Healthcare Disparities

CASE STUDY Impacts of a Cultural Ecology: Historical Trauma, American Indians/Alaska Natives, and Health The concept of historical trauma has been used in recent years in reference to the health and social effects of long-term population level violence experienced by an entire people as a result of colonialism, slavery, genocide, and other profound historical circumstances. The result of these experiences is often marginalization, poverty, and poor health for these peoples within the context of a broader political-economic system of which they are a part. The social ecology we are talking about, then, involves the relationship between a given population group and the society that structures that historical trauma experience. Cultural patterns related to health for that group evolve out of that relationship, as a process of coping over time. While historical trauma has also been used regarding Holocaust victims, Japanese survivors of World War II internment camps, and to some extent African Americans, it has most often been used in connection to health issues among American Indian/Alaska native populations in the United States. The use of historical trauma in this sense has primarily referred to the American Indian experience of chronic, intergenerational trauma and unresolved grief spanning generations, resulting from the genocidal loss of lives, land, and culture from European contact and colonialism (Brave Heart & DeBruyn 1998; Brave Heart-Jordan 1995). As noted earlier (in Chapter 4), historical trauma has poignantly been referred to as a “soul wound.” Here is a brief list of key points in that history that relate to the historical trauma. When the Europeans arrived, there were significant populations of American Indians/ Alaska Natives in North America—estimates vary widely, but anywhere from just under 1 million to over 12 million (Lord 1997).The native population of the Americas had been • there since approximately 12,000 BCE (specific estimates vary on this date), when successive waves of Eurasians came to what is now the United States across the Bering land bridge be-tween Siberia and Alaska called Beringia (now submerged, as the Bering Strait) and expanded throughout North and South America, creating everything from hunter-gatherer societies to the more complex Iroquois and Anasazi (Pueblo) in the United States and the Olmec, Aztec, Maya, and Inca in Central and South America. Early on, the relationship between the expanding colonial society in North America and Indian peoples was complex, sometimes involving alliances and collaboration, sometimes involving forced dislocation, conflict, and violence. Indian peoples were, however, typically viewed as un-civilized and subordinate in character to Europeans, and the power of European weaponry enforced an emerging social hierarchy. Healthcare Disparities

In addition, native peoples were decimated by diseases such as smallpox brought over from Europe. With American independence and • rapid population growth, the new country began to expand westward, heightening conflicts over land. In 1830, the Indian Removal Act was passed, authorizing the removal of Indian peoples in the Southeastern states and territories to make way for settlers. This was the setting for the infamous Trail of Tears (Carter 1976), in which some 17,000 Cherokee left or were removed from their homes and 4,000 died during the forced relocation to what is now Oklahoma. Healthcare Disparities

As settlers moved into the Great • Plains and western United States, they met with increased resistance, and there followed a long and violent period of Indian wars between settlers or the U.S. army and Indian peoples. These conflicts became increasingly brutal, and the army’s mission focused on the extermination of Indians who did not surrender and resettle in designated reservations. On these reservations, the land was generally poor, and it was difficult to make a living. Following the wars, boarding schools were established with the aim of civilizing and acculturating Indian children by forbidding the practice of their indigenous cultures and religions, prohibiting the use of Indian languages, and often seeking to convert the children to Christianity. Attendance at these boarding schools was common throughout even much of the 20th century, with peak levels in the 1970s. The experience was widely viewed as traumatic. Over time, much of the land held by American Indians was appropriated by • force or by violating treaties (some was also sold), resulting in the continued loss of both economic and cultural/religious resources. Healthcare Disparities

Only in recent years have a number of tribes sued for the return of their lands and been able to control and exploit the resources available to them. As a result of the long historical experience of colonization, appropriation, cultural suppression, violence, and marginalization, the current situation includes poverty rates twice that of the U.S. population as a whole, and even higher rates for some tribes such as the Sioux, Navajo, and Apache. Factors related to historical trauma have been associated with a range of social pathologies and negative health/mental health outcomes among American Indians and Alaska Natives (see Struthers and Lowe 2003), such as: A high prevalence of cardiovascular disease risk factors such as cigarette smoking and hypertension among American Indians • and Alaska Natives, for example, has been related to perceived discrimination and its effects (Krieger, 2000; Johansson, Jacobsen, & Buchwald, 2006).Studies have reported strong associations between perceived discrimination and increased depressive symptoms in adult • American Indians in the upper Midwest (Whitbeck et al. 2002). Healthcare Disparities

Loss of self-esteem, depression, poverty, and loss of traditional male roles have been cited as additional factors related to • cardiovascular disease (Rhoades 2003).Health risk behavior among male American Indians and Alaska Natives may be due to a loss of traditional male roles (Oet- • ting et al. 1998), unresolved grief from historical trauma (Brave Heart & DeBruyn, 1998), and particularly among younger men, anomie and a loss of cultural identity (O’Nell & Mitchell, 1996).Studies suggest that there is a range of phenomena that may form part of an overall historical trauma syndrome that in turn is associated with numerous health conditions. How does that happen? Whitbeck et al. (2004) made an important contribution by attempting to disentangle the mechanisms through which historical trauma affects American Indians and Alaska Natives. Because the experience was often voiced in terms of loss , this important research sought to identify the kinds of losses and resulting emotions associated with historical trauma. Identified losses were converted to items on an historical loss scale and included: Loss of land, language, culture, and traditional spiritual ways • Loss of family ties because of boarding schools; loss of families due to government relocation • Loss of self-respect due to poor treatment by government officials

• Loss of trust in whites from broken treaties • Losses from the effects of alcohol • Loss of respect for elders Loss of people through early death • Loss of respect by children for traditional ways • Emotions (symptoms) produced by these losses were then converted to items on an historical loss associated symptoms scale. These included: Sadness, depression • Anger, rage • Anxiety/nervousness • Being uncomfortable around white people when thinking of these losses • Shame when thinking of these losses • Loss of concentration • Feeling isolated or distant from other people when thinking of these losses • Loss of sleep • Fearful or distrust concerning the intentions of white people • Feeling like the loss is happening again • Feeling like avoiding people or places that are reminders of the losses Healthcare Disparities

• High loss scores were significantly associated with clusters of emotional symptoms. In another significant effort to understand the phenomenon, Evans-Campbell (2008) proposed a multilevel framework for studying the impacts of historical trauma at three levels: individual, family, and community. 1. Individual impacts include symptoms characteristic of posttraumatic stress disorder, guilt, anxiety, grief, depression, and other symptoms. 2. At the family level, impacts may include impaired family communication and parenting stress. 3. Community -level impacts are said to include breakdown of traditional culture and values, loss of traditional rites of pas-sage, alcoholism, physical illness, and internalized racism. Evans-Campbell also highlighted two key issues regarding historical trauma, as opposed to other kinds of trauma: (1) it is a collective phenomenon, something that happens to a community or a people; and (2) it does not refer to just any kind of trauma, but trauma “perpetrated by outsiders with purposeful and often destructive intent” (ibid., pp. 321).These are both significant efforts to identify the specific nature and inherent mechanisms of historical trauma as a political-economic and cultural phenomenon. At the same time, it may be limiting to confine the historical trauma triggers to individual experience with actual land loss, disruption in family systems as a secondary impact, or even loss of specific cultural practices, for example. Many American Indians/Alaska Natives (younger adults, youth) no longer think actively about land loss, the impact of specific historical events, or traditional culture loss. Yet they experience similar/related emotional symptom clusters as do those who attribute their emotions to those issues. It is possible that historical trauma exerts its effect as a broader, socially shared and cross-generational phenomenon, and that to fully understand and address it will require more examination of mediat-ing mechanisms, the ways in which it influences individual interpretation of events, and other indirect impacts.All of this suggests that an important dimension of the experience called historical trauma lies in the way people link their own self-image to their perceived social status, in contrast to other segments of society that were once the perpetrators of their historical experience. The self-image aspect refers to identification as a member of an historically oppressed group, and a general, perceived loss of power, control and status. So it isn’t just the loss, but the meaning of that loss (what it rep-resents), which in turn has a broad impact on collective, shared psychological experiences of a people Healthcare Disparities

.In 1969, the anthropologist Anthony Wallace, in his work on cultural destruction and revitalization (much of it focusing on the Iroquois people), described cultural traumas as externally induced stress on the “mazeway”—a mental image people maintain about themselves and their society (Wallace 1969; 1956). Such severe mazeway stressors can result in sociocultural breakdown progressing through various stages, in which cultural well-being and efficacy—the positive, predictive value of culture—is re-duced or lost, followed by psychological consequences such as anomie, anxiety, frustration, increased sociopathy. Wallace called these “psychodynamically regressive” responses. While his research occurred some time ago, his general description remains very relevant to the nature of historical trauma. Historical trauma-related cultural beliefs people share about patterns of limitation or negative probability regarding the future, are often played out in day-to-day lived experiences that reinforce the model—e.g., poor health, discrimination, other negative occurrences—as well as the general content of people’s conversations and explanations concerning why things are the way they are. So, in response to negative health and social circumstances, Mashpee Wampanoag (a Massachusetts Copyright | Jones & Bartlett Learning | Essentials of Health, Culture, and Diversity | kris_ncar_fan@hotmail.com | Printed from www.chegg.com … Healthcare Disparities