234_editor's choice.qxd USABMJPrimary Care Medicine for the American Physician BMJ USA is published monthly by Jobson Publishing in conjunction with the British Medical Association. EDITOR, BMJ USA EDITOR, BMJ Steven H Woolf, MD, MPH Dr. Richard Smith Professor, Department of Family Practice Chief Executive Professor, Department of Preventive BMJ Publishing Group and Community Medicine London, UK Virginia Commonwealth University Fairfax, Virginia ASSOCIATE EDITORS Paul S Frame, MD Joanne C Roberts, MD, FACP Tri-County Family Medicine Medical Director Cohocton, New York Whatcom Hospice Clinical Professor of Family Medicine Center for Senior Health University of Rochester School of St Joseph Hospital Medicine and Dentistry Bellingham, Washington Rochester, New York Jo Ann Rosenfeld, MD Rebekah Wang-Cheng, MD, FACP Assistant Professor of Medicine Clinical Professor of Medicine Johns Hopkins University School of Medical College of Wisconsin Medicine Milwaukee, Wisconsin Baltimore, Maryland Private Practice, St Helena, California EDITORIAL BOARD Margaret I Aguwa, DO, MPH David Atkins, MD, MPH Chairperson Center for Practice and Technology Dept of Family & Community Medicine Assessment College of Osteopathic Medicine Agency for Healthcare Research Michigan State University and Quality East Lansing, Michigan Washington, DC Regina M Benjamin, MD, MBA Klea D Bertakis, MD, MPH Assistant Dean for Chairperson Rural Health Dept of Family & Community Medicine University of South Alabama School of Medicine College of Medicine University of California, Davis Mobile, Alabama Sacramento, California Mark A Kelley, MD Thomas E Kottke, MD, MSPH Executive Vice President and Professor of Medicine Chief Medical Officer (Cardiovascular Diseases) Henry Ford Health System Mayo Clinic Detroit, Michigan Rochester, Minnesota Rosanne M Leipzig, MD, PhD David C Slawson, MD Associate Professor B Lewis Barnett, Jr, Professor of Dept of Geriatrics & Adult Development Family Medicine Mount Sinai School of Medicine University of Virginia New York, New York Charlottesville, Virginia Edward H Wagner, MD, MPH Director W A MacColl Institute for Healthcare Innovation Group Health Cooperative of Puget Sound Seattle, Washington BMJ USA (ISSN 1531-5177) is published monthly by the BMJ and Jobson Publishing, LLC, 100 Avenue of the Americas, New York, NY 10013-1678. Periodicals postage paid at New York, NY, and additional mailing offices. POSTMASTER: Send address changes to BMJ USA, Jobson Publishing, LLC, 100 Avenue of the Americas, New York, NY 10013-1678. Subscription rates: $150 per year in the US ($75 per year for students). Copyright © 2003 by BMJ and Jobson Publishing, LLC. Printed in the USA. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form, or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior permission, in writing, from the publishers. Circulation: 94,940 office-based physicians specializing in primary care or cardiology. BMJ USA is a registered trademark. 234 BMJ USA VOLUME 3 MAY 2003 Editor’s choice The first Americans In an 1808 letter to Congress, Thomas Jefferson wrote, “With our Indian neighbors the public peace has been steadily maintained. Some instances of individual wrong have, as at other times, taken place, but in nowise implicating the will of the nation…. And, generally, from a conviction that we con- sider them as part of ourselves, and cherish with sincerity their rights and interests, the attachment of the Indian tribes is gaining strength daily—is extending from the nearer to the more remote, and will amply requite us for the justice and friendship practised towards them” (http://memory.loc .gov/ammem/mtjhtml/mtjhome.html). Now, 200 years later, it can hardly be said that Native Americans have been the beneficiaries of overabundant “justice and friendship.” One need not recount their bar- baric treatment in the 19th century and the vestiges that remain on today’s reservations, but the social injustice that modern society affords the first Americans does weigh on the conscience. Large numbers suffer from poverty, poor housing, loss of culture, and sickness. The high disease rates and poor health care experi- enced by Native Americans are not unique but appear to be part of a global phenomenon among indigenous peo- ples, as the New Zealander Mason Durie writes in this issue (p 241). The public health histories of New Zealand’s Maori, Australia’s aborigines, Norway’s Saami, native Ha- waiians, and the First Nations of Canada bear striking re- semblances to historical and modern patterns among Na- tive Americans. A companion editorial by Charles Grim, director of the US Indian Health Service, paints a more positive picture, noting recent advances in the health care of Native Americans (p 242). For example, their life ex- pectancy has increased by 7 years since 1973. Tribes are more engaged in self-management of health affairs. This is certainly good news, but there is still too much bad news. Rates of cigarette smoking, binge drinking, and illicit drug use remain higher among Native Americans than among whites. Fully 38% of Native Americans lack health insurance (the same is true for only 15% of whites). One out of every 5 Native American youths has not been to a doctor within the year. Infant, neonatal, and post- neonatal mortality rates are 50% higher than those of whites. Among adults, 8% of whites—but 17% of Native Americans—rate their health as fair or poor. Having a chronic disease limits activity for 12% of whites but for 20% of Native Americans. Among women age 40 and older, more than 70% of whites but only 47% of Native Americans have had a recent mammogram. Society faces an ethical imperative to address the socio- economic deprivation of Native Americans that lies at the heart of these disparities if, as Jefferson wrote, we “con- sider them as part of ourselves, and cherish with sincerity their rights and interests.” Otherwise, it can be said that inaction is, indeed, “implicating the will of the nation.” ✦ —Steven H Woolf, MD, MPH o n 5 A p ril 2 0 2 1 b y g u e st. P ro te cte d b y co p yrig h t. h ttp ://w w w .b m j.co m / B M J: first p u b lish e d a s 1 0 .1 1 3 6 /b m ju sa .0 3 0 5 0 0 0 1 o n 1 Ju n e 2 0 0 3 . D o w n lo a d e d fro m http://www.bmj.com/