Abstract:
Indigenous older adults are a diverse and growing population that is not equitably included in gerontological research and continues to experience disparate health outcomes in later life. Resolving structural inequities endured by Indigenous peoples across the lifespan using existing policy mechanisms will only be possible if we better develop our theoretical frameworks to include Indigenous perspectives and develop research agendas that center minoritized aging populations. We illustrate this approach by proposing modifications to Title VI of the Older Americans Act and the Indian Healthcare Improvement Act.
Key Words:
Indigenous, health equity, structural determinants of health, health policy
Gerontology has recently shifted attention to the development of research that not only includes, but centers, older adults who are minoritized on the basis of race, ethnicity, and gender sexuality, as well as other marginalized identities. As an Indigenous scholar, I frequently find myself asking: how often are gerontologists thinking about the “I” in BIPOC? Historically, Indigenous Older Adults (IOAs) have been conspicuously absent from research, interventions, and policies, and they remain marginalized from these spheres today.
Despite this lack of attention, Indigenous communities in the United States have a larger number of older adults than at any other time in the last century. Estimates suggest that by 2060 the population of Native Americans and Alaska Natives will more than double (Administration on Aging, 2020). One likely outcome of this trend will be a disproportionate increase in the number of IOAs living with multiple chronic conditions, functional limitations, and dementias. Unfortunately, critical deficiencies in our knowledge about the health and historical context of the older Indigenous population, theories that guide our research, and policies designed to support Indigenous elders may create new challenges for aging Indigenous communities.
Indigenous communities also have important strengths that could be leveraged to amplify the impact of future interventions. In this article, I explore the relationship between historical trauma, intergenerational stress, and protective factors like informal support and community activity among Indigenous Americans. I then discuss integrating health equity, productive aging, and Gero-Indigenous theories and propose an example of how modifications to existing U.S. policy informed by this context can support the development of community-centered research and interventions in Indigenous communities.
Historical Origins of Contemporary Health Inequities
Indigenous peoples in the United States are broadly defined under three categories: Native Americans, Alaska Natives, and Native Hawaiians. Here I focus on the Native American and Alaska Native populations in recognition of the distinct cultural, geographic, and political context of Native Hawaiians. Beginning in the 18th century, government policies facilitated the extermination or relocation of the majority of Indigenous peoples in the United States. Many tribes were confined to low-resource, rural reservations that limited access to equitable employment, education, and healthcare infrastructures. These acts of structural violence were reinforced by cultural assimilation programs, such as state-sponsored religious/residential schools, that worked to dismantle Indigenous religions, languages, and cultural practices and replace them with European equivalents (Treuer, 2019).
In the most recent U.S. Census, about 5.2 million people identified as Native Americans or Alaska Natives, and 2.9 million claimed only a single Indigenous racial/ethnic identity. This represents just less than 2% of the total U.S. population (Administration on Aging, 2020).
Indigenous elders report higher levels of perceived racial discrimination in healthcare settings than do White residents.
There are 573 federally recognized tribal nations in the continental United States and Alaska. Tribal status, and access to the rights and benefits associated with membership in a tribal nation, are granted under criteria established by each tribal nation. About half of all Native Americans and Alaska Natives live off of reservations (National Congress of American Indians, 2019).
After four centuries of trauma, cultural extermination, and physical marginalization, inequities in wealth and health between Indigenous and White populations remain apparent today. Indigenous people in the United States have lower levels of educational attainment and experience lower quality education than do White U.S. residents (Woods, 2020). They also are likely to live in or near poverty. As of 2021, 26% of Indigenous households in the United States lived below the federal poverty line, more than double the proportion of White people living in poverty (Kaiser Family Foundation, 2022). IOAs also report higher levels of perceived racial discrimination in healthcare settings than do White residents (Stepanikova & Oates, 2017).
My work with data from the Health and Retirement Study paints a similar picture of inequities in multiple domains (see Figure 1, below). Using data collected between 2006 and 2020, I found that 39% of IOAs have less than a high school education, 33% have annual incomes in the lowest quartile of the sample, 35% experienced interpersonal discrimination events a few times per month or more, and 21% reported having a psychiatric diagnosis. This context suggests that IOAs, like Black older adults, may be at increased risk of developing health issues earlier in life (Ferraro & Shippee, 2009).
However, these data also paint a picture of IOAs as strongly engaged with their communities. More than half of Indigenous elders in this sample reported engaging in any informal volunteering in the previous year and a quarter were engaged in formal volunteering activities. These rates of informal volunteerism may even be underestimates of social contributions from IOAs given that community involvement is seen as a core component of life in many Native communities (Estes et al., 2023).
Given this context of structural disadvantage, IOAs predictably report high rates of chronic health conditions in later life. Relative to the general population, they have higher rates of diabetes (Acton et al., 2003), obesity, cardiovascular diseases (Hutchinson & Shin, 2014), depression (Browne et al., 2017), and alcohol abuse (Cobb et al., 2014). The prevalence of these diseases suggests that IOAs experience high levels of chronic stress across the lifespan that may put them at special risk for developing age-related chronic conditions, like dementias (Cooper et al., 2015). Given the troubling context of lifespan stressors among IOAs, it is no surprise that they are at risk for accelerated aging processes and mental health issues.
Pervasive inequities in the domains of wealth and health combine to multiplicatively impact the lives of Indigenous Americans and often shape the ways that they die. The National Center for Health Statistics' (NCHS) recent estimates on life expectancies illuminated a trend that those of us involved in Indigenous health research both anticipated and feared. The life expectancy of Native Americans and Alaska Natives decreased by 6.6 years between 2019 and 2021 during the COVID pandemic (Arias et al., 2022).
This COVID-19–driven drop in life expectancy wiped out more than 30 years of progress toward closing the gap between Indigenous life expectancies and those of the general population. While COVID-19 accounted for 21.4% of the 6.6-year decline in life expectancy among Indigenous Americans, other modifiable risk factors such as unintentional injuries (21.3%), liver diseases (18.6%), suicide (5.4%), and heart diseases (3.4%) accounted for a large proportion of their declining life expectancies.
Whether Indigenous Americans died due to COVID-19, were sex-trafficked or murdered (Bureau of Indian Affairs, n.d.), overdosed on opiates (Joshi et al., 2018), or took their own lives (Murphy et al., 2020), it is clear that the United States as a society has failed to respond to the critical health and safety needs of Indigenous Americans.
‘Engaging in activities that contribute economically to society can act protectively to preserve multiple domains of health in later life.’
However, despite the overwhelming force of structural disadvantages leaning on Indigenous communities, we also have important evidence of strength and resilience. For example, in an analysis of post-stroke subjective decline Burns et al. (2019) found that IOAs reported extremely high levels of perceived access to social support relative to all other groups. Fully 99.1% of all IOA respondents reported being able to “always, usually, or sometimes get help” when confusion or memory loss interfered with their ability to perform day-to-day activities.
Strong perceptions of community membership may be related to informal volunteering among IOAs, but no U.S. studies to date have applied productive aging frameworks to the lives of Indigenous older adults. A recent Canadian scoping review (Viscogliosi et al., 2020) of formal and grey literature on intergenerational solidarity in Indigenous communities found that the social participation of Indigenous elders was primarily organized around interpersonal relationships and engagement in intergenerational civic activities, such as shared teaching activities (e.g., elders teaching Indigenous knowledge practices to young people, young people teaching elders about technology).
It also found that these informal forms of civic engagement contributed to multiple domains of well-being across generations. Despite inattention from gerontologists in the United States, many tribes and urban Indigenous organizations already are investing in the development of intergenerational programs to support at-risk youth and elders (Kahn et al., 2016), and it is imperative that researchers advocate for increased federal and state financial support for these programs.
Integrating Health Equity, Productive Aging, and Critical Gero-Indigenous Frameworks
A positivistic research philosophy undergirds many scientific methods today and emphasizes the importance of objective, distant measurement by an unbiased researcher. As a product of this perspective, the notion of a “single truth” established by the dominant cultural group is privileged above alternative forms of knowledge, including Indigenous land practices and storytelling. Health equity frameworks are not immune to this bias. Historically, policymakers and researchers discussed differences in health using the language of health disparities. The term “disparity” was intended to indicate a particular type of variation in health between groups—between the socially advantaged and the socially disadvantaged (Braveman, 2006). A health equity lens integrates a social-justice perspective into the framework of public health. One consequence of state-sponsored oppression (and extermination) of Indigenous communities was the exclusion of Indigenous perspectives from much of scientific history.
Investigations into Indigenous volunteerism also suggest that we will have to adapt productive aging frameworks to our work with these communities. Productive aging frameworks contend that engaging in activities that contribute economically to society can act protectively to preserve multiple domains of health in later life (Gonzales et al., 2015), but existing operationalizations of volunteerism are likely not effectively capturing forms of community engagement like hunting and gathering, spiritual and traditional activities, and Elderhood (Estes et al., 2023). To avoid the reproduction of post-colonial inequities, we as gerontologists must critique the ways that our methods for creating new knowledge might unintentionally alienate those who can benefit most from that knowledge.
Increasing Indigenous engagement with, and willingness to participate in, population-level research will be critical for researchers, practitioners, and IOAs in the decades to come. Shifting away from positivistic and toward decolonizing perspectives on knowledge may help researchers build buy-in from Indigenous communities and foster increased trust in large-scale research. Braun and colleagues (2014) suggest that the following strategies be integrated into all levels of research conducted with Indigenous persons whenever possible: 1) Collect Indigenous data in partnership with Indigenous organizations; 2) Adapt standardized measurement tools to Indigenous contexts; 3) Integrate qualitative methods; 4) Employ participatory practices; and 5) Use decolonizing, critical, or life-course theoretical perspectives to guide research design. Including these research strategies may help to frame the quality of knowledge produced as valuable to Indigenous communities and better acquaint researchers with the needs of IOA research participants. These methods can also be integrated into policy reform efforts.
Using Policy to Drive Innovation in Indigenous Health Interventions
As a cognitive health researcher, I focus on how structural factors, like socioeconomic inequity and systemic racism, impact the cognitive health of Indigenous older adults in later life. Below I apply integrated health equity, productive aging, and Gero-Indigenous frameworks to illustrate how federal policies can be modified to resolve a critical gap in our knowledge about Alzheimer’s Disease and Dementias in Indigenous communities: How common are these diseases and do communities have the resources to manage them? An existing federal policy, Title VI of the Older Americans Act, could be used to answer these questions.
Amending Title VI of the Older Americans Act
The Older Americans Act (OAA) was signed into law on July 14, 1965, by President Lyndon B. Johnson and was designed to increase funding for community and social services for Older Adults. The OAA provides states with funding proportional to the number of adults ages 60 and older and promotes the ability of older adults to age in place by funding the use of evidence-based preventive services, like Meals on Wheels.
The OAA was amended in 1978 with Title VI, a provision designed to fund community services for Indigenous Americans. In fiscal year 2020, about $44 million was budgeted to provide services for Alaskan Natives, American Indians, and Native Hawaiians. Title VI allocates $34 million of this budget toward community, meal, and health-based preventive services for eligible tribal organizations. The remaining $10 million is allocated for Indigenous caregiver support services.
‘While IOAs have been granted a seat at the table for service funding under Title VI, they have been denied equitable funding for research activities.’
Activists contend that Title VI chronically underfunds services for IOAs (Ujvari et al., 2019). The National Congress of American Indians (NCAI; 2019) consistently requests about 25% more funds than Congress authorizes to provide adequate meal services, legal services, respite care, home health aides, and referral services. A critical oversight in Title VI is the lack of funding for research related to the health and well-being of IOAs.
The OAA allocates roughly 3% of its total budget to research and training grants (Ujvari et al., 2019). However, there are no specific earmarks for Indigenous-focused research and supporting a pipeline of Indigenous scholars from high school to post-PhD. While IOAs have been granted a seat at the table for service funding under Title VI, they have been denied equitable funding for research activities. Critical gaps in knowledge about Indigenous health and community engagement are likely to remain entrenched so long as these inequities persist.
To address these issues, I suggest that Title VI should be allocated an additional 0.9% of OAA’s total budget (~$22M in 2023 dollars). This increase would, for the first time, allow Title VI’s program funding goals to be fully met and will improve Indigenous access to stable, consistent, and high-quality community supports. This increase in funding also could fund existing intergenerational programming and greater intergenerational solidarity in Indigenous communities. Without access to stable, tribe-managed social services, it is unlikely that IOAs will be able to achieve any health equity.
I also recommend that Title VI be amended to allocate an additional 1% of the annual OAA budget to research focused on IOA health and well-being (~$23M in 2023 dollars). Such funding could be focused on the development of longitudinal health data and research methods that decolonize the collection of such data and leverage Braun et al.’s (2014) Gero-Indigenous research design principles. Additionally, by applying methods like mixed-method participatory research, developing community advisory boards, and training Indigenous community members to lead data collection and management efforts, we can develop a better understanding of how Indigenous communities are supporting the civic engagement of elders, and how we can leverage federal dollars to support intergenerational relationships in Indigenous communities.
Conclusion
In coming years, Indigenous communities in the United States likely will face new challenges as they age. The United States may be able to moderate the impact of this demographic shift by providing adequate funds for researchers and tribes to develop culturally centered, preventive services and research agendas that reflect the needs and desires of Indigenous communities. The impact of these programs could be augmented by small increases to research funding via Title VI grants that deploy resources to communities to support intergenerational programs, and encourage participatory research to develop community-centered health and community engagement tools validated with IOAs.
These proposed changes also have a relatively low sticker price. The total annual budget increase for all the policy recommendations above would fall in the range of $30–$40 million annually and could dramatically improve the lives of all IOAs in the country.
Some state-level programs, such as the Memory Keepers Medical Discovery Team at the University of Minnesota School of Medicine, already are testing similar methods. Funded by a $60 million grant from the state, this program seeks to close the rural-urban health divide faced by many Indigenous communities by increasing access to care and developing measurement tools that are culturally attuned and validated, and focused on leveraging intergenerational volunteering to support elders aging with dementias.
Scaling this type work up to federal policies will enable research and clinical intervention to better understand the health and community engagement of IOAs. As gerontologists invested in responding to the needs of a diverse and growing aging population, we must think creatively about policy mechanisms we can leverage to advance health equity and volunteering initiatives in communities we have failed to support historically.
Cliff Whetung is an Ojibwe scholar and PhD Candidate at the Silver School of Social Work at New York University.
Photo credit: Shutterstock/Ruslana Iurchenko
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