Urban American Indians, Alaska Natives struggle with growing disparities in health status.

In 1970, Keep America Beautiful, a community improvement organization, launched a series of television and print ads showing an American Indian weeping over a piece of litter on the ground. The ads permeated the public's consciousness and raised awareness of what was then a fledgling environmental movement. Today, faced with severe health problems, American Indians are again weeping, but their cries have fallen largely on deaf ears and Madison Avenue has yet to craft a campaign to raise awareness of their plight.

Since the mid-1970s, more than a million American Indians and Alaska Natives have left reservations and other areas, either by choice or by force, and moved to metropolitan areas. Today, nearly seven out of 10 American Indians and Alaska Natives, or 2.8 million people, live in or near a U.S. city. For many urban Indians, the transition has resulted in or exacerbated extreme poverty, cultural isolation and severe health problems, including diabetes, cardiovascular disease, alcoholism and depression, all of which afflict them at higher rates than the general population. Though the health disparities are significant, American Indians and Alaska Natives living in or near U.S. cities are "seemingly invisible" to health care providers and federal and state policy-makers, according to a new report from the Urban Indian Health Commission, a group convened in 2005 by the Robert Wood Johnson Foundation to raise awareness of the growing health disparities among urban American Indians and Alaska Natives.

Cardiovascular disease, diabetes and depression are among the diseases and health conditions that afflict American Indians and Alaska Natives in disproportionate numbers, said the report, "Invisible Tribes: Urban Indians and Their Health in a Changing World." More American Indians and Alaska Natives ages 45 and older die from cardiovascular disease than cancer, diabetes and unintentional injuries combined. American Indians and Alaska Natives also have a higher prevalence of diabetes than the general population, a greater mortality rate from diabetes and an earlier age of onset of the disease. Depression also afflicts American Indians and Alaska Natives in disproportionate disproportionate numbers. About 30 percent of all American Indian and Alaska Native adults suffer from depression, the report said, with the prevalence of depression greatest among American Indian people living in cities.

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Sadly, recent policies rob many American Indians and Alaska Natives of their right to health care when they move to cities, even though legislation and various treaties signed over the last century guarantee their right to health care, said the report.

With invisibility comes issues of access to care. Urban Indians are more likely to seek health care from urban Indian health organizations than from other clinics. However, just 1 percent of the federal Indian health budget is allocated to urban programs within the Indian Health Service, according to the report, and IHS operated clinics are struggling to obtain the funds, resources and infrastructure needed to serve the growing urban American Indian population, even though urban Indians face an even greater risk of unnecessary death and disability.

"The collective health of this growing population continues to suffer, and disproportionately, compared to other Americans," said APHA member Ralph Forquera, MPH, director of the Urban Indian Health Institute, at a Washington, D.C., news conference releasing the report in November. "The report illustrates the need for health care providers, policy-makers and local, state and national private and public sector leaders to work together to provide better care to this seemingly invisible population."

Although much has been done to address racial and ethnic disparities in health care, American Indians and Alaska Natives who live in cities have been largely left out of the discussions and approaches, said APHA member Michael Bird, MPH, MSW, a national American Indian health advocate and former APHA president.

"If you don't include, you exclude," Bird told The Nation's Health. "That's the bottom line. There are some agencies, some foundations, some health departments that get it and say, 'If we're going to do this right, we have to try to reach out to all communities.'"

Leadership, capacity and infrastructure are what is needed to at least begin to address the barriers to health care for urban American Indians, Bird said.

Martin Waukazoo, chief executive officer of the Native American Health Center in Oakland, said the 34 urban American Indian health programs scattered across the United States have made significant progress in addressing urban Indians' health needs, "but the resources are not coming in to address the growing population."

APHA is calling for increased attention to American Indian and Alaska Native health as part of the Indian Health Care Improvement Act Amendments of 2007. Currently before Congress, the bill, known in the House as H.R. 1328 and in the Senate as S. 1200, would work to expand and improve delivery of health care services for the populations. One segment of the bill would replace the Urban Health Programs Branch with a Division of Urban Indian Health, among other measures.

To send a message to Congress in support of the bill, visit http://capwiz.com/ apha/issues/alert/?alertid= 10686906.

For more on the report, visit www.uihi.org.