles focus on important emergent health outcomes currently affecting our Native communities. A team led by Mary Beth Cox from the Injury and Violence Prevention Branch of the North Carolina Division of Public Health shines a light on the opioid epidemic in American Indian communities across the state [9]. This crisis, often seen as an issue among young, White males, is devastating American Indian communities, particularly in the era of the COVID-19 pandemic [10-12]. A team of researchers from UNC-Pembroke and North Carolina Central University led by Dr. Tracie Locklear, a member of the Lumbee and Coharie tribes and a research assistant professor at NCCU, provides much-needed data in their NIH-funded BRAVE study, which provides an understanding of the contributors to vaccine hesitancy in Native communities. Of note, Robeson County has the lowest vaccination rate of any county in North Carolina [13]. Finally, Dr. Brittany Hunt, a member of the Lumbee Tribe, cohost of the “Red Justice Project” podcast, raises awareness of the horrors experienced by missing and murdered indigenous women (MMIW), which are not only getting state attention, but are also being addressed in the Biden White House through the appointment of Secretary of the Interior Deb Haaland, a member of the Pueblo of Laguna in New Mexico [14].
Dr. Megan Irby, assistant professor of psychiatry and behavioral medicine at the Wake Forest School of Medicine, highlights the work of a team from the Maya Angelou Center for Health Equity at Wake Forest and the UNC American Indian Center that is designed to help clinicians and others who work with American Indians better understand the health issues and needs of these communities across the state [15]. The project, Native Pathways to Health, takes a unique approach by recruiting adult and youth Tribal Health Ambassadors from each of North Carolina’s tribal communities to conduct Talking Circles and assess health priorities in a culturally appropriate manner. This work was completed in November 2020 and efforts are underway to disseminate the project results.
Kaitlin Phillips, managing editor of the NCMJ, provides a profile of Dr. Jim Jones, a hero to many in the American Indian health care profession in our state and nation. He is a pioneer in the field of Family Medicine and has led a number of important initiatives to promote access to quality health care in underserved populations [16]. We are grateful to have such a great treasure as Dr. Jones in our state. Finally, this issue is capped off by a new feature: a review of federal and state policies relevant to the issue topic [17].
Achieving health equity requires concerted understanding and initiatives at the individual, interpersonal, organizational, community, and policy levels. Collecting high-quality data across the spectrum of health and health care outcomes is critical, particularly in areas where data on American Indians have not previously been available, such as mental health and oral health. Policy initiatives should also be implemented to address racial misclassification in public health and health care settings. Collaborative programs between our state’s academic institutions and tribal communities should continue to train the next generation of American Indian health care providers. Finally, coordinated efforts are needed to develop and implement sustainable, culturally appropriate public health interventions focused on the most critical health issues affecting our tribal communities.
Acknowledgments
R.A.B. serves as a scientific editor for the North Carolina Medical Journal, editing articles for the original research section of the publication. He assisted in the planning of this issue and reviewed each article. All articles were edited by Editor-in-Chief Peter Morris and Managing Editor Kaitln Phillips. No further interests were disclosed.
Footnotes
↵a It should be noted that the 2020 US Census indicates that the state of New York reported a larger number of residents than North Carolina who indicate American Indian race only. The US Census allows for residents to indicate more than one race, and taking that number into consideration puts North Carolina ahead of New York.
↵b The term “American Indian” is used here as a component of the formal race term used by the US Census (American Indian or Alaska Native). Throughout this issue, our authors use the terms, “American Indian,” “Native,” “Native American” and “Indigenous” interchangeably.
- ©2021 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.
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