Disenrollment Background Papers and Resolution

Dr. Walker Disenrollment Background Paper

Dr. Adachi Disenrollment Background Paper

Dr. Hill Background on Resolution

AAIP Resolution on Disenrollment

 Resolution on Tribal Disenrollment

WHEREAS the Association of American Indian Physicians was founded in 1971 and has over 400 American Indian and Alaska Native physicians as members and;

WHEREAS the mission of the Association of American Indian Physicians is to pursue excellence in Native American health care by promoting education in the medical disciplines, honoring traditional healing principles and restoring the balance of mind, body, and spirit and;

WHEREAS the loss of cultural identity leads to grief, depression, anxiety and more serious mental health problems and increases the morbidity and mortality of American Indian and Alaska Native people and;

WHEREAS tribal disenrollment leads to the loss of cultural identity and access to health care, education opportunity, job opportunity, and housing which are social determinants of health and;

WHEREAS the health of Indian Tribes and Nations are only as healthy as the members of the Indian Tribes and Nations and ;

WHEREAS the Association of American Indian Physicians respects the sovereignty of all Indian Tribes and Nations to determine their membership;

THEREFORE BE IT RESOLVED that the Association of American Indian Physicians urges Indian Tribes and Nations to reconsider decisions to dis-enroll and to consider re-enrollment of former tribal members in order to improve the health of Native American individuals, communities, Tribes and Nations.

Association of American Indian Physicians Disenrollment Background Paper Submitted By Dale Walker, MD, AAIP Member and Past President

The Association of American Indian Physicians, formed in 1971, is the largest Native health care organization in North America representing over 400 physicians and their patients nationwide. Our primary goal is to improve the health of American Indian and Alaska Natives. Our mission is “to pursue excellence in Native American health care by promoting education in the medical disciplines, honoring traditional healing principles and restoring the balance of mind, body, and spirit”.

We are reaching out regarding a matter of great health concern to Indian Tribes and Nations nationwide. That issue is Tribal Disenrollment. We approach you with great respect for tribal sovereignty, but also to inform you of the negative health consequences this will have on both the disenfranchised members and those tribal members who remain. We ask that you reconsider your disenrollment decision and consider reinstating these members. A motion for this request was made and, after debate, it passed unanimously at our recent Annual Meeting in early August 2015.

The critical issues concerning tribal disenrollment are the psychiatric implications and other medical issues that affect the morbidity and mortality of all members. It is important to note that not just current families are affected but families of future generations as well. Those issues are presented below.

IDENTITY: For hundreds of years, the challenge to one’s Native identity was external to the tribe. Now the focus has shifted to internal forces that challenge who we are. Such decisions are traumatic to both the ones who lose their identity and other tribal members who are reminded that disenrollment has been happening over several generations to all tribal members. Therefore, the intergenerational trauma is continued and oftentimes made worse. Individual identity and one’s tribal identity are the driving forces to empowerment and realization, but cultural identity loss leads to grief, depression, anxiety and more serious mental health problems. It is well known that these problems lead to longer term health care issues and increases morbidity and mortality. Tribal disenrollment does not make these problems go away; it makes them worse. Further, it does not just nullify a person’s tribal affiliation; it strips them entirely of their cultural identity.

Who determines identity? The fact that it is determined externally to the individual or family has tremendous impact on the entire family and future generations. It also affects members inside the tribe who are reminded of their own historical challenges of being “Indian.”

BELONGING: Having a sense of belonging is a common experience. Belonging means acceptance as a member or part. A sense of belonging is a human need, just like the need for food and shelter. Feeling that you belong is most important in seeing value in life and in coping with intensely painful emotions. A single instance of being excluded can undermine self-control and well-being and often creates pain and conflict. A sense of belonging to a greater community improves your motivation, health, and happiness.  When you see your connection to others, you know that all people struggle and have difficult times. You are not alone. There is comfort in that knowledge. Disenrollment leaves Natives ‘culturally homeless’. The ability to belong centers an individual’s growth and development. It provides the safety and security to bond with others in the community and promote tribal growth and expansion.

MEDICALHEALTH: How long one lives (mortalty) and the quality of health (morbidity) are directly affected by tribal disenrollment. Access to health care, education opportunity, job opportunities, and housing are all tied in to social determinants of health. These will affect not only the disenrolled but other tribal members as well. While there may seem to be short term gains, the tribe will continue to struggle with these issues and continue to be divided by political infighting.

SOCIAL, ECONOMIC AND SPIRITUAL WELLBEING:  The ramifications of disenrollment affects the social, economic and spiritual well-being of those who are facing disenrollment and those who have been disenrolled. It threatens the relationship between tribal leadership and tribal members because it calls into question the fairness and legality of their motives. It threatens the continued economic growth and stability of tribal and Native owned business ventures because the negative press surrounding tribes involved in disenrollment battles may cause investors to second guess or pull their funding. It threatens federal funding as well as recognition as tribal entities, since funding and federal/state tribal recognition is often determined by the number of tribal members. It opens to door to Federal Government interference with Tribal sovereignty with added definitions of “Indian”. What’s worse is that it CAN happen to anyone, at any time and in any tribe regardless of their blood quantum, ancestral lineage, traditional participation or community standing.

CONCLUSION:Historically, our Native nations were inclusive communities with clear cultural and spiritual identities. We incorporated other individuals and families into our community in order to gain in numbers and function. This openness is evidence of our cultural confidence and generosity that is the hallmark of all Native people. That history is now challenged by decisions to remove longstanding members with kinship bonds tied deeply into other tribal families. This inconsistency cannot be overlooked. Please reconsider your vote of disenrollment and bring your families together. We are convinced it is for the better mental health of your Indian Tribes and Nations and will serve as a distinct and hopeful model for all Indian Nations.

Association of American Indian Physicians Background Paper on Disenrollment

Submitted By Katya Adachi, AAIP Board Member

The Association of American Indian Physicians, formed in 1971, is the largest Native health care organization in North America, representing over 400 physician members and their patients nationwide. Our primary goal is to improve the health of American Indian and Alaska Natives. AAIP’s mission is “to pursue excellence in Native American health care by promoting education in the medical disciplines, honoring traditional healing principles and restoring the balance of mind, body, and spirit”.

Strong community engagement provides American Indian/Alaska Natives (AI/AN) with a sense of belonging and cultural identity that is crucial for the physical, mental, and spiritual health and wellness of our people.  Maintaining strong community engagement is an important protective factor for the health of AI/AN people. Specifically, strong cultural identity has been shown to be a preventative factor against suicide.1 Community engagement and positive cultural identity is also important to healing historical trauma. As Braveheart and DeBryun describe, “communal support, strength, identity, and the maintenance or replacement of extended family networks as well as communal responses facilitate healing from unresolved grief.” 2  In the Indigenist model of mental health, described by Walters, Simoni, Evans-Campbell, “poverty has been described as being without relatives” and “reconnecting the ‘sick’ person with family and community is central to the healing process.”3 Disenrollment thus perpetuates historical trauma by creating a loss of community and culture that further worsens the individual’s “implicit, unresolved, fixated, or anticipatory grief about perceived abandonment as well as affiliated cultural disruption”2 that is associated with historical loss.

Historical loss has been found strongly associated with depression4, PTSD, and poly-drug use in Native youth5. Exposure to historical loss, the symptom manifestation of historical trauma, is now understood as a “relevant ACE (adverse childhood events) factors for Native American populations.”5 The resultant health risks are significant. These health risks include “high rates of suicide, homicide, accidental deaths, domestic violence, child abuse, and alcoholism, as well as other social problems. Suicide rates are high among our American Indian/Alaska Native nations and, in particular, suicide rates are highest among our youth.”2 Historical trauma poses significant health risks due to the “accompanying self-destructive behaviors that have been passed from generation to generation.”2 Thus the cultural and historical loss impact of disenrollment thus affects both current and future generations.

Disenrollment further worsens the impact of these health risks through its impact on the social environment, including access to health care, housing and opportunities in education and employment, which are known social determinants of health that contribute to health disparities. 6

Thus, it is clear that the health of Indian Tribes and Nations are only as healthy as their community members.  The Association of American Indian Physicians respects the sovereignty of all Indian Tribes and Nations to determine their membership.  In the interest of the health of American Indian/Alaska Native people, the Association of American Indian Physicians urges Indian Tribes and Nations to reconsider decisions to dis-enroll and to consider re-enrollment of former tribal members in order to improve the health of Native American individuals, communities, Tribes and Nations.

1. BigFoot, DS. Cultural Issues in Historical Trauma and Implications for Youth at Risk. 2007.
2. Brave Heart, MYH, DeBruyn, LM. The American Indian holocaust: Healing historical unresolved grief. Amer Indian and Alaska Native Mental Health Research, 1998; 8(2): 60-82.
3. Walters, KL, Simoni, JM, Evans-Campbell, T. Substance Use Among American Indians and Alaska Natives: Incorporating Culture in an “Indigenist” Stress-Coping Paradigm. Pub Health Reports, 2002;  117(S1):S104-S117.
4. Whitbeck, L., Walls, M., Johnson, K., Morrisseau, A., & McDougall, C. (2009). Depressed affect and historical loss among North American indigenous adolescents. American Indian Alaska Native Mental Health Research, 16(3), 16–41.
5. Brockie, NT, Dana-Sacco, G, Wallen, GR, Wilcox, HC, Campbell, JC. The Relationship of Adverse Childhood Experiences to PTSD, Depression, Poly-Drug Use and Suicide Attempt in Reservation-Based Native American Adolescents and Young Adults. Am J Community Psychol, 2015. 1-11.
   1. US Dept. of Health & Human Services. Healthy People 2020: An Opportunity to Address Societal Determinants of Health in the United States: Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020, 2010.

Association of American Indian Physicians Disenrollment Resolution Background

Submitted By Gerald Hill, MD, AAIP President

At the 2015 Annual Meeting of the Association of American Indian Physicians our members brought forth the issue of disenrollment at our business meeting.  The membership participated in an extensive discussion of disenrollment and the effects of disenrollment on the health of individual Native Americans and on the health of Native communities.  Throughout the discussion the recognition of tribal sovereignty and the right of tribes to determine membership was respected.

The discussion led to a motion made and passed unanimously by the AAIP membership directing the AAIP Executive Board to develop a resolution expressing concern regarding the possible adverse health effects of disenrollment

One AAIP member with recognized expertise in historical trauma and social determinants of health offered to prepare background information for the Executive Board to draft the resolution on disenrollment.  In addition, an AAIP Executive Board member offered to develop a supporting document focusing on research documenting the health effects of the loss of identity that may accompany the loss of tribal membership.

The background information confirmed and supported the concerns of the membership and of the Executive Board.  Disenrollment has the potential to negatively affect the health of Native individuals and communities by negatively affecting the mental health of individuals and by disrupting Native communities.  In addition, loss of tribal membership may also lead to the loss of health care and the loss of housing, education, and employment opportunities that are often tied to tribal membership and are recognized social determinants of health.

On September 15, 2015 the AAIP Executive Board unanimously passed a resolution on disenrollment.  This resolution states the concerns noted above regarding the health of Native American individuals and communities. It also recognizes the right of American Indian Tribes and Nations to determine membership.  Finally, the resolution urges Indian Tribes and Nations to reconsider disenrollment decisions and to consider re-enrollment of former tribal members in order to improve the health of Native American individuals, communities, Tribes and Nations.

In summary, the resolution of the Association of American Indian Physicians regarding disenrollment began with the membership and rests on concerns for the health of Native American individuals, Tribes, and Nations.  The AAIP respects the sovereignty and the right of Indian Tribes and Nations to determine tribal membership.  However, the primary goal of the AAIP is to improve the health of Native Americans.  We are concerned that the disenrollment of tribal members will have negative health consequences for Native American individuals and for Native communities.