THE HISTORY of the federal government's relationship with Indians is generally pretty unattractive. But there are some bright spots, and the success of the Indian Health Service is one. Before 1954, health facilities on reservations were run by the Bureau of Indian Affairs, and the record was dismal. Infant mortality among Indians was nearly double that of the rest of the population, and death rates from tuberculosis were more than six times the overall U.S. figure.
In 1954, the Congress moved responsibility to HEW, believing that health professionals would do better, and the bet paid off. Again the numbers tell the story: infant mortality rates are now virtually indistinguishable from those of the general population (though still to high); maternal deaths in childbirth have gone down 91 percent; and tuberculosis death rates have decreased 89 percent, to a rate a few points higher than that for the population as a whole. All this has been managed by aggressive expansion of hospitals and clinics, both on reservations and in urban areas, and a vigorous education program to get people to use the services.
This success story is especially striking because in the 1950s many Indians still had not been exposed to the effects of antibiotics and modern obstetrical techniques. The revolutionary improvements in their health over the past 25 years are comparable to what happened to the general population several decades before. Although there is still some way to go before Indian health is as good as that of the average American, the Indian Health Service is beginning to face the same question -- what to do next? -- that is puzzling the health world in general. Now the leading causes of death among the Indian population are alcoholism, suicide, accidents and homicide. Venereal disease rates remain high. Doctors are not nearly as well organized to deal with the complex social, economic and cultural sources of these kinds of troubles -- either on the reservations or anywhere else.
The good news is that increasingly the benefits of medicine have become available to the most needy group of people in our country. The news would be better if it were clearer now how to prevent illness with difficult economic and psychological stresses that Indians and other poor people are especially vulnerable to. That step we will all have to figure out together, and it may mean major changes even in successful enterprises like the Indian Health Service. From their record to date, it seems pretty certain that they will be able to handle it.