B. JOSEA KRAMER
URBAN AMERICAN INDIAN AGING 1
ABSTRACT. Although the majority of American Indians do not live on reservations, little attention has been focused on urban American Indian elderly. Urban American Indian elders have aged in place, and the majority intend to remain in cities. First, the needs of American Indian elders are assessed and the under-utilization of Older Americans Act services documented. Then barriers to access are discussed and means to increase participation recommended. Key Words: elders, health, Native Americans, needs assessment, policy
INTRODUCTION Urban A m e r i c a n Indians are under-represented in the literature on minority aging (Cuellar, Stanford and Miller-Soule 1982; Kramer, H y d e and Polisar 1990). This paper (1) reviews the status o f older urban American Indians' demography, health, mental health, nutrition and activities o f daily living; and (2) reports on utilization o f services funded by the Older Americans Act. The research on urban American Indian aging was largely conducted in conjunction with or under the auspices o f American Indian organizations; much o f this research has not been widely reported. Older urban American Indians are a segment o f the U.S. population in greatest social and economic need for supportive services. However, recent research (Kramer et al. 1990) indicates a systematic under-utilization o f existing support services funded b y the Older Americans Act. Barriers reducing access to services are discussed in this paper. Finally, recommendations are made for research, policy and practices to improve the delivery o f support services to older urban American Indians at the level o f the local planning and service area. Compounding a general lack of awareness o f urban American Indian eiders' needs and conditions are a number o f persistent myths. Erroneous beliefs have significantly reduced the response o f the aging network in conducting applied research and planning for their needs (Briggs 1987). F o u r c o m m o n misperceptions must be clarified before describing the current state o f knowledge and the implications o f recent research on planning and service delivery. Misperceptions 1. When American Indians get old, they retire to reservations. The vast majority o f elders do not return to reservations. F o r over a decade, American Indian organizations have produced local reports - unfortunately with narrow dissemination - noting that their elders have aged in place and that no services seem to be available due to lack o f recognition o f that fact (Eck and St. Louis 1972; Los Angeles City/County Native American Indian Commission 1982; Montana Journal of Cross-Cultural Gerontology6:205-217, 1991. © 1991 KluwerAcademic Publishers. Printed in the Netherlands.
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United Indian Association 1976). From my conversations with Area Agency on Aging (AAA) planners, this misperception has hindered both research on the needs of this population and serious planning efforts to fill these needs.
2. American Indians are eligible for special services because they are wards of the government. All American Indians are U.S. citizens, and they are not wards of the government. There is a unique and special relationship between the Federal government and tribal entities. This Trust relationship recognizes American Indian societies as self-governing "domestic dependent nations" and the Federal government as having fiduciary responsibilities for land title and social services (U.S. Commission on Civil Rights 1981). However, these services may be linked exclusively to the reservation and the sovereign tribal government. Health care is a good example. After a period of 120 days residence off-reservation, an American Indian is no longer eligible for medical care by the Indian Health Service. The federal responsibility is transferred to state public health departments (Smith 1987; Stuart and RathboneMcCuan 1988). Urban American Indians have long been turned away from health clinics by providers who misunderstand the federal regulations and tell Indians to get their service from the Indian Health Service (National Indian Council on Aging - NICOA 198 lb). As U.S. citizens, American Indians are taxpayers. Any resident on a Federal reservation (e.g., military reservations, American Indian reservations) is exempt from paying state residence taxes and state taxes on goods and services delivered to consumers on those reservation lands (e.g., the military PX). 3. Title VI of the Older Americans Act provides funds for nutrition and community services to American Indian tribal governments and therefore Title III providers have limited responsibility to serve older American Indians. Noting that older American Indians were not benefitting from the nutrition and community services provided to older Americans under Title III of the Older Americans Act, Congress added a sixth entitlement which directly funds American Indian tribes to deliver these services in remote reservation areas. The Older Americans Act Amendments of 1987 (P.L. 100-175) contains specific wording to indicate that American Indians are also eligible for Title III services. According to the law, if a "significant population" of older American Indians lives in the planning and service area, the Area Agency on Aging is obliged to conduct outreach to those individuals. The Federal legislation does not define the number of older Americans which constitute a significant population; the definition is determined by each State. All Title VI programs are limited to reservations and are contracted with tribal entities. There are 278 reservations and 209 Alaskan Native Villages but only 81 Title VI programs. Obviously the majority of elders living on reservations are not in a position to receive Title VI services, which are limited mostly to nutrition programs. But the majority of the American Indian population does not live on reserva-
U~BAN AMERICAN INDIAN AGING
207
tions, The t980 U.S. Census documented that neariy half of the American Indians over age 65 live in cities and, from the perspective of Older Americans Act services, should be served exclusively by Title III programs. 4. American Indians have a homogeneous culture. Popular images of American Indians tend to mix together elements of different indigenous cultures. Most Americans are unaware of the great diversity of American Indian cultures. Despite the effects of conquest and participation in the dominant U.S. society, 150 distinct American Indian languages continue to be spoken today. Cultural understandings underlie perceptions of appropriate behaviors. For instance, while elders are universally respected, there have always been tremendous differences in the treatment of frail elderly. Among Pueblo peoples, for instance, the extended family offered nurture and protection to frail older adults; in contrast, Apache customarily abandoned eiders who were no longer selfsufficient (Cooley, Ostendorf and Bickerton 1979). However, since the 1970s, a political homogeneity has existed among urban American Indian organizations and national Indian organizations. Forging a pan-Indian identity, these organizations recognize their shared concerns as native peoples despite their cultural differences. STATUS OF OLDER URBAN AMERICAN INDIANS Profiles of older urban American Indian demography, socioeconomic status, health, support service utilization patterns and service needs were gathered in two research studies. The Urban American Indian Elders Outreach Project was conducted in Los Angeles from 1987 to 1989 as a demonstration project of outreach and linkage (Weibel-Orlando and Kramer 1989). The project's peer outreach coordinators were active older American Indians. They identified local elders, administered an extensive needs assessment questionnaire, and assisted elders to access support services. Expanding on that project to a nationwide scope, the literature and the patterns of Title III.service access and utilization were examined (Kramer et al. 1990), Data were gathered from library and archival research, from Management Infolxnation System (MIS) reporting by each site provider and from surveys of both urban American Indian organizations and Area Agencies on Aging in 18 cities with major concentrations of American Indians, Demographics Older urban American Indians are a little known population (Block 1979; Edwards 1983). Most of the literature on urban American Indians examined their adjustment to city life in the period 1950 to 1970 (Thornton, Sandefeur and Grasmick 1982). This was a period of great migration from rural reservations to cities, a migration underwritten by relocation programs which were part of the federal policy to terminate the special relationship with the tribes. Research
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conducted in that period concentrated on the negative impact of urbanization: crime, alcoholism, unemployment, maladjustment. Equal emphasis was not given to successful adaptive strategies, no doubt, because funding was generally tied to solving social problems. The impression given to an unwary reader is that American Indians were unable to establish themselves in urban areas. For many relocatees this was true. Early in the program the rate of return to reservations was 75% but this later dropped to 35% (Ablon 1965). Even given the high return rate of those who were not highly motivated to live in cities, the percentage of American Indians living off reservations jumped from only 7% in 1940 to 50% in 1977 (Neils 1971; Sorkin 1978). The literature also notes that older American Indians are less successful at adjustment and more likely to return to their reservations (Ablon 1964; Graves 1970; Graves and Van Arsdale 1966; Guillemin 1975; Price 1968). The concept "older" was not generally defined, and readers might mistakenly infer postretirement age. In this context an older American Indian was someone over either age 25 or a g e 30 depending on the specific analysis of the Bureau of Indian Affairs case files (Martin 1964). Those individuals who did adjust, and did remain in cities, over the last 40 years are now at retirement age. Whether in Phoenix, Los Angeles or San Diego elders reported that they did not plan to return to their natal reservations (Dukepoo 1980; Eck and St. Louis 1972; Weibel-Orlando and Kramer 1989). In fact, in our Los Angeles survey, age was associated with an increasing commitment to remain in the city (Kramer 1989). The life expectancy and longevity of American Indians remains below that of the general U.S. population although these rates have shown improvement since World War II. The average life expectancy of American Indians is eight years less than non-Indians. Many American Indians do not live long enough to qualify for "older" American services, and impairments associated with aging typically occur twenty years earlier than in the general population (NICOA 1981a). Title VI of the Older Americans Act recognizes the need to provide support services to older American Indians living on reservations who may not yet be 60 or older. The legislation allows a tribal contractor to serve frail middle-aged elders if fifty adults age 60+ are also served. That waiver is not extended to elders living in urban settings. Chronological age is not a clear indicator of frailty in American Indians. In a national sample, American Indians at middle-age were found to suffer physical, emotional and social impairments which are characteristic of the general U.S. population aged 65 or older (NICOA 198ta). On reservations, individuals appeared aged at 45 years and in urban areas, American Indians were aged by 55 years. Indeed, American Indians do not define aging by chronology. The notion of calendar date birthdays and attendant celebrations of life stages was only introduced during the reservation period. This notion of aging has not been accepted by American Indians as normative (Williams 1980). In Los Angeles, the median age for both men and women who were considered elders by the community was 58 years. The American Indian community
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209
both on and off reservations uses social role functioning (e.g., grandparenting) and decline in physical activities as indicators to define which individuals are considered "elders" (Weibel-Orlando 1989). Treating elders according to their abilities is rooted in cultural practices. Based on the differing expectations of the aged, eligibility criteria for social service programs (e.g., Job Training Partnership Act programs, poverty programs) bear reevaluation. Aged American Indians are a population in great social and economic need. The 1980 U.S. Census indicates that nowhere in the U.S. did the income of urban American Indians aged 65+ equal that of elderly whites (Manson 1988). Approximately one-third of urban American Indians have incomes below or slightly above the poverty level in contrast to one fifth of whites who live at that level of poverty. Despite the income difference, there are no substantial differences in the labor participation and employment of whites and urban American Indians aged 65+. About half the urban American Indian population aged 75 or older live with family members. American Indian families with elders in residence have three times the proportion of their population living in poverty as compared to whites. As Manson (1988) notes, generalizations about family support systems must be tempered with the knowledge that their resources are scarce and irregular. Poverty increases the stress of care-giving. Health
There is no comprehensive data base on urban American Indian health problems and health care needs. The Indian Health Service collects no systematic data from its urban health project providers. Nor does the National Center for Health Statistics and other sources have data on urban American Indians. The American Indian Physicians Association (1979) presumes that American Indian elderly share the general health characteristics of the American Indian population at large. There is a high frequency of cataracts. Rheumatoid arthritis appears to occur with higher frequency than among non-Indians. Obesity, diabetes, cigarette use plus moderately elevated blood pressure and serum cholesterol levels are consistent with the high cardio-vascular mortality and morbidity. Obesity is common and is a risk factor not just for diabetes and cardio-vascular conditions but also for cerebrovascular disease. Gillum, Gillum and Smith (1984) report these risk factors and associated diseases for an urban American Indian population. The information available on urban eiders' health was collected in surveys conducted at various times through the auspices of American Indian organizations. In Phoenix 144 elders were surveyed in 1972; in Los Angeles a survey interviewed 328 elders in 1988; in a multi-site survey the National Indian Council on Aging reported on 712 elders in 1981; and, in Denver, a survey ongoing since 1987 has contacted 524 elders (Tyon 1990). The findings appear to be consistent. While responding with generally positive self-assessments on
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13.JOSEAKRAMER
TABLE I Comparison of prevalence of morbidity for self-reported disease or specific symptom by percent in Los Angeles Indians 45+, nationwide Indians 45+, Cleveland general population 65+ and U.S. general population 45+ Health problem
Eyesight Arthritis/rheumatics Hypertension Hearing problems Diabetes Sleep problems Heart problems Breathing problems Allergies Headaches Asthma Stroke Speech problems Liver problems Kidney stones Mental illness Amputation Cancer
L.A. Indian aged 45+ (except homeless) 65.9 36.4 30.7 21.0 19.8 17.0 14.8 13.1 12.0 11.0 8.1 4.9 4.6 3.5 3.2 3.2 2.8 2.5
Number of men Number of women
99 184
Total number
283
National Indian aged 45+a
54.6 42.6 19.3 44.4 12.5 30.4 16.1 34.0 28.5 4.3 3.2 1.4 1.6 8.9 7.9 1.2 1.1
Cleveland all races aged 65+a
40.4 41.9 16.5 37.3 4.2 33.5 15.6 23.0 14.8 3.2 4.6 1.2 0.4 1.9 4.4 2.1 0.9
National all races aged 45+b
m
26.9 25.9 15.9 5.2 12.9 9.0 4.1 2.8
687 1037 712
1834
a NICOA 1981a. b U.S~Dept. of Commerce, 1988. Excerpted from Weibel-Odando and Kramer 1989. their health, most elders suffered from health problems at the time of their interview. The Los Angeles sample of respondents age 45+ does not compare favorably on morbidity rates to either the national American Indian sample of elders aged 45+ or to the Cleveland general population sample of 65+ (Table I). Los Angeles elders report higher frequencies of eye disease, speech pathologies, asthma, hypertension, cancer, stroke, amputation, diabetes, and liver disease than American Indian elders nationwide. Similar complaints were noted for elders living in Phoenix where the most common health problems were diabetes, arthritis and rheumatism, hypertension, heating problems and visual disorders. In comparison to the general urban sample reported in Cleveland, American Indians in Los Angeles have dramatically higher frequencies of certain diseases.
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211
For instance, diabetes occurs four times more frequently and liver disease occurs almost nine times more frequently. Hypertension was reported by nearly a third (31%) of the respondents aged 45+. Although no comparable data were collected by the National Indian Council On Aging, a high frequency of dental problems was noted in Los Angeles; these comprised the third most frequently identified health problem. Nutrition One small study on nutrition of urban elders was conducted in Lincoln, Nebraska (Betts and Crase 1986). Unlike their peers living on reservations (American Indian Physicians Association 1979), malnutrition was not found. However, both elderly whites and American Indians in Lincoln were found to be below recommended levels in total food energy, vitamin A and calcium intakes. Utilization of Mental Health Services The low use of mental health practitioners by elderly American Indians indicates either less need than the general American Indian population or more selective barriers for this aging population. To some extent both of these variables interact. On one hand, the positive role of "the elder" has been equated with the low incidence of self-destructive behaviors such as alcoholism and suicide, behaviors that are found with high frequency among younger American Indians, especially on reservations reporting these data (American Indian Physicians Association 1979; Mclntosh 1984; McIntosh and Santos 1981). On the other hand, the notions of evaluating and treating mental health problems are highly stigmatized in the American Indian community. This may be especially true in urban areas. In Los Angeles, community disapproval of discussing this issue was so strong that questions overtly regarding mental health were removed from the needs assessment instrument used by the Urban American Indian Elders Outreach Project. There are no data on the mental health utilization patterns of urban elders. However, the reservation-based elders' most frequent mental health complaint is anxiety and their most frequent physical complaints are for chronic illnesses (Rhoades, Marshall, Attneave, Echohawk, Bjofk, and Beiser 1975, 1980). Stress has been associated with chronic disease. Older urban American Indians have been especially disadvantaged by their (and their health care providers') lack of awareness of psychological, social or economic resources which might ameliorate their conditions (Manson, Murray and Cain 1981). When questioned, elders expressed concern about "what people would think" if they solicited help. Differences in life satisfaction existed between urban and reservation elders attending the second annual National Indian Council on Aging annual meeting in 1978 (Manson and Pambrun 1979). Greater dissatisfaction was expressed by urban elders and was associated with: (1) lack of planned entertainment for American Indian senior citizens; (2) isolation; and (3) transportation problems. All are conditions which senior center activities and services could remedy.
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B. JOSEAKRAMER
Activities of Daily Living In the Los Angeles needs assessment, the majority of respondents were not impaired in any Activity of Daily Living (ADL) or Instrumental Activity of Daily Living (IADL). However, the majority of those reporting impairments were unable to function independently in more than one ADL or IADL. Age correlated with multiple impairment. Those aged 60+ years tended to have more impairments than the younger self-identified population of "elders." Only in three areas were there no statistically significant differences between persons younger than 60 years and those older than 60 years: dressing, toileting and feeding. As shown in Table II, age-specific differences occurred for bathing, transfer, mobility in the home, using the telephone, money management, shopping, transportation, meal preparation and light housework. The greatest number of impairments and the strongest relationships to age occur in the IADL categories. TABLE II Frequency of impaired Activities of Daily Living and Instrumental Activities of Daily Living by age, Los Angeles American Indian elders, 1988 ADL activities Bathing" Dressing Toileting Transfera Feeding Mobilityb Tot~
(N=286) (N=286) (N=286) (N=284) (N=287) (N=283)
< 60
60+
IADL activities
< 60
6 5 4 5 2 9
16 12 10 18 5 28
Telephonea Financesb Shopping~ Transport¢ Mealsb Houseworkc
3 4 15 15 13 15
13 17 41 41 31 42
31
89
Tot~
65
185
(N=294) (N=290) (N=294) (N=292) (N=289) (N=290)
60+
a Significant at p < 0.05 [Z2]. = p < 0.005 [Z2]. c p < 0.0001 [zz]. Source: Kramer 1990. Frail elders were receiving informal and some formal assistance although in no case did the elder perceive that help to be sufficient. Although most elders in Los Angeles live alone or with a spouse, it is the frail community members who are found in large multigenerational households. Quite often unmarried grandchildren or children are the care-givers. The extended family role in these cases is significant. However, accessing formal services may have been somewhat reduced: until a crisis stage is reached, there may be little incentive to endure bureaucratic application procedures in order to receive supportive services. Furthermore, the eligibility requirements of some agencies may not support the extended family's residential arrangements and continued involvement.
URBANAMERICANINDIANAGING
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ACCESS AND UTILIZATION OF TITLE III In examining Management Information System (MIS) reporting of Title III services for fiscal year 1989 in 18 Planning and Service Areas which have large concentrations of urban American Indians, one startling pattern emerged. This pattern suggests that American Indians in the greatest social and economic need have not benefitted from Older Americans Act supportive services. Nine of the 18 areas investigated did not provide Title IIIc services in proportion with the percentage of the American Indian population aged 65+ living in poverty (Kramer et al. 1990). Arrayed in Table III are the percentages of American Indians living in poverty at the 1980 decennial U.S. Census by region, compared to the percentage of that American Indian population over age 60+ served by Title III in 1989. Despite the time span, these are the most recent data bases available at this time. Unduplicated statistics for Title 11I services are only available for comparing congregate meals. While we cannot know if those served by Title III service providers are living in poverty, clearly the areas with the lowest percentage of service cannot be reaching those elders in the greatest need. The underlying causes and policies for this apparently uneven distribution of resources thus far remain unaddressed. While American Indians generally represent less than 1% of the elderly population in any metropolitan area, allocation of resources based on an economy of scale is insufficient. For whatever reason, failure to serve an ethnic minority and those persons in greatest social and economic need, is hardly in keeping with the spirit of the Older Americans Act. American Indian elders are considered a hard-to-serve population by planning and service agencies of the aging network. A number of barriers reduce access to health and supportive services. American Indians are not adept at cutting through the "white" tape and are unwilling to accept services delivered as charity. Distrust, lack of communication, and cultural insensitivity too often characterize interactions between American Indian elders and non-Indian service providers. Our society exhibits a systematic bias which few non-Indians seem to grasp. 2 But close attention makes it obvious. In professional, college or amateur sports, for example, it quickly becomes evident that some teams are named after an ethnic group while most are named after animals or mascots. American Indian stereotypes are promoted in caricatures used to sell commercial products, such as the Savage rifle. On Halloween there will be superheroes and princesses and "Indian braves," but not "Chinamen" or black face. Nor will other ethnic minorities be represented as animals on greeting cards such as the bunnies and chipmunks invariably dressed in feathered headbands and moccasins on Thanksgiving cards. Some toys have taken a negative characterization of Indians, such as the battery-powered gorilla banging on a tom-tom. Public schools perpetuate the stereotype of the feather-headdressed Indian to such an extent that children react with disbelief to meeting an American Indian person
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B. JOSEA KRAMER
TABLE III Percentage of older American Indians living in poverty and percentage of older American Indians served by Title III % American Indians aged 65+ below poverty in 1979a
% American Indians aged 60+ served by planning and service areas in 1989 b
American Indian elders in planning and service areas in 1980c
Northeast
24.1
Midwest
25.8
South
28.8
West
20.6
Boston New York Milwaukee Omaha Chicago Minn./St. Paul St. Louis Dallas Oklahoma City Tulsaa San Francisco Oakland Seattle Denver Los Angeles~ Phoenix Albuquerque Portland
125 (0.13 %) 1192 (0.09%) 273 (0.16%) 103 (1.17%) 438 (0.09%) 680 (0.26%) 77 (0.07%) 348 (0.20%) 1477 (1.48%) 2955 (3.62%) 416 (0.30%) 401 (0.25%) 744 (0.40%) 392 (0.22%) 3572 (0.34%) 1264 (0.52%) 728 (1.47%) 318 (0.31%)
U.S.
region
43.20 4.53 30.77 25.24 17.84 12.06 00.00 17.82 13.68 64.90 62.09 55.91 35.20 20.44 7.59 6.59 1.57
Manson 1988. b Based on unduplicated MIS reporting of Title III(c)1. c S o u r c e : U.S. Dept. of Commerce, Bureau of the Census 1983. a Data not available. Los Angeles County and City PSA's combined. S o u r c e : Kramer et al. 1990. a Source:
dressed in any other way. American literature and entertainment media reflect historic relations with American Indians in a limited range of images ranging from the noble savage to the bloodthirsty savage to the lazy drunkard (Stedman 1982). The United States is a society in which American Indians, as an ethnic group, are not represented as people. Elders are likely to have encountered blatant racism and also suffered the pernicious effects of stereotyping during their lives. Added to this are the elders' cultural perceptions that many typical non-Indian attitudes are intolerably rude: getting right down to business, addressing strangers in loud confident tones and frequently interrupting speakers. Those attitudes increase social distance and decrease confidence in non-Indian professionals. Given their previous experiences, some elders would hesitate to approach the aging network and would hesitate to expect positive results. Older American Indians reported that they did not expect to be treated fairly by non-Indian service providers; fear of the service providers and negative contact experiences were also reported (National Indian Council on Aging 1982).
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There are successful solutions and ways around these barriers. Demonstration projects in Montana (Montana United Indian Association 1976), Albuquerque (NICOA 1982) and Los Angeles (Weibel-Orlando and Kramer 1989) have successfully linked elders to aging network services through peer group outreach programs. Information and referral alone are not sufficient to meet the multiple needs of frail American Indian elders. The case management approach taken by these outreach projects has been effective. In Los Angeles, 128 linkages to 47 agencies were effected. Without the outreach intervention by peer paraprofessionals, access to support services would not have occurred. American Indian staffing patterns are essential to overcoming cultural differences and systematic barriers. If adding additional staff is not a possibility, certainly coordination with local American Indian organizations is not precluded. The multipurpose urban Indian centers have developed staff positions for information and referral. The centers could be involved in outreach and follow-up as well as in advisory roles. Finally, contracting Older Americans Act services with urban Indian centers dramatically increases the range of assistance available within the community (Kramer et al. 1990). Indian centers are a significant node which attract a dispersed clientele. In Phoenix, for instance, the Indian Center served (an unduplicated) 48 persons whereas the generic senior center meal sites served no more than two American Indian elders at any site. It is at this level that an economy of scale does seem to apply. It is hard to provide culturally sensitive activities for one or two persons at a congregate meal site. Overcoming the distances and dispersion of urban elders throughout a metropolitan area is a major challenge which Indian organizations have overcome in a number of locations. Area Agencies on Aging and service providers need the expertise of the American Indian community. Conversely, urban American Indian communities need the resources provided under Title 1-H. Coordinated service delivery systems are one solution to meeting the intent of the Older Americans Act. NOTES 1 This research was supported in part by Department of Health and Human Services, Administration on Aging demonstration grant AM0273 and Administration on Aging research grant AR0118. 2 The author thanks Dr. Karen NoLand of Ohio State University and University of Wisconsin at Stevens Point for sharing her insights and material collection of contemporary artifacts on stereotyping of American Indians. REFERENCES CITED Ablon, J. 1964 Relocated American Indians in the San Francisco Bay Area: Social Interaction and Indian Identity. Human Organization 23:296-304. Ablon, J. 1965 American Indian Relocation: Problems of Dependency and Management in the City. Phylon 26:362-371. American Indian Physicians Association 1979 Physical and Mental Health of Elderly American Indians. The Continuum of Life: Health Concerns of the Indian Elderly,
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Final Report of the 2nd National Indian Conference on Aging, Billings, Montana, August 15-18, 1978. Pp 123-154. Albuquerque, NM: National Indian Council on Aging. Betts, N.M. and C. Crase 1986 Nutrient Intake of Urban Elderly American Indians. Journal of Nutrition for the Elderly 5(4): 11-18. Block, M.R. 1979 Exiled Americans: The Hight of Indian Aged in the United States. In Ethnicity and Aging: Theory, Research and Policy. D.E. Gelfand and A.V. Kutzek, eds. Pp. 184-192. New York: Springer. Briggs, E. 1987 Personal communication. Cooley, R.C., D. Ostendorf and D. Bickerton 1979 Outreach Services for Elderly Native Americans. Social Work 24(2): 151-153. Cuellar, J.B., E.P. Stanford and D.I. Miller-Soule 1982 Understanding Minority Aging: Perspectives and Sources. University Center on Aging. San Diego, CA: San Diego State University. Dukepoo, F.C. 1980 The Elder American Indian. San Diego: Campanile Press. Eck, R.D. and R.D. St. Louis 1972 Research Results Concerning the Economic and Social Problems of The Elderly Urban Indian in Phoenix, AZ. Phoenix: Nutritional and Coordinated Services for the Elderly Urban Indian Project. Edwards, E.D. 1983 Native American Elders: Current Issues and Social Policy Implications. In Aging in Minority Groups. R.L. McNeely and J.L. Cohen eds. Pp. 74-82. Beverly Hills, CA: Sage. Gillum, R.F., B.S. Gillum, and N. Smith 1984 Cardiovascular Risk Factors Among Urban American Indians: Blood Pressure, Serum Lipids, Smoking, Diabetes, Health Knowledge and Behavior. American Heart Journal 107(4):765-776. Graves, T. 1970 The Personal Adjustment of Navajo Indian Migrants to Denver, Colorado. American Anthropologist 72:35-54. Graves, T.D. and M. Van Arsdale 1966 Values, Expectations and Relocation: The Navajo Migrant in Denver. Human Organization 24(4):300-307. Guillemin, J. 1975 Urban Renegades: The Cultural Strategies of American Indians. New York: Columbia University Press. Kramer, B.J. 1990 Urban American Indian Aging. Paper presented at the American Society on Aging annual meetings, San Francisco, CA. Kramer, B.J. 1989 A Study of Urban American Indian Aging. Paper presented at the American Society on Aging annual meetings, Washington, D.C. Kramer, B.J., J.C. Hyde, and D. Polisar 1990 Study of Urban American Indian Aging. Final Report Administration on Aging Research Grant AR0118. Los Angeles City/County Native American Indian Commission 1982 Report on Los Angeles Urban Indian Elderly. Public Hearings. Manson, S.M. 1988 Older American Indians: Status and Issues in Income, Housing and Health. Paper prepared for the American Association of Retired Persons Conference "Toward Empowering Minority Elderly," September 8-9. St. Louis. Manson, S.M. and A.M. Pambrun 1979 Social and Psychological Status of American Indian Elderly: Past Research, Current Advocacy and Future Inquiry. White Cloud Journal 1(3): 18-25. Manson, S.M., C.M. Murray, and L.D. Cain 1981 Ethnicity, Aging, and Support Networks: An Evolving Methodological Strategy. Journal of Minority Aging 6(2): 11-37. Martin, H.W. 1964 Correlates of Adjustment Among American Indians in an Urban Environment. Human Organization 23:290--295. Mclntosh, J.L. 1984 Suicide Among Native Americans: Further Tribal Data and Considerations. Omega 14(3):215-229. Mclntosh, J.L. and J. Santos 1981 Suicide Among Native Americans: A Compilation of Findings. Omega 11 (4):303-316.
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Montana United Indian Association 1976 Final Report Montana United Indian Association Elderly Urban Indian Project. Helena, MT: Montana United Indian Association. National Indian Council on Aging [NICOA] 1981a American Indian Elderly: A National Prof'fle. Albuquerque, NM: NICOA/Cordova. National Indian Council on Aging [NICOA] 1981b Indian Elderly and Entitlement Programs. Albuquerque, NM: NICOA. National Indian Council on Aging [NICOA] 1982 Access: A Demonstration Project Entitlement Programs for Indian Elders. Albuquerque, NM: NICOA. Neils, E.M. 1971 Reservation to City. Department of Geography Research Paper 131. Chicago IL: University of Chicago. Price, J. 1968 The Migration and Adaptation of American Indians in Los Angeles. Human Organization 27:168-175. Rhoades, E.R., M. Marshall, C. Atmeave, M. Echohawk, J. Bjork, mad M. Beiser 1975 Impact of Mental Disorders upon Elderly American Indians as Reflected in Visits to Ambulatory Care Facilities. Journal of the American Geriatrics Society 28(1):33-39. Rhoades, E.R., M. Marshall, C. Attneave, M. Echohawk, J. Bjork, and M. Beiser 1980 Mental Health Problems of American Indians Seen in Outpatient Facilities of Indian Health Service, 1975. Public Health Reports 95(4):329-335. Smith, E.M. 1987 Health Care for Native Americans: Who Will Pay? Health Affairs 6:123-128. Sorkin, A. 1978 The Urban American Indian. Lexington, MA: DC Heath and Co. Stedman, R.W. 1982 Shadows of the Indian: Stereotypes in American Culture. Norman, OK: University of Oklahoma Press. Stuart, P. and E. Rathbone-McCuan 1988 Indian Elderly in the United States. In North American Elders: United States and Canadian Perspectives. E. Rathbone-McCuan and B. Havens, eds. Pp. 235-253. New York: Greenwood Press. Thornton, R., D.G. Sandefeur, and H.G. Grasmick 1982 The Urbanization of American Indians: A Critical Bibliography. Newberry Library Center, Bloomington: Indiana University Press. Tyon, M. 1990 Personal communication. Weibel-Orlando, J. 1989 Elders and Elderlies: Well-being in Indian Old Age. American Indian Culture and Research Journal 13(3/4):75-84. Weibel-Orlando, J. and Kramer, B,J. t989 The Urban American Indian Elders Outreach Project. Final Report of Administration on Aging demonstration project 90 AMO273, Los Angeles CA: County of Los Angeles. Williams, G.C. 1980 Warriors No More: A Study of the American Indian Elderly. In Aging in Culture and Society. C.L Fry, ed. Pp. 101-111. New York: Bergin & Garvey Publishers, Inc. U.S. Department of Commerce, Bureau of the Census 1983 1980 Census of Population and Housing: Census Tracts, PCH80-2. Washington, D.C.: U.S. Government Printing Office. U.S. Department of Commerce, Bureau of the Census 1988 Statistical Abstract of the United States 1988. 108 edition. Washington, D.C.: U.S. Government Printing Office. U.S. Commission on Civil Rights 1981 Indian Tribes: A Continuing Quest for Survival. Washington, D.C.: U.S. Government Printing Office.
County of Los Angeles Department of Community and Senior Citizens Services 1102 Crenshaw Boulevard Los Angeles, CA 90019-3198, U.S.A.
URBAN AMERICAN INDIAN AGING 1
ABSTRACT. Although the majority of American Indians do not live on reservations, little attention has been focused on urban American Indian elderly. Urban American Indian elders have aged in place, and the majority intend to remain in cities. First, the needs of American Indian elders are assessed and the under-utilization of Older Americans Act services documented. Then barriers to access are discussed and means to increase participation recommended. Key Words: elders, health, Native Americans, needs assessment, policy
INTRODUCTION Urban A m e r i c a n Indians are under-represented in the literature on minority aging (Cuellar, Stanford and Miller-Soule 1982; Kramer, H y d e and Polisar 1990). This paper (1) reviews the status o f older urban American Indians' demography, health, mental health, nutrition and activities o f daily living; and (2) reports on utilization o f services funded by the Older Americans Act. The research on urban American Indian aging was largely conducted in conjunction with or under the auspices o f American Indian organizations; much o f this research has not been widely reported. Older urban American Indians are a segment o f the U.S. population in greatest social and economic need for supportive services. However, recent research (Kramer et al. 1990) indicates a systematic under-utilization o f existing support services funded b y the Older Americans Act. Barriers reducing access to services are discussed in this paper. Finally, recommendations are made for research, policy and practices to improve the delivery o f support services to older urban American Indians at the level o f the local planning and service area. Compounding a general lack of awareness o f urban American Indian eiders' needs and conditions are a number o f persistent myths. Erroneous beliefs have significantly reduced the response o f the aging network in conducting applied research and planning for their needs (Briggs 1987). F o u r c o m m o n misperceptions must be clarified before describing the current state o f knowledge and the implications o f recent research on planning and service delivery. Misperceptions 1. When American Indians get old, they retire to reservations. The vast majority o f elders do not return to reservations. F o r over a decade, American Indian organizations have produced local reports - unfortunately with narrow dissemination - noting that their elders have aged in place and that no services seem to be available due to lack o f recognition o f that fact (Eck and St. Louis 1972; Los Angeles City/County Native American Indian Commission 1982; Montana Journal of Cross-Cultural Gerontology6:205-217, 1991. © 1991 KluwerAcademic Publishers. Printed in the Netherlands.
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United Indian Association 1976). From my conversations with Area Agency on Aging (AAA) planners, this misperception has hindered both research on the needs of this population and serious planning efforts to fill these needs.
2. American Indians are eligible for special services because they are wards of the government. All American Indians are U.S. citizens, and they are not wards of the government. There is a unique and special relationship between the Federal government and tribal entities. This Trust relationship recognizes American Indian societies as self-governing "domestic dependent nations" and the Federal government as having fiduciary responsibilities for land title and social services (U.S. Commission on Civil Rights 1981). However, these services may be linked exclusively to the reservation and the sovereign tribal government. Health care is a good example. After a period of 120 days residence off-reservation, an American Indian is no longer eligible for medical care by the Indian Health Service. The federal responsibility is transferred to state public health departments (Smith 1987; Stuart and RathboneMcCuan 1988). Urban American Indians have long been turned away from health clinics by providers who misunderstand the federal regulations and tell Indians to get their service from the Indian Health Service (National Indian Council on Aging - NICOA 198 lb). As U.S. citizens, American Indians are taxpayers. Any resident on a Federal reservation (e.g., military reservations, American Indian reservations) is exempt from paying state residence taxes and state taxes on goods and services delivered to consumers on those reservation lands (e.g., the military PX). 3. Title VI of the Older Americans Act provides funds for nutrition and community services to American Indian tribal governments and therefore Title III providers have limited responsibility to serve older American Indians. Noting that older American Indians were not benefitting from the nutrition and community services provided to older Americans under Title III of the Older Americans Act, Congress added a sixth entitlement which directly funds American Indian tribes to deliver these services in remote reservation areas. The Older Americans Act Amendments of 1987 (P.L. 100-175) contains specific wording to indicate that American Indians are also eligible for Title III services. According to the law, if a "significant population" of older American Indians lives in the planning and service area, the Area Agency on Aging is obliged to conduct outreach to those individuals. The Federal legislation does not define the number of older Americans which constitute a significant population; the definition is determined by each State. All Title VI programs are limited to reservations and are contracted with tribal entities. There are 278 reservations and 209 Alaskan Native Villages but only 81 Title VI programs. Obviously the majority of elders living on reservations are not in a position to receive Title VI services, which are limited mostly to nutrition programs. But the majority of the American Indian population does not live on reserva-
U~BAN AMERICAN INDIAN AGING
207
tions, The t980 U.S. Census documented that neariy half of the American Indians over age 65 live in cities and, from the perspective of Older Americans Act services, should be served exclusively by Title III programs. 4. American Indians have a homogeneous culture. Popular images of American Indians tend to mix together elements of different indigenous cultures. Most Americans are unaware of the great diversity of American Indian cultures. Despite the effects of conquest and participation in the dominant U.S. society, 150 distinct American Indian languages continue to be spoken today. Cultural understandings underlie perceptions of appropriate behaviors. For instance, while elders are universally respected, there have always been tremendous differences in the treatment of frail elderly. Among Pueblo peoples, for instance, the extended family offered nurture and protection to frail older adults; in contrast, Apache customarily abandoned eiders who were no longer selfsufficient (Cooley, Ostendorf and Bickerton 1979). However, since the 1970s, a political homogeneity has existed among urban American Indian organizations and national Indian organizations. Forging a pan-Indian identity, these organizations recognize their shared concerns as native peoples despite their cultural differences. STATUS OF OLDER URBAN AMERICAN INDIANS Profiles of older urban American Indian demography, socioeconomic status, health, support service utilization patterns and service needs were gathered in two research studies. The Urban American Indian Elders Outreach Project was conducted in Los Angeles from 1987 to 1989 as a demonstration project of outreach and linkage (Weibel-Orlando and Kramer 1989). The project's peer outreach coordinators were active older American Indians. They identified local elders, administered an extensive needs assessment questionnaire, and assisted elders to access support services. Expanding on that project to a nationwide scope, the literature and the patterns of Title III.service access and utilization were examined (Kramer et al. 1990), Data were gathered from library and archival research, from Management Infolxnation System (MIS) reporting by each site provider and from surveys of both urban American Indian organizations and Area Agencies on Aging in 18 cities with major concentrations of American Indians, Demographics Older urban American Indians are a little known population (Block 1979; Edwards 1983). Most of the literature on urban American Indians examined their adjustment to city life in the period 1950 to 1970 (Thornton, Sandefeur and Grasmick 1982). This was a period of great migration from rural reservations to cities, a migration underwritten by relocation programs which were part of the federal policy to terminate the special relationship with the tribes. Research
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conducted in that period concentrated on the negative impact of urbanization: crime, alcoholism, unemployment, maladjustment. Equal emphasis was not given to successful adaptive strategies, no doubt, because funding was generally tied to solving social problems. The impression given to an unwary reader is that American Indians were unable to establish themselves in urban areas. For many relocatees this was true. Early in the program the rate of return to reservations was 75% but this later dropped to 35% (Ablon 1965). Even given the high return rate of those who were not highly motivated to live in cities, the percentage of American Indians living off reservations jumped from only 7% in 1940 to 50% in 1977 (Neils 1971; Sorkin 1978). The literature also notes that older American Indians are less successful at adjustment and more likely to return to their reservations (Ablon 1964; Graves 1970; Graves and Van Arsdale 1966; Guillemin 1975; Price 1968). The concept "older" was not generally defined, and readers might mistakenly infer postretirement age. In this context an older American Indian was someone over either age 25 or a g e 30 depending on the specific analysis of the Bureau of Indian Affairs case files (Martin 1964). Those individuals who did adjust, and did remain in cities, over the last 40 years are now at retirement age. Whether in Phoenix, Los Angeles or San Diego elders reported that they did not plan to return to their natal reservations (Dukepoo 1980; Eck and St. Louis 1972; Weibel-Orlando and Kramer 1989). In fact, in our Los Angeles survey, age was associated with an increasing commitment to remain in the city (Kramer 1989). The life expectancy and longevity of American Indians remains below that of the general U.S. population although these rates have shown improvement since World War II. The average life expectancy of American Indians is eight years less than non-Indians. Many American Indians do not live long enough to qualify for "older" American services, and impairments associated with aging typically occur twenty years earlier than in the general population (NICOA 1981a). Title VI of the Older Americans Act recognizes the need to provide support services to older American Indians living on reservations who may not yet be 60 or older. The legislation allows a tribal contractor to serve frail middle-aged elders if fifty adults age 60+ are also served. That waiver is not extended to elders living in urban settings. Chronological age is not a clear indicator of frailty in American Indians. In a national sample, American Indians at middle-age were found to suffer physical, emotional and social impairments which are characteristic of the general U.S. population aged 65 or older (NICOA 198ta). On reservations, individuals appeared aged at 45 years and in urban areas, American Indians were aged by 55 years. Indeed, American Indians do not define aging by chronology. The notion of calendar date birthdays and attendant celebrations of life stages was only introduced during the reservation period. This notion of aging has not been accepted by American Indians as normative (Williams 1980). In Los Angeles, the median age for both men and women who were considered elders by the community was 58 years. The American Indian community
URBANAMERICANINDIANAGING
209
both on and off reservations uses social role functioning (e.g., grandparenting) and decline in physical activities as indicators to define which individuals are considered "elders" (Weibel-Orlando 1989). Treating elders according to their abilities is rooted in cultural practices. Based on the differing expectations of the aged, eligibility criteria for social service programs (e.g., Job Training Partnership Act programs, poverty programs) bear reevaluation. Aged American Indians are a population in great social and economic need. The 1980 U.S. Census indicates that nowhere in the U.S. did the income of urban American Indians aged 65+ equal that of elderly whites (Manson 1988). Approximately one-third of urban American Indians have incomes below or slightly above the poverty level in contrast to one fifth of whites who live at that level of poverty. Despite the income difference, there are no substantial differences in the labor participation and employment of whites and urban American Indians aged 65+. About half the urban American Indian population aged 75 or older live with family members. American Indian families with elders in residence have three times the proportion of their population living in poverty as compared to whites. As Manson (1988) notes, generalizations about family support systems must be tempered with the knowledge that their resources are scarce and irregular. Poverty increases the stress of care-giving. Health
There is no comprehensive data base on urban American Indian health problems and health care needs. The Indian Health Service collects no systematic data from its urban health project providers. Nor does the National Center for Health Statistics and other sources have data on urban American Indians. The American Indian Physicians Association (1979) presumes that American Indian elderly share the general health characteristics of the American Indian population at large. There is a high frequency of cataracts. Rheumatoid arthritis appears to occur with higher frequency than among non-Indians. Obesity, diabetes, cigarette use plus moderately elevated blood pressure and serum cholesterol levels are consistent with the high cardio-vascular mortality and morbidity. Obesity is common and is a risk factor not just for diabetes and cardio-vascular conditions but also for cerebrovascular disease. Gillum, Gillum and Smith (1984) report these risk factors and associated diseases for an urban American Indian population. The information available on urban eiders' health was collected in surveys conducted at various times through the auspices of American Indian organizations. In Phoenix 144 elders were surveyed in 1972; in Los Angeles a survey interviewed 328 elders in 1988; in a multi-site survey the National Indian Council on Aging reported on 712 elders in 1981; and, in Denver, a survey ongoing since 1987 has contacted 524 elders (Tyon 1990). The findings appear to be consistent. While responding with generally positive self-assessments on
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13.JOSEAKRAMER
TABLE I Comparison of prevalence of morbidity for self-reported disease or specific symptom by percent in Los Angeles Indians 45+, nationwide Indians 45+, Cleveland general population 65+ and U.S. general population 45+ Health problem
Eyesight Arthritis/rheumatics Hypertension Hearing problems Diabetes Sleep problems Heart problems Breathing problems Allergies Headaches Asthma Stroke Speech problems Liver problems Kidney stones Mental illness Amputation Cancer
L.A. Indian aged 45+ (except homeless) 65.9 36.4 30.7 21.0 19.8 17.0 14.8 13.1 12.0 11.0 8.1 4.9 4.6 3.5 3.2 3.2 2.8 2.5
Number of men Number of women
99 184
Total number
283
National Indian aged 45+a
54.6 42.6 19.3 44.4 12.5 30.4 16.1 34.0 28.5 4.3 3.2 1.4 1.6 8.9 7.9 1.2 1.1
Cleveland all races aged 65+a
40.4 41.9 16.5 37.3 4.2 33.5 15.6 23.0 14.8 3.2 4.6 1.2 0.4 1.9 4.4 2.1 0.9
National all races aged 45+b
m
26.9 25.9 15.9 5.2 12.9 9.0 4.1 2.8
687 1037 712
1834
a NICOA 1981a. b U.S~Dept. of Commerce, 1988. Excerpted from Weibel-Odando and Kramer 1989. their health, most elders suffered from health problems at the time of their interview. The Los Angeles sample of respondents age 45+ does not compare favorably on morbidity rates to either the national American Indian sample of elders aged 45+ or to the Cleveland general population sample of 65+ (Table I). Los Angeles elders report higher frequencies of eye disease, speech pathologies, asthma, hypertension, cancer, stroke, amputation, diabetes, and liver disease than American Indian elders nationwide. Similar complaints were noted for elders living in Phoenix where the most common health problems were diabetes, arthritis and rheumatism, hypertension, heating problems and visual disorders. In comparison to the general urban sample reported in Cleveland, American Indians in Los Angeles have dramatically higher frequencies of certain diseases.
URBAN AMERICAN INDIAN AGING
211
For instance, diabetes occurs four times more frequently and liver disease occurs almost nine times more frequently. Hypertension was reported by nearly a third (31%) of the respondents aged 45+. Although no comparable data were collected by the National Indian Council On Aging, a high frequency of dental problems was noted in Los Angeles; these comprised the third most frequently identified health problem. Nutrition One small study on nutrition of urban elders was conducted in Lincoln, Nebraska (Betts and Crase 1986). Unlike their peers living on reservations (American Indian Physicians Association 1979), malnutrition was not found. However, both elderly whites and American Indians in Lincoln were found to be below recommended levels in total food energy, vitamin A and calcium intakes. Utilization of Mental Health Services The low use of mental health practitioners by elderly American Indians indicates either less need than the general American Indian population or more selective barriers for this aging population. To some extent both of these variables interact. On one hand, the positive role of "the elder" has been equated with the low incidence of self-destructive behaviors such as alcoholism and suicide, behaviors that are found with high frequency among younger American Indians, especially on reservations reporting these data (American Indian Physicians Association 1979; Mclntosh 1984; McIntosh and Santos 1981). On the other hand, the notions of evaluating and treating mental health problems are highly stigmatized in the American Indian community. This may be especially true in urban areas. In Los Angeles, community disapproval of discussing this issue was so strong that questions overtly regarding mental health were removed from the needs assessment instrument used by the Urban American Indian Elders Outreach Project. There are no data on the mental health utilization patterns of urban elders. However, the reservation-based elders' most frequent mental health complaint is anxiety and their most frequent physical complaints are for chronic illnesses (Rhoades, Marshall, Attneave, Echohawk, Bjofk, and Beiser 1975, 1980). Stress has been associated with chronic disease. Older urban American Indians have been especially disadvantaged by their (and their health care providers') lack of awareness of psychological, social or economic resources which might ameliorate their conditions (Manson, Murray and Cain 1981). When questioned, elders expressed concern about "what people would think" if they solicited help. Differences in life satisfaction existed between urban and reservation elders attending the second annual National Indian Council on Aging annual meeting in 1978 (Manson and Pambrun 1979). Greater dissatisfaction was expressed by urban elders and was associated with: (1) lack of planned entertainment for American Indian senior citizens; (2) isolation; and (3) transportation problems. All are conditions which senior center activities and services could remedy.
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B. JOSEAKRAMER
Activities of Daily Living In the Los Angeles needs assessment, the majority of respondents were not impaired in any Activity of Daily Living (ADL) or Instrumental Activity of Daily Living (IADL). However, the majority of those reporting impairments were unable to function independently in more than one ADL or IADL. Age correlated with multiple impairment. Those aged 60+ years tended to have more impairments than the younger self-identified population of "elders." Only in three areas were there no statistically significant differences between persons younger than 60 years and those older than 60 years: dressing, toileting and feeding. As shown in Table II, age-specific differences occurred for bathing, transfer, mobility in the home, using the telephone, money management, shopping, transportation, meal preparation and light housework. The greatest number of impairments and the strongest relationships to age occur in the IADL categories. TABLE II Frequency of impaired Activities of Daily Living and Instrumental Activities of Daily Living by age, Los Angeles American Indian elders, 1988 ADL activities Bathing" Dressing Toileting Transfera Feeding Mobilityb Tot~
(N=286) (N=286) (N=286) (N=284) (N=287) (N=283)
< 60
60+
IADL activities
< 60
6 5 4 5 2 9
16 12 10 18 5 28
Telephonea Financesb Shopping~ Transport¢ Mealsb Houseworkc
3 4 15 15 13 15
13 17 41 41 31 42
31
89
Tot~
65
185
(N=294) (N=290) (N=294) (N=292) (N=289) (N=290)
60+
a Significant at p < 0.05 [Z2]. = p < 0.005 [Z2]. c p < 0.0001 [zz]. Source: Kramer 1990. Frail elders were receiving informal and some formal assistance although in no case did the elder perceive that help to be sufficient. Although most elders in Los Angeles live alone or with a spouse, it is the frail community members who are found in large multigenerational households. Quite often unmarried grandchildren or children are the care-givers. The extended family role in these cases is significant. However, accessing formal services may have been somewhat reduced: until a crisis stage is reached, there may be little incentive to endure bureaucratic application procedures in order to receive supportive services. Furthermore, the eligibility requirements of some agencies may not support the extended family's residential arrangements and continued involvement.
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ACCESS AND UTILIZATION OF TITLE III In examining Management Information System (MIS) reporting of Title III services for fiscal year 1989 in 18 Planning and Service Areas which have large concentrations of urban American Indians, one startling pattern emerged. This pattern suggests that American Indians in the greatest social and economic need have not benefitted from Older Americans Act supportive services. Nine of the 18 areas investigated did not provide Title IIIc services in proportion with the percentage of the American Indian population aged 65+ living in poverty (Kramer et al. 1990). Arrayed in Table III are the percentages of American Indians living in poverty at the 1980 decennial U.S. Census by region, compared to the percentage of that American Indian population over age 60+ served by Title III in 1989. Despite the time span, these are the most recent data bases available at this time. Unduplicated statistics for Title 11I services are only available for comparing congregate meals. While we cannot know if those served by Title III service providers are living in poverty, clearly the areas with the lowest percentage of service cannot be reaching those elders in the greatest need. The underlying causes and policies for this apparently uneven distribution of resources thus far remain unaddressed. While American Indians generally represent less than 1% of the elderly population in any metropolitan area, allocation of resources based on an economy of scale is insufficient. For whatever reason, failure to serve an ethnic minority and those persons in greatest social and economic need, is hardly in keeping with the spirit of the Older Americans Act. American Indian elders are considered a hard-to-serve population by planning and service agencies of the aging network. A number of barriers reduce access to health and supportive services. American Indians are not adept at cutting through the "white" tape and are unwilling to accept services delivered as charity. Distrust, lack of communication, and cultural insensitivity too often characterize interactions between American Indian elders and non-Indian service providers. Our society exhibits a systematic bias which few non-Indians seem to grasp. 2 But close attention makes it obvious. In professional, college or amateur sports, for example, it quickly becomes evident that some teams are named after an ethnic group while most are named after animals or mascots. American Indian stereotypes are promoted in caricatures used to sell commercial products, such as the Savage rifle. On Halloween there will be superheroes and princesses and "Indian braves," but not "Chinamen" or black face. Nor will other ethnic minorities be represented as animals on greeting cards such as the bunnies and chipmunks invariably dressed in feathered headbands and moccasins on Thanksgiving cards. Some toys have taken a negative characterization of Indians, such as the battery-powered gorilla banging on a tom-tom. Public schools perpetuate the stereotype of the feather-headdressed Indian to such an extent that children react with disbelief to meeting an American Indian person
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B. JOSEA KRAMER
TABLE III Percentage of older American Indians living in poverty and percentage of older American Indians served by Title III % American Indians aged 65+ below poverty in 1979a
% American Indians aged 60+ served by planning and service areas in 1989 b
American Indian elders in planning and service areas in 1980c
Northeast
24.1
Midwest
25.8
South
28.8
West
20.6
Boston New York Milwaukee Omaha Chicago Minn./St. Paul St. Louis Dallas Oklahoma City Tulsaa San Francisco Oakland Seattle Denver Los Angeles~ Phoenix Albuquerque Portland
125 (0.13 %) 1192 (0.09%) 273 (0.16%) 103 (1.17%) 438 (0.09%) 680 (0.26%) 77 (0.07%) 348 (0.20%) 1477 (1.48%) 2955 (3.62%) 416 (0.30%) 401 (0.25%) 744 (0.40%) 392 (0.22%) 3572 (0.34%) 1264 (0.52%) 728 (1.47%) 318 (0.31%)
U.S.
region
43.20 4.53 30.77 25.24 17.84 12.06 00.00 17.82 13.68 64.90 62.09 55.91 35.20 20.44 7.59 6.59 1.57
Manson 1988. b Based on unduplicated MIS reporting of Title III(c)1. c S o u r c e : U.S. Dept. of Commerce, Bureau of the Census 1983. a Data not available. Los Angeles County and City PSA's combined. S o u r c e : Kramer et al. 1990. a Source:
dressed in any other way. American literature and entertainment media reflect historic relations with American Indians in a limited range of images ranging from the noble savage to the bloodthirsty savage to the lazy drunkard (Stedman 1982). The United States is a society in which American Indians, as an ethnic group, are not represented as people. Elders are likely to have encountered blatant racism and also suffered the pernicious effects of stereotyping during their lives. Added to this are the elders' cultural perceptions that many typical non-Indian attitudes are intolerably rude: getting right down to business, addressing strangers in loud confident tones and frequently interrupting speakers. Those attitudes increase social distance and decrease confidence in non-Indian professionals. Given their previous experiences, some elders would hesitate to approach the aging network and would hesitate to expect positive results. Older American Indians reported that they did not expect to be treated fairly by non-Indian service providers; fear of the service providers and negative contact experiences were also reported (National Indian Council on Aging 1982).
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215
There are successful solutions and ways around these barriers. Demonstration projects in Montana (Montana United Indian Association 1976), Albuquerque (NICOA 1982) and Los Angeles (Weibel-Orlando and Kramer 1989) have successfully linked elders to aging network services through peer group outreach programs. Information and referral alone are not sufficient to meet the multiple needs of frail American Indian elders. The case management approach taken by these outreach projects has been effective. In Los Angeles, 128 linkages to 47 agencies were effected. Without the outreach intervention by peer paraprofessionals, access to support services would not have occurred. American Indian staffing patterns are essential to overcoming cultural differences and systematic barriers. If adding additional staff is not a possibility, certainly coordination with local American Indian organizations is not precluded. The multipurpose urban Indian centers have developed staff positions for information and referral. The centers could be involved in outreach and follow-up as well as in advisory roles. Finally, contracting Older Americans Act services with urban Indian centers dramatically increases the range of assistance available within the community (Kramer et al. 1990). Indian centers are a significant node which attract a dispersed clientele. In Phoenix, for instance, the Indian Center served (an unduplicated) 48 persons whereas the generic senior center meal sites served no more than two American Indian elders at any site. It is at this level that an economy of scale does seem to apply. It is hard to provide culturally sensitive activities for one or two persons at a congregate meal site. Overcoming the distances and dispersion of urban elders throughout a metropolitan area is a major challenge which Indian organizations have overcome in a number of locations. Area Agencies on Aging and service providers need the expertise of the American Indian community. Conversely, urban American Indian communities need the resources provided under Title 1-H. Coordinated service delivery systems are one solution to meeting the intent of the Older Americans Act. NOTES 1 This research was supported in part by Department of Health and Human Services, Administration on Aging demonstration grant AM0273 and Administration on Aging research grant AR0118. 2 The author thanks Dr. Karen NoLand of Ohio State University and University of Wisconsin at Stevens Point for sharing her insights and material collection of contemporary artifacts on stereotyping of American Indians. REFERENCES CITED Ablon, J. 1964 Relocated American Indians in the San Francisco Bay Area: Social Interaction and Indian Identity. Human Organization 23:296-304. Ablon, J. 1965 American Indian Relocation: Problems of Dependency and Management in the City. Phylon 26:362-371. American Indian Physicians Association 1979 Physical and Mental Health of Elderly American Indians. The Continuum of Life: Health Concerns of the Indian Elderly,
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