In this Special Feature, we draw from the work of experts on American Indian health inequities to highlight the unfair disparities this population faces as a result of historical trauma.

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Trauma has profound implications for mental and physical health. Historical trauma can create health inequities centuries later.

The past few years have revealed injustice throughout so many layers of society.

The coronavirus pandemic and the Black Lives Matter (BLM) movement have brutally exposed racial and socioeconomic injustices. It is now impossible to hold on to the airbrushed narratives of the past.

Thanksgiving, for example, is a beloved holiday for many people in America, but it is also a controversial one, riddled with historical inaccuracies.

For some people, memories of genocide, colonialism, and historical trauma supercede its associations with peace, harmony, and understanding.

As American Indian health experts have pointed out, reckoning with historical trauma and the impact it has had on the health and well-being of entire populations is the first step toward achieving health equity.

On Native American Heritage Day and every day, it’s important to examine the impact of historical trauma on present-day inequities among American Indian and Alaska Native (AI/AN) communities, as seen in the research of experts on the subject.

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Illustration by Wenzdai Figueroa

When it comes to health inequities, few groups are as underserved as AI/AN populations. The health disparities in this group are stark.

This was made clear in a talk given by Roger Dale Walker, MD, director of the One Sky Center for American Indian/Alaska Native health, education, and research, at the 2020 Journalism Summit on Infectious Disease.

In a speech entitled “Native behavioral health during COVID-19,” Dr. Walker outlined the disparities in morbidity that affected AI/AN populations even before the pandemic.

He noted that a number of conditions were alarmingly more prevalent and severe in AI/AN individuals than in the general population, citing:

  • a sixfold higher risk of alcohol use disorder
  • a sixfold higher risk of tuberculosis
  • a 3.5 times higher risk of diabetes
  • a threefold higher risk of depression
  • a twofold higher risk of suicide

Similar points have been made by Donald Warne, MD, the associate dean of diversity, equity, and inclusion at the University of North Dakota School of Medicine and Health Sciences. In a 2019 talk at the University of Washington School of Public Health, Dr. Warne spoke of the unresolved trauma that AI/AN people have inherited over centuries due to genocide, displacement, and forced boarding school participation. He specifically looked at health inequities in his hometown of Kyle, South Dakota, located within the Pine Ridge reservation.

In Pine Ridge, he said, the average age of death for men is 48 years. For women, it is 54. By comparison, the average age at death in North Dakota is 77.4 for the white population.

Kyle itself is in a food desert, he added. The closest supermarket is 90 miles away, and people have limited access to healthful food choices.

“We have a lot of built-in inequity because of our distribution of population,” Dr. Warne said. He pointed out that 15 states in the U.S. do not have federally recognized tribes, and their political representatives may not be as motivated to advocate for nationwide health services that benefit AI/AN individuals.

Dr. Warne then highlighted the historical context that gave rise to the collective trauma of these groups.

The “Indian Removal Act” of 1830 forcibly relocated Cherokee, Seminole, and Choctaw individuals, he said, separating them from their homes and families. Thousands of AI people were killed when the government delivered smallpox-containing blankets to them, in the “first documented case of bioterrorism” on American soil. And the scalping and murder of AI individuals was legitimized by bounties during the Dakota War of 1862.

These and other acts led to a decline in the AI population from over five million in 1492 to fewer than 200,000 in 1900.

“It was almost a complete genocide,” Dr. Warne said. “In many ways, this is the American Holocaust.”

The 2010 Census showed that the AI/AN population was again at five million, but Dr. Warne wondered about the toll taken by the past.

“When you have this pattern of loss — loss of life, loss of population, loss of land, loss of culture, loss of resources — does it have a health impact, and can that health impact be passed from one generation to the next?” he asked.

‘Historical trauma is like generational post-traumatic stress’

For Dr. Warne, historical trauma is defined as “the collective emotional wounding across generations that results from massive cataclysmic events.”

This trauma is “held personally and transmitted over generations. Thus, even family members who have not directly experienced the trauma can feel the effects of the event generations later.”

Dr. Walker, who is Cherokee, concurs. “Historical trauma is like generational post-traumatic stress,” he told MNT. “We now theorize that epigenetic changes occur across generations to extend PTSD [Post-traumatic Stress Disorder] symptoms.”

“These symptoms extend to future generations with anxiety, depression, reduced coping mechanisms, and impulsive behavior. Substance use disorders and suicide incidence are increased.”

– Dr. Roger Dale Walker

Trauma may lead to premature death in unknown ways. As Dr. Warne said in his talk, children forced to attend boarding schools have experienced excess deaths, although researchers do not always know why.

In a webinar, Dr. Warne went further. “We have entire generations of Indigenous peoples in the U.S., Canada, Australia, and other parts of the world, where boarding schools and residential schools were used to try to integrate people, get rid of the Indigenous cultures,” he said. “It was done through abuse: physical abuse, mental abuse, sexual abuse.”

Early childhood, toxic stress, and epigenetic changes

So how does this trauma get passed on? As both Dr. Warne and Dr. Walker observed, it may be partially due to epigenetics — the way that behavior and environment change the activity of genes.

Epigenetic changes do not affect DNA sequences, but they can impact how the body “reads” DNA sequences, and thereby alter gene expression. Environment and psychosocial factors can trigger some genes and switch others off.

Factors such as toxic stress can also affect gene expression. In fact, pre- and post-natal experiences can chemically change the structure of genes—and that can have a lasting impact on a child’s brain development.

When a child’s early experiences are negative, it can cause long-term damage to both their mental and physical health. As Dr. Warne noted in a paper he co-wrote with Denise Lajimodiere, a recently retired associate professor of educational leadership at North Dakota State University, Fargo:

“Adverse childhood experiences are also a strong predictor of risk for numerous chronic and behavioral health conditions, including heart disease, diabetes, cancer, depression, suicide attempts, and tobacco use.”

Dr. Warne later speculated that epigenetic changes may be why some of the boarding school survivors have shorter telomeres — protective protein structures that typically shorten with age.

To draw a useful comparison, he noted that some studies show the descendants of Jewish Holocaust survivors have worse health outcomes than controls who did not descend from that group.

Although more robust studies are necessary to prove a link between epigenetics, trauma, higher mortality, and poor health outcomes among American Indians, Warne and Lajimodiere found in their paper that:

“A long history of genocide and the American Indian boarding school experience has led to pervasive and unresolved historical trauma and its associated poor mental health outcomes.”

The intergenerational effects of maternal stress

Another link in the chain of intergenerational trauma is perpetuated through gestational stress, which can be caused by difficult life events, depression and anxiety, economic inequality, racism, and poverty, among other factors.

Stress experienced in this way modifies the developmental biology in offspring, increasing their risk for everything from diabetes and heart disease to obesity, and lowering their ability to be resilient and handle stress well. In adulthood, they may find that any stress compounds the mental and physical impact of that early stress.

Warne and Lajimodiere added that “[a]dverse adulthood experiences, including poverty, racism, and substance abuse, lead to depression, anxiety, and poor health outcomes. These social circumstances can have an impact on the quality of parenting skills for the next generation, leading to continued intergenerational health disparities.”

While reflecting on historical inequities is uncomfortable for many people, the experts featured in this article say it must be done to address health disparities and achieve equity.

As Dr. Warne himself has said, “If we are ever going to get to equity, we have to walk through truth, even when it’s unpleasant. Even when it makes us uncomfortable.”

Dr. Walker offered one last thought to MNT readers.

“I believe it is time to consider a Marshall Plan for Native people throughout North America. We must assist and empower tribes and Native communities in developing successful policies for governance [and help them obtain] education and access to health care at the same standard as the general population.”

– Dr. Roger Dale Walker