220
NEGLECTED MINORITY - URBAN INDIANS AND MENTAL HEALTH PATRICK
BORUNDA, B.A. Director, Manpower Programs, City of Portland Former Director, Urban Indian Program, Portland, Oregon and
1 JAMES H. SHORE, M.D. Director, Community Psychiatry Training Program and Associate Professor, Oregon Health Sciences Center, 3181 S. W. Sam Jackson Park Road, Portland, Oregon 97201 1 Address correspondence to Dr. Shore
Department of Psychiatry, University of The
Neglected Minority - Urban
Indians:
In 1970, 45 percent of all American Indians were living in urban, offreservation settingsl. These Indian people have frequently brought from the reservation many health problems that are compounded by the pressures of city life. These include infectious disease, problems of cultural shock and maladjustment, the latter manifested in alcoholism and suicide. This minority population is ineligible for Federal programmes that serve reservation residents. They are often ignored or effectively excluded from state and municipal services. This situation is made grave by evidence from population studies that the urban Indian group will experience an accelerated growth within the next decade. The 1970 Censusu Report of 45 percent of all American Indians living in offreservation, urban settings, an increase from 25 percent in 1960, equals an urban population of 340,000 Indian peoplel. In describing the role of migration in Papago Indian adaption Hackenburg and Wilson2 have concluded that migration from reservation to urban areas is permanent and such that functional impairment of reservation communities will eventually occur. They observed that ’For the next several decades the residual growth rate after migration will remain at 1.4 percent per year which will be sufficient to sustain the reservation social system but explosive growth of Papago Indian enclaves in surrounding communities will take place.’ In a separate report Stull3 has studied accident rates, Papago Indian adjustment, and their relationship to acculturation pressures. Since the high accident rate for American Indians parallels high morbidity states in certain health conditions, such as alcoholism, it is alarming to take Stull’s conclusions and apply them to urban Indian adjustment. Stull concluded ’Both traditional and modern (Indian) individuals in progressive communities had significantly greater accident rates than in conservative communities. Rates for traditional and modern individuals in conservative communities were low and not significantly different. However, when modem and traditional individuals living in progressive communities were compared the rates were twice as high among the former. There is an interactional effect between modem individual and progressive community which greatly elevates the level of stress measured by a frequency of accidental injury.&dquo; From above evidence both studies support the hypothesis that urban Indian enclaves will show an explosive population growth within the next decade and that certain segments of this population will be in a high morbidity category for specific illnesses of emotional and physical health and accidents.
Downloaded from isp.sagepub.com at WESTERN OREGON UNIVERSITY on June 4, 2015
221 The
Planning Process: In 1973, the Portland City Council expressed support for urban Indian programs by budgeting for an urban Indian program planner. Although the estimated population of 2,500 represented less than one percent of the metropolis, it was 14 percent of Oregon’s total Indian population4. In the spring of 1973 the planner was assigned from Portland’s Model Cities Agency to develop a programme for urban Indian health. The planner began a survey of the health needs and the available community resources. Members of the Indian community were contacted through the Urban Indian Council, the Indian community congress. Existing Indian projects, city, county, state, and federal agencies were invited to provide input and contribute resources.
The Portland Indian community is composed of 50 different tribes. Seventyfive percent of the community members were one time reservation dwellers. Because of this, the reservation experience was considered a significant common factor in understanding the community. The reservation experience includes an average per capita income of $1,200, average rate of unemployment at 40 percent, dropout rate for Indian students at 42 percent, sub-standard housing, and high disease rates reflected in tuberculosis, infant mortality and alcoholism. In an earlier attitude survey, Indians in Portland had indicated three areas of high priority5. These were education, employment and family adjustment. These values are conventional values in the dominant white community. Given the conventional nature of these stated priorities and the unique nature of Indian cultural experience on the reservation, the Indian immigrant into Portland is immediately faced with a conflict involving his traditional values, his current capabilities, and his goals. A study of urban Indian problems in Multnomah County in November, 1972, and follow-up in 1973, provided specific information about the current status of this group and its conflicts in Portland. An unemployment rate of 27 percent contrasted to that of 5 percent for the general population. Households with incomes of less than $5,000 per year comprise 55 percent of the Indian sample, compared to 16 percent of the general population sample. Twenty-five percent of Indian households were purchasing their home, compared to 48 percent of black households and 65 percent of whites. Only five Indian owned businesses were located throughout the entire
city. In a detailed examination of health factors the following picture appeared : services of the U.S. Public Health Service through the Indian Health Service were found to be anchored to the reservation and unavailable to Portland Indians. This condition existed despite a clear relationship between reservation and city in TB epidemiology. Although Indians are less than one percent of Multnomah County’s population, they accounted for 65 percent of the county’s new active cases of tuberculosis in 1973. Forty-six percent of the Portland Indian population indicated that they were without a family doctor in 1972 compared to 34 percent of the population surveyed in the Model Cities area. Thirteen percent of the Model Cities’ population had not seen a doctor in the one year preceding the survey, compared to 24 percent of the Indian population. Easily corrected health problems, poor vision, and dental caries were very serious problems for Portland Indians. Indian respondents in the community stressed the need for mental health education and for direct services. Seventy-eight percent regarded alcoholism as a serious health problem, 48 percent so classified drug addiction and 32 percent Downloaded from isp.sagepub.com at WESTERN OREGON UNIVERSITY on June 4, 2015
222 identified general mental health problems as a serious factor. Despite these indications of significant need only five American Indians received mental health support from the county health service from July, 1972 through June, 1973. Althuogh 43 percent of Indian households reported annual earnings of less than $3,000, their utilization of Public Assistance was remarkably low across the board. County Welfare provided aid to 14 percent of the Indian respondents. One percent collected unemployment, 7 percent received medical assistance, 19 percent used food stamps. Utilization of Public Assistance was highest, with 20 percent; for
publicI
housing.
utilizing this data for program planning the authors concluded that lack of knowledge of availability might be one factor for the low Indian use of public resources. However, it is also likely that this low utilization is caused by a lack of understanding of the processes of resource agencies, discouragement by unexplained delays and red tape. The availability of the service is often dependent on a nonIndian style of aggression and on contact with a non-Indian resource person. This is a sharp contrast to the reservation Indian culture where resources are understood in the light of Indian treaty relationship with the U.S. Government and a historical pattern of relating to agencies which have clear Indian identity. From the initial survey the evidence indicated that approximately one-third of the native American Indian population was successfully integrated into the urban economic structure. Job stability was established and access to housing, medical attention, and other community resources was similar to that of other citizens. We believe that the successful group is composed largely of the 25 percent of urban Indians that had not lived on a reservation. The remaining 75 percent is a high risk subgroup, less successful in attempts to survive in the urban environment. Briefly, Indians arriving in an urban area from reservations are unfamiliar with the customs and common courtesies for the dominant culture. Lacking familiarity with appropriate procedures and resources, they are finding it difficult to establish and maintain a foothold on their own. Aggravating their initial situation then is the fact that they are frequently unprepared to deal with processes of seeking and securing public resources. Their physical and psychological problems can grow so severe before health services are obtained that the individual’s capacity for acculturation is severely impaired. A true cycle of poverty is established. This cycle, reinforced by alcohol misuse, turns cities into traps more destructive than the reservation experience Indians has left, seeking new opportunities. In
Alcoholism and Urban Adjustment: The most striking evidence of the urban Indian’s maladjustment and cultural conflict was obtained through the arrest records from the Portland Police Department. In 1970, this group, less than one percent of the population, accounted for 19 percent of all arrests for drunkenness in the city during the same year. In 1972, 18 percent of arrests for drunkenness were Indian with an additional 10 percent classified ’other alcohol offenses’. The latter category included public consumption and minors in possession. Although Indian involvement in disorderly conduct and assault charges have risen in recent years to 6 percent of all arrests, there is also a direct relationship to alcohol addiction in many of these cases. At the beginning of 1973, the metropolitan alcohol rehabilitation program reported that more than 20 percent of their chronic alcoholic clients were Indian. High rates of alcohol abuse and the relationship to arrest are also evident in Seattle. During 1969 Indians accounted for 20 percent of all alcohol related arrests, almost identical to Portland’s pattern in 19706.. _
Downloaded from isp.sagepub.com at WESTERN OREGON UNIVERSITY on June 4, 2015
1
223 DISCUSSION
In
a
psychiatric epidemiology profile of a major Northwest Indian reservation Shore et, al., defined major mental health problems. The major
community7
problems that have relevance to urban Indian communities were alcoholism as demonstrated above, anxiety and depression, and maladjustment. Shore further demonstrated that the most severe emotional impairment was experienced by those Indian people with the least access to traditional medical or mental health services. In reporting the pattern of urban Indian alcoholism in Chicago, Littman8 hypothesizes four factors to explain the nature of urban Indian drinking. These are : drinking to relieve anxiety, drinking to release repressed aggression, drinking to relieve pressures from acculturation, and drinking to promote group solidarity. In the authors’ experience the later factor must be strongly emphasized as one in which positive cultural reinforcement plays a major role. Kuttner and Lorinz9 described the pattern of alcoholism and addiction among urbanized Sioux Indians in Omaha, Nebraska. They concluded that ’acceptance of alcoholism as a way of life may be dismissed as another example of Indian fatalism, but it seems to be more profitable to attribute this resignation to the lack of readily attainable patterns of life’. High suicide rates have ben emphasized by many health planners for both urban and reservation Indians. However, recent findings in suicidologylO demonstrate that a high morbidity for Indian suicide may be tribal-specific and that tribal differences in completed suicide rates are highly significant. These findings emphasize the importance of understanding the differences among American Indians in health and behaviour patterns, especially in an effort to identify specific high-risk
subgroups for an outreach, case-finding approach. The importance of Indian sponsorship and participation of Indian people in care-giving roles has been demonstrated to be a crucial factor in determining acceptance of these services by the Indian population. And yet, urban Indian sponsorship of health programmes has sometimes created a situation where rivalry and factionalism within the Indian community blocked programme development.
In a review entitled ’The Dilemna of Urban Indian Health’, Mito and Sata6 described the impact of internal community friction in Seattle. In the past ’dissent has resulted in direct and indirect loss of funds, and compounding of the confusion experienced by both the federal government and the Indian people themselves. Duplication of services and similar interest areas by Indian organizations has contributed to a dilution of effort to such a degree that some programs have had little impact’. The authors feel that the essential issue is effective health services for a clearly neglected population and that this goal can only be obtained by sensitive treatment of issues such as tribal diversity, traditional values, and positive cultural reinforcements. This effort must not be sabotaged by issues of Indian fractionalism or bureaucratic isolation. Since joint planning responsibilities in Portland were assumed by both the City Council and the Urban Indian Council, an alliance was created that survived the immediate pitfalls of fiscal uncertainty and the potential for rivalry. The significant components of this alliance were : ( 1 ) a definitive step by government to formally recognize the urban Indian
community. (2) (3)
a coalition of available funding resources, and program implementation under consumer direction with Indian outreach workers. Two years after the initial development efforts ,an urban Indian health z
Downloaded from isp.sagepub.com at WESTERN OREGON UNIVERSITY on June 4, 2015
224 programme is established and functioning with services for Alcohol rehabilitation, child care, outreach casefinding, and mental health planning. A special component emphasizes traditional Indian medicine practices. The addition of federal support through the Indian Health Service is a recent development that adds significantly to the coalition of available funding, while o~cially recognizing the documented health care needs. Under the Urban Indian Council the health programme has recruited a staff that is predominantly Indian and that gradually opens health care access for this neglected population.
REFERENCES
Sclar, Lee J.: Participation by Off-reservation Indians in Programs of the Bureau of Indian Affairs and the Indian Health Service. California Indian Legal Services, 477 Fifteenth, Oakland, California Memeo 46 pages, 1972. 2. Hackenburg, Robert A., and Wilson, Roderick C.: Reluctant Immigrants; the Role of Migration in Papago Indian Adaptation. Human Organization 32:171-186, 1972. 3. Stull, Donald D.: Victims of Modernization; Accident Rates and Papago Indian 1.
4.
5. 6.
7. 8. 9. 10.
Adjustment. Human Organization, 31 :227-240, 1972. Borunda, Patrick: A Preliminary Report and Proposed Strategy on Urban Indian Health, City Manpower Programs, 620 S.W. 5th Portland, Oregon. memeo 21 pages, July 1973. The Grant-Morgan Study on Urban Indians in Multnomah County, City Manpower Programs, 620 S.W. 5th, Portland, Oregon. memeo 100 pages ,1973. Mito, Bob; and Sata, Linbery S.: The Dilemma of Urban Indian Health, Department of Psychiatry, University of Washington, Seattle, Wash. memeo 39 pages, 1972. Shore, J. H.; Kinzie, J. D.; Hampson, J. L., et al: Psychiatric Epidemiology of an Indian Village. Psychiatry 36 : 70-81, 1973. Littman, G.: Alcoholism, Illness, and Social Pathology Among American Indians in transition. Am. J. Pub. Health 60: 1769-1787, 1970. Kuttner, R. E.; Lorincz, A. B.: Alcoholism and Addiction in Urbanized Sioux Indians. Mental Hygiene 4:530-542, 1967. Shore, J. H.: American Indian Suicide: Fact and Fantasy. Psychiatry 38 : 86-91, 1975.
Downloaded from isp.sagepub.com at WESTERN OREGON UNIVERSITY on June 4, 2015
I
NEGLECTED MINORITY - URBAN INDIANS AND MENTAL HEALTH PATRICK
BORUNDA, B.A. Director, Manpower Programs, City of Portland Former Director, Urban Indian Program, Portland, Oregon and
1 JAMES H. SHORE, M.D. Director, Community Psychiatry Training Program and Associate Professor, Oregon Health Sciences Center, 3181 S. W. Sam Jackson Park Road, Portland, Oregon 97201 1 Address correspondence to Dr. Shore
Department of Psychiatry, University of The
Neglected Minority - Urban
Indians:
In 1970, 45 percent of all American Indians were living in urban, offreservation settingsl. These Indian people have frequently brought from the reservation many health problems that are compounded by the pressures of city life. These include infectious disease, problems of cultural shock and maladjustment, the latter manifested in alcoholism and suicide. This minority population is ineligible for Federal programmes that serve reservation residents. They are often ignored or effectively excluded from state and municipal services. This situation is made grave by evidence from population studies that the urban Indian group will experience an accelerated growth within the next decade. The 1970 Censusu Report of 45 percent of all American Indians living in offreservation, urban settings, an increase from 25 percent in 1960, equals an urban population of 340,000 Indian peoplel. In describing the role of migration in Papago Indian adaption Hackenburg and Wilson2 have concluded that migration from reservation to urban areas is permanent and such that functional impairment of reservation communities will eventually occur. They observed that ’For the next several decades the residual growth rate after migration will remain at 1.4 percent per year which will be sufficient to sustain the reservation social system but explosive growth of Papago Indian enclaves in surrounding communities will take place.’ In a separate report Stull3 has studied accident rates, Papago Indian adjustment, and their relationship to acculturation pressures. Since the high accident rate for American Indians parallels high morbidity states in certain health conditions, such as alcoholism, it is alarming to take Stull’s conclusions and apply them to urban Indian adjustment. Stull concluded ’Both traditional and modern (Indian) individuals in progressive communities had significantly greater accident rates than in conservative communities. Rates for traditional and modern individuals in conservative communities were low and not significantly different. However, when modem and traditional individuals living in progressive communities were compared the rates were twice as high among the former. There is an interactional effect between modem individual and progressive community which greatly elevates the level of stress measured by a frequency of accidental injury.&dquo; From above evidence both studies support the hypothesis that urban Indian enclaves will show an explosive population growth within the next decade and that certain segments of this population will be in a high morbidity category for specific illnesses of emotional and physical health and accidents.
Downloaded from isp.sagepub.com at WESTERN OREGON UNIVERSITY on June 4, 2015
221 The
Planning Process: In 1973, the Portland City Council expressed support for urban Indian programs by budgeting for an urban Indian program planner. Although the estimated population of 2,500 represented less than one percent of the metropolis, it was 14 percent of Oregon’s total Indian population4. In the spring of 1973 the planner was assigned from Portland’s Model Cities Agency to develop a programme for urban Indian health. The planner began a survey of the health needs and the available community resources. Members of the Indian community were contacted through the Urban Indian Council, the Indian community congress. Existing Indian projects, city, county, state, and federal agencies were invited to provide input and contribute resources.
The Portland Indian community is composed of 50 different tribes. Seventyfive percent of the community members were one time reservation dwellers. Because of this, the reservation experience was considered a significant common factor in understanding the community. The reservation experience includes an average per capita income of $1,200, average rate of unemployment at 40 percent, dropout rate for Indian students at 42 percent, sub-standard housing, and high disease rates reflected in tuberculosis, infant mortality and alcoholism. In an earlier attitude survey, Indians in Portland had indicated three areas of high priority5. These were education, employment and family adjustment. These values are conventional values in the dominant white community. Given the conventional nature of these stated priorities and the unique nature of Indian cultural experience on the reservation, the Indian immigrant into Portland is immediately faced with a conflict involving his traditional values, his current capabilities, and his goals. A study of urban Indian problems in Multnomah County in November, 1972, and follow-up in 1973, provided specific information about the current status of this group and its conflicts in Portland. An unemployment rate of 27 percent contrasted to that of 5 percent for the general population. Households with incomes of less than $5,000 per year comprise 55 percent of the Indian sample, compared to 16 percent of the general population sample. Twenty-five percent of Indian households were purchasing their home, compared to 48 percent of black households and 65 percent of whites. Only five Indian owned businesses were located throughout the entire
city. In a detailed examination of health factors the following picture appeared : services of the U.S. Public Health Service through the Indian Health Service were found to be anchored to the reservation and unavailable to Portland Indians. This condition existed despite a clear relationship between reservation and city in TB epidemiology. Although Indians are less than one percent of Multnomah County’s population, they accounted for 65 percent of the county’s new active cases of tuberculosis in 1973. Forty-six percent of the Portland Indian population indicated that they were without a family doctor in 1972 compared to 34 percent of the population surveyed in the Model Cities area. Thirteen percent of the Model Cities’ population had not seen a doctor in the one year preceding the survey, compared to 24 percent of the Indian population. Easily corrected health problems, poor vision, and dental caries were very serious problems for Portland Indians. Indian respondents in the community stressed the need for mental health education and for direct services. Seventy-eight percent regarded alcoholism as a serious health problem, 48 percent so classified drug addiction and 32 percent Downloaded from isp.sagepub.com at WESTERN OREGON UNIVERSITY on June 4, 2015
222 identified general mental health problems as a serious factor. Despite these indications of significant need only five American Indians received mental health support from the county health service from July, 1972 through June, 1973. Althuogh 43 percent of Indian households reported annual earnings of less than $3,000, their utilization of Public Assistance was remarkably low across the board. County Welfare provided aid to 14 percent of the Indian respondents. One percent collected unemployment, 7 percent received medical assistance, 19 percent used food stamps. Utilization of Public Assistance was highest, with 20 percent; for
publicI
housing.
utilizing this data for program planning the authors concluded that lack of knowledge of availability might be one factor for the low Indian use of public resources. However, it is also likely that this low utilization is caused by a lack of understanding of the processes of resource agencies, discouragement by unexplained delays and red tape. The availability of the service is often dependent on a nonIndian style of aggression and on contact with a non-Indian resource person. This is a sharp contrast to the reservation Indian culture where resources are understood in the light of Indian treaty relationship with the U.S. Government and a historical pattern of relating to agencies which have clear Indian identity. From the initial survey the evidence indicated that approximately one-third of the native American Indian population was successfully integrated into the urban economic structure. Job stability was established and access to housing, medical attention, and other community resources was similar to that of other citizens. We believe that the successful group is composed largely of the 25 percent of urban Indians that had not lived on a reservation. The remaining 75 percent is a high risk subgroup, less successful in attempts to survive in the urban environment. Briefly, Indians arriving in an urban area from reservations are unfamiliar with the customs and common courtesies for the dominant culture. Lacking familiarity with appropriate procedures and resources, they are finding it difficult to establish and maintain a foothold on their own. Aggravating their initial situation then is the fact that they are frequently unprepared to deal with processes of seeking and securing public resources. Their physical and psychological problems can grow so severe before health services are obtained that the individual’s capacity for acculturation is severely impaired. A true cycle of poverty is established. This cycle, reinforced by alcohol misuse, turns cities into traps more destructive than the reservation experience Indians has left, seeking new opportunities. In
Alcoholism and Urban Adjustment: The most striking evidence of the urban Indian’s maladjustment and cultural conflict was obtained through the arrest records from the Portland Police Department. In 1970, this group, less than one percent of the population, accounted for 19 percent of all arrests for drunkenness in the city during the same year. In 1972, 18 percent of arrests for drunkenness were Indian with an additional 10 percent classified ’other alcohol offenses’. The latter category included public consumption and minors in possession. Although Indian involvement in disorderly conduct and assault charges have risen in recent years to 6 percent of all arrests, there is also a direct relationship to alcohol addiction in many of these cases. At the beginning of 1973, the metropolitan alcohol rehabilitation program reported that more than 20 percent of their chronic alcoholic clients were Indian. High rates of alcohol abuse and the relationship to arrest are also evident in Seattle. During 1969 Indians accounted for 20 percent of all alcohol related arrests, almost identical to Portland’s pattern in 19706.. _
Downloaded from isp.sagepub.com at WESTERN OREGON UNIVERSITY on June 4, 2015
1
223 DISCUSSION
In
a
psychiatric epidemiology profile of a major Northwest Indian reservation Shore et, al., defined major mental health problems. The major
community7
problems that have relevance to urban Indian communities were alcoholism as demonstrated above, anxiety and depression, and maladjustment. Shore further demonstrated that the most severe emotional impairment was experienced by those Indian people with the least access to traditional medical or mental health services. In reporting the pattern of urban Indian alcoholism in Chicago, Littman8 hypothesizes four factors to explain the nature of urban Indian drinking. These are : drinking to relieve anxiety, drinking to release repressed aggression, drinking to relieve pressures from acculturation, and drinking to promote group solidarity. In the authors’ experience the later factor must be strongly emphasized as one in which positive cultural reinforcement plays a major role. Kuttner and Lorinz9 described the pattern of alcoholism and addiction among urbanized Sioux Indians in Omaha, Nebraska. They concluded that ’acceptance of alcoholism as a way of life may be dismissed as another example of Indian fatalism, but it seems to be more profitable to attribute this resignation to the lack of readily attainable patterns of life’. High suicide rates have ben emphasized by many health planners for both urban and reservation Indians. However, recent findings in suicidologylO demonstrate that a high morbidity for Indian suicide may be tribal-specific and that tribal differences in completed suicide rates are highly significant. These findings emphasize the importance of understanding the differences among American Indians in health and behaviour patterns, especially in an effort to identify specific high-risk
subgroups for an outreach, case-finding approach. The importance of Indian sponsorship and participation of Indian people in care-giving roles has been demonstrated to be a crucial factor in determining acceptance of these services by the Indian population. And yet, urban Indian sponsorship of health programmes has sometimes created a situation where rivalry and factionalism within the Indian community blocked programme development.
In a review entitled ’The Dilemna of Urban Indian Health’, Mito and Sata6 described the impact of internal community friction in Seattle. In the past ’dissent has resulted in direct and indirect loss of funds, and compounding of the confusion experienced by both the federal government and the Indian people themselves. Duplication of services and similar interest areas by Indian organizations has contributed to a dilution of effort to such a degree that some programs have had little impact’. The authors feel that the essential issue is effective health services for a clearly neglected population and that this goal can only be obtained by sensitive treatment of issues such as tribal diversity, traditional values, and positive cultural reinforcements. This effort must not be sabotaged by issues of Indian fractionalism or bureaucratic isolation. Since joint planning responsibilities in Portland were assumed by both the City Council and the Urban Indian Council, an alliance was created that survived the immediate pitfalls of fiscal uncertainty and the potential for rivalry. The significant components of this alliance were : ( 1 ) a definitive step by government to formally recognize the urban Indian
community. (2) (3)
a coalition of available funding resources, and program implementation under consumer direction with Indian outreach workers. Two years after the initial development efforts ,an urban Indian health z
Downloaded from isp.sagepub.com at WESTERN OREGON UNIVERSITY on June 4, 2015
224 programme is established and functioning with services for Alcohol rehabilitation, child care, outreach casefinding, and mental health planning. A special component emphasizes traditional Indian medicine practices. The addition of federal support through the Indian Health Service is a recent development that adds significantly to the coalition of available funding, while o~cially recognizing the documented health care needs. Under the Urban Indian Council the health programme has recruited a staff that is predominantly Indian and that gradually opens health care access for this neglected population.
REFERENCES
Sclar, Lee J.: Participation by Off-reservation Indians in Programs of the Bureau of Indian Affairs and the Indian Health Service. California Indian Legal Services, 477 Fifteenth, Oakland, California Memeo 46 pages, 1972. 2. Hackenburg, Robert A., and Wilson, Roderick C.: Reluctant Immigrants; the Role of Migration in Papago Indian Adaptation. Human Organization 32:171-186, 1972. 3. Stull, Donald D.: Victims of Modernization; Accident Rates and Papago Indian 1.
4.
5. 6.
7. 8. 9. 10.
Adjustment. Human Organization, 31 :227-240, 1972. Borunda, Patrick: A Preliminary Report and Proposed Strategy on Urban Indian Health, City Manpower Programs, 620 S.W. 5th Portland, Oregon. memeo 21 pages, July 1973. The Grant-Morgan Study on Urban Indians in Multnomah County, City Manpower Programs, 620 S.W. 5th, Portland, Oregon. memeo 100 pages ,1973. Mito, Bob; and Sata, Linbery S.: The Dilemma of Urban Indian Health, Department of Psychiatry, University of Washington, Seattle, Wash. memeo 39 pages, 1972. Shore, J. H.; Kinzie, J. D.; Hampson, J. L., et al: Psychiatric Epidemiology of an Indian Village. Psychiatry 36 : 70-81, 1973. Littman, G.: Alcoholism, Illness, and Social Pathology Among American Indians in transition. Am. J. Pub. Health 60: 1769-1787, 1970. Kuttner, R. E.; Lorincz, A. B.: Alcoholism and Addiction in Urbanized Sioux Indians. Mental Hygiene 4:530-542, 1967. Shore, J. H.: American Indian Suicide: Fact and Fantasy. Psychiatry 38 : 86-91, 1975.
Downloaded from isp.sagepub.com at WESTERN OREGON UNIVERSITY on June 4, 2015
I
