Authors: Expert Panel: Robert M. Schacht, Ph.D. Spero Manson, Ph.D. Rebecca Vanderbilt, M.A. Treva Roanhorse Amenia C. Wiggins, M.A. Emmett Chase, M.D., MPH Melissa Jurgensen, M.A. Carleen Anderson, M.Ed.340

Introduction
The Task Force on Emergent Disability Issues among American Indians and Alaska Natives has evaluated public health data sets and systems, which might lead to planning more effective policies, prevention strategies, and vocational rehabilitation for American Indians and Alaska Natives with disabilities. Socioeconomically disadvantaged groups are greatly over represented with respect to poor health indicators despite public health successes in reducing the incidence of many organic diseases. These and a myriad of health and developmental disorders have been termed the New Morbidity, which rests on the interactions among the following categories of variables (Baumeister et al., 1993, pp. 35-37): (1) Predisposing variables that are demographic, behavioral, and genetic/biologic; (2) Catalytic variables, such as poverty; (3) Resource variables, such as community support and a variety of social, educational, and medical services; (4) Proximal variables, including prenatal factors and prenatal problems; and (5) Outcome variables, including developmental disabilities and other chronic health problems. In conjunction with the New Morbidity model, the Epidemiologic Transition model (Young, 1994, p. 216), which “is characterized by the precipitous decline in the incidence of infectious diseases, followed by the rise of chronic, non-communicable diseases and accidents and violence,” may prove useful in understanding emerging disability issues of concern to American Indians and Alaska Natives.

Three core questions were addressed when evaluating the data sets and systems:

1. Are there detectable emergent disability trends; that is, are there increases in the magnitude and rates of disability among those who are most vulnerable – e.g., American Indians and Alaska Natives who live in poverty?

2. What do existing monitoring systems tell us about these trends? What are the limitations of these systems?
   

3. What are the resultant policy implications for these systems? What effects will these trends have on planning, services, and personnel development in public health programs?

The methods used here involved a combination of secondary analyses, evaluation of existing public health monitoring systems, expert panels, and the analysis, integration, and synthesis of recent needs and policy assessments. The main sources of data to evaluate these questions were the Indian Health Service (IHS), a division of the U.S. Department of Health and Human Services and the Healthy People 2000 review process.

Results
Specific disabilities and risk factors were reviewed to detect emergent disabling trends among infectious diseases, chronic non-communicable diseases, accidents and violence. Meningitis remains among the 10 leading causes of death for American Indian children between 1 to 4 years of age, and pneumonia and influenza rank among the 10 leading causes of death for American Indians and Alaska Natives across all ages in the IHS service population, at 19.5 per 100,000 between 1991 – 1993. Those same years show that the leading cause death among American Indians and Alaska Natives in the IHS service population was heart disease, including hypertension, and that the cancer death rate is rising. Although the general U.S. rate has been relatively stable, deaths due to malignant neoplasm has climbed to over 74% of the overall U.S. rate. Deaths due to accidents are 212% greater than the U.S. rate, and violence-related deaths, such as homicide is 41% greater than the U.S. average. In addition, age-adjusted suicide rates among American Indian and Alaska Native males has fluctuated around 20 per 100,000, which is an alarmingly high number compared to national averages.

Positive trends in the American Indian population have showed overall improvements in life expectancy, infant mortality rates, and access to primary care, as well as an increase of high school graduates and college and university enrollment. However, negative trends in the American Indian population revealed movement away from targets set by Healthy People 2000 (Office of Disease Prevention and Health Promotion). For example, improvements have not been shown in the prevalence rates of obesity, cirrhosis, fetal alcohol syndrome (FAS), and diabetes.

Healthy People 2000 summarized data available since 1984 and estimates overall prevalence rates of 36 – 48% for American Indians and Alaska Natives, with no clear trend. Alcohol abuse or dependence is still most frequent among American Indians and Alaska Natives than any other ethnic group, and according to RSA-911 files from 1996-1997, is listed as both the major disabling condition and the secondary disabling condition. Hence, disabilities that are alcohol-related show to be well above national averages. For instance, cirrhosis deaths for American Indians and Alaska Natives were 21.6 per 100,000 compared to 8 per 100,00 for the total U.S. population in 1993, and the FAS rate was 40 per 1,000 compared to 5.2 per 1,000 for the total U.S. population in 1990. Diabetes was rarely diagnosed among American Indian populations until the 1930’s, but has soared to a prevalence rate of 70 in 1,000.