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A Chronological History of IHS

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Vernellia R. Randall
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A HISTORICAL CHRONOLOGY (Pre-Contact to 1995 )

excerpted from: Betty Pfefferbaum, Rennard Strickland, Everett R. Rhoades, Rose L. Pfefferbaum, Learning How to Heal: an Analysis of the History, Policy, and Framework Of Indian Health Care, 20 American Indian Law Review 365-391 (1995-1996)(177 Footnotes)

Pre 19th

Contagious diseases were the major health problem. Before the Century nineteenth century, government's role in the health care of Indians and society at large was minimal.

Early 19th

The relationship between sanitation and disease and the effects of Century urbanization and crowding on health were recognized. Health care efforts were aimed at preventing the spread of contagious diseases.


The federal government became officially involved with Indian health care and assigned responsibility for it to the War Department.


Federal legislation provided for annual appropriations of $10,000 to religious groups which provided medical services.


The government appropriated $12,000 to hire physicians and provide vaccinations.


The Public Health Act of 1848 provided a foundation for public intervention in combating and preventing contagious disease.


The Indian medical service was transferred from military to civilian control when the BIA was transferred from the War Department to the Department of the Interior.

Late 19th

U.S. health care delivery became institutionalized, and the first Century large hospitals opened.


With passage of the Indian Appropriation Act, Indian tribes ceased to be considered independent nations for the purpose of treaty negotiations.


The Division of Education and Medicine was established.


The medical division was discontinued because of inadequate funding.


The BIA operated four hospitals and employed seventy-seven physicians.


Commissioner Thomas J. Morgan called for hospitals at every agency and boarding school.


The General Allotment or Dawes Act sought to break up tribal landholdings into individual homesteads. The Act granted US (and, via the Fourteenth Amendment, state) citizenship to allottees.


Doctors in the Indian service were required to pass competitive examinations and possess medical degrees.


The Indian Medical Association was formed but activities were discouraged.

Early 20th

The scientific method was introduced and applied to health care. Century


Congress conferred citizenship on all Indians in the Indian Territory.


Indian schools were instructed to enroll only healthy children. Attention to hygiene, overcrowding, and ventilation became a priority in schools after a long period of high morbidity and mortality due to infectious diseases like tuberculosis and trachoma.


Commissioner William A. Jones undertook a comprehensive survey of health in schools and on reservations. The Commissioner's Report concluded that tuberculosis was widespread and related to problems of inadequate sanitation, infection control, and medical attention. The report criticized Indians for their lack of confidence in treatments provided.


Commissioner Francis Ellington Leupp appointed a special committee to address the problem of contagious diseases at schools and designated agency and school doctors as "health officers" with authority to direct and enforce sanitation efforts. The first chief medical supervisor of the Indian service was appointed, but funding for health services did not follow until 1910.


Public health offices were established at local and state levels.


Commissioner Robert Grosvenor Valentine conducted a national effort to conquer trachoma. A campaign to increase funding for prevention and treatment of disease was only partially successful. Valentine encouraged the hiring of Indians for positions dealing with Indian health.


Congress appropriated $40,000 for Indian health care.


President William Howard Taft delivered a Special Message to Congress on Indian health, raising public awareness of the serious medical conditions among Indians. He requested an appropriation of $253,000 for medical care for Indians; the request was only partially funded.


Congress appropriated $200,000 for Indian health care.


Congress appropriated $300,000 for Indian health care.


Congress appropriated $300,000 for Indian health care.


Congress appropriated $350,000 for Indian health care. World War I Staffing in the Indian medical service was cut drastically, and there was little new construction or repairs of plant and equipment.


Recommendations for transferring the Indian medical services to the PHS were not followed. The BIA opposed the transfer, arguing that health should not be separated from educational and societal efforts.


The Snyder Act was passed, consolidating various previous acts and defining the scope of federal Indian programs. Administrative responsibility for Indian programs was assigned to the BIA. The Act established a discretionary program, it did not adequately define eligibility for services, and it did not identify levels or goals for funding.


The BIA was reorganized under Commissioner Charles Henry Burke. A health division was created with a chief medical supervisor who had direct access to the commissioner, and medical directors were assigned to four medical districts. Substantial numbers of the professionals who joined the service were poorly qualified; salaries were low and turnover was high.


Public health nurses were added to the medical service. The Citizenship Act of 1924 provided for the naturalization of noncitizen Indians born within US territory.


Officers from the PHS assumed positions in the Indian health program though primary responsibility for administration remained with the BIA.


Lewis Meriam's study, The Problem of Indian Administration, was published. Meriam described the impoverished living conditions and poor health of Indians, documenting low salaries, incompetent staff, inadequate facilities, and minimal preventive medicine. He called for public health and preventive measures, recommending additional staffing, efficient operations, and data-based information gathering to guide planning and policy. Meriam also recognized the importance of Indian self-determination.


Commissioner Charles James Rhoads endorsed the Meriam report, and under his administration, appropriations for education, health, and welfare increased. The first preventive medicine program, emphasizing maternal and infant health, was established.


The Johnson-O'Malley Act was passed, allowing states, other political subdivisions, and private entities to provide for the health, education, and welfare of Indians through contracts and grants. The Indian Reorganization Act, passed as part of President Franklin D. Roosevelt's New Deal legislation, provided the foundation for tribal self-governance.


The Social Security Act was passed. In addition to providing retirement benefits, the Act established federal grant-in-aid programs for states to establish public health services and training. Congress appropriated $3,486,085 for Indian health care.


Congress appropriated $4,011,620 for Indian health care. There were ninety-one hospitals and sanatoria in operation. The Indian death rate decreased to 15.1 per thousand.


Congress authorized the collection of fees for medical (as well as certain other) services from Indians who were able to pay. There was considerable discretion in levying charges and the legislation was not extensively implemented. World War Approximately 65,000 Indians left reservations to participate in II the armed forces and war-related industries. Budget decreases and shortages of medical personnel hampered the provision of medical services.


The movement for Indian termination began with the aim of eliminating Indian tribes as well as special programs for Indians.


BIA program objectives called for a standard of living for Indians comparable to that of other Americans and the step-by-step transfer of BIA functions to Indians themselves or to other appropriate government agencies.


The BIA established a Division of Program to work with individual tribes to accomplish the Bureau's 1951 objectives (see 1951 above). Congress authorized the extension of state jurisdiction over reservations in a number of states.


The Department of Health, Education, and Welfare was established, assuring the federal government's involvement in health care and ushering in significant changes in the nation's health care delivery system. House Concurrent Resolution 108 was passed, officially launching a campaign to terminate the federal government's involvement in Indian affairs.


The IHS was transferred to the PHS. Four major functions were identified: training and technical assistance; coordinating available health resources through federal, state, and local programs; advocating for Indian health; and providing comprehensive health services. Eligibility for care and charges were not addressed in the transfer legislation.


The Indian Health Facilities Act of 1957 was passed, granting funds to communities to construct hospitals to serve Indians and non-Indians. The Act authorized the IHS to contribute funds to construct community hospitals when Indians would be better served by such hospitals than by PHS facilities.


The Indian Sanitation Facilities Act was enacted, providing authority and funding for the development of safe water and waste disposal in Indian communities.


Benefits of the Manpower Development and Training Act were made available to Indians.


Congress passed legislation to provide health care for the elderly (Medicare) and the poor (Medicaid).


President Lyndon B. Johnson delivered a Special Message to the Congress on "The Forgotten American." The President called for the establishment of a National Council on Indian Opportunity whose purposes would include encouraging all government agencies to make their services available to Indians. President Johnson also suggested that the concept of "termination" should be replaced by Indian "self-determination." Presidential candidate Richard M. Nixon spoke out against termination, noting that American society should allow many different cultures to flourish in harmony.


In a Special Message to Congress on Indian Affairs, President Richard M. Nixon called for the US to break decisively with the past and create conditions for a new era in which the future of Indians would be determined by Indian acts and Indian decisions.


Health care and health policies became critical issues for the nation as a whole. President Nixon favored private rather than public solutions and during his administration, federal programs were reduced and funds were transferred to state and local governments.


The Indian Self-Determination Act was passed, providing a mechanism for transferring programs traditionally administered by the BIA and IHS to tribal governments.


Task Force Six, a national study, examined the IHS and made recommendations to the American Indian Policy Review Commission. The study revealed insufficient funding and poor management. The Task Force called for more realistic goals; services to Indians both on and off reservations; provision of a basic health package; and an evaluation of the structure and level of funding, with modifications to reflect increased needs. Task Force Eight addressed the problems of nonreservation Indians. The Indian Health Care Improvement Act was passed with the goal of providing the highest possible health status to Indians. The Act sought to engage Indians in planning and managing services, and it authorized a scholarship program to train Indian students in the health professions in exchange for service in the IHS, tribes, or Indian communities. Comprehensive in scope, the Act authorized a number of programs that serve as models for public health care and national health planning.


The IHS operated forty-five hospitals with 1988 beds, sixty-five health centers, and more than 200 other clinics. Tribes operated ix hospitals, sixty-two health centers, and over 200 other clinics. An additional 1000 beds were available through contract services.


Indian Health Service granted agency status within the Public Health Service.


Only thirty-one Indian men and thirty Indian women received medical degrees; seven men and six women received dental degrees; and one man and one woman received pharmacy degrees.


Conservative estimates placed Indian mortality rates at a level 25% greater than the general population.


The federal appropriation for the IHS for fiscal year 1991 was $1.4 billion.


Amendments to the Indian Health Care Improvement Act reaffirmed the government's responsibility and legal obligation to assure the highest possible health status for Indians.


The IHS directly operated forty-one hospitals and 114 ambulatory facilities, and tribes operated eight hospitals and 347 ambulatory clinics.


The federal appropriation for the IHS for fiscal year 1995 was $1.9 billion.

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Professor Vernellia R. Randall
Institute on Race, Health Care and the Law
The University of Dayton School of Law
300 College Park 
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Email: randall@udayton.edu


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