97091 • Providing Care to Alaska Natives

Table of Contents

97091 • Providing Care to Alaska Natives

How to Receive Credit

Course Overview

Audience

Accreditations & Approvals

Designations of Credit

Individual State Nursing Approvals

Individual State Behavioral Health Approvals

Special Approvals

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planners

Division Planners Disclosure

Director of Development and Academic Affairs

Director Disclosure Statement

About the Sponsor

Disclosure Statement

Implicit Bias in Health Care

1. INTRODUCTION

2. DEFINITIONS AND DEMOGRAPHICS

3. HISTORY OF ALASKA AND ALASKA NATIVES

4. ALASKA NATIVES AND THE U.S. GOVERNMENT

ALASKA NATIVE ALLOTMENT ACT OF 1906

ALASKA NATIVE CLAIMS SETTLEMENT ACT (ANCSA)

MARINE MAMMAL PROTECTION ACT (MMPA) OF 1972

TITLE VIII OF ALASKA NATIONAL INTEREST LANDS CONSERVATION ACT (ANILCA)

5. SOURCES OF DISCRIMINATION

LOCAL SUBSISTENCE ECONOMY

RACISM

THE URBAN/RURAL DIVIDE

6. HEALTH AND MENTAL HEALTH

SPECIFIC HEALTH ISSUES

IMPACT OF CLIMATE CHANGE

TRADITIONS AND BELIEFS THAT AFFECT HEALTH

7. BARRIERS TO OPTIMAL HEALTH AND CARE

CULTURAL BARRIERS

GEOGRAPHIC ISOLATION

INADEQUATE PLUMBING AND SEWAGE DISPOSAL

EDUCATION

LACK OF REPRESENTATION IN HEALTH RESEARCH

8. BEST PRACTICES WHEN WORKING WITH ALASKA NATIVE CLIENTS

9. CONCLUSION

Works Cited

97091 • Providing Care to Alaska Natives

Lauren E. Evans, MSW

www.netce.com

Copyright © 2024 NetCE, All rights reserved.

Due in part to changes of the traditional way of life that Alaska Natives practiced for thousands of years before Europeans settled in Alaska, Alaska Natives have several unique health and mental health challenges. This course will offer a brief history of the State of Alaska and Alaska Natives, as well as the relationship between the federal government and Native populations. The particular health and mental health concerns facing Alaska Natives will be discussed at length. Sources of discrimination and barriers to the care of Native people will also be explored.

97091 • Providing Care to Alaska Natives

Education Category. Ethics - Human Rights

Release Date. 06/01/2024

Expiration Date. 05/31/2027

How to Receive Credit

To complete this course for continuing education credit please go to http://www.netce.com/course/2819 in your browser.

For assistance with receiving continuing education credit, please contact us at help@netce.com.

Course Overview

Due in part to changes of the traditional way of life that Alaska Natives practiced for thousands of years before Europeans settled in Alaska, Alaska Natives have several unique health and mental health challenges. This course will offer a brief history of the State of Alaska and Alaska Natives, as well as the relationship between the federal government and Native populations. The particular health and mental health concerns facing Alaska Natives will be discussed at length. Sources of discrimination and barriers to the care of Native people will also be explored.

Audience

This course is designed for social workers, counselors, therapists, nurses, and other healthcare professionals who may provide care to Alaska Natives.

Accreditations & Approvals

In support of improving patient care, TRC Healthcare/NetCE is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. NetCE has been approved by NBCC as an Approved Continuing Education Provider, ACEP No. 6361. Programs that do not qualify for NBCC credit are clearly identified. NetCE is solely responsible for all aspects of the programs. As a Jointly Accredited Organization, NetCE is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. Regulatory boards are the final authority on courses accepted for continuing education credit. Continuing Education (CE) credits for psychologists are provided through the co-sponsorship of the American Psychological Association (APA) Office of Continuing Education in Psychology (CEP). The APA CEP Office maintains responsibility for the content of the programs. NetCE is accredited by the International Accreditors for Continuing Education and Training (IACET). NetCE complies with the ANSI/IACET Standard, which is recognized internationally as a standard of excellence in instructional practices. As a result of this accreditation, NetCE is authorized to issue the IACET CEU. NetCE is recognized by the New York State Education Department's State Board for Social Work as an approved provider of continuing education for licensed social workers #SW-0033. This course is considered self-study, as defined by the New York State Board for Social Work. NetCE is recognized by the New York State Education Department's State Board for Mental Health Practitioners as an approved provider of continuing education for licensed mental health counselors #MHC-0021. This course is considered self-study by the New York State Board of Mental Health Counseling. NetCE is recognized by the New York State Education Department's State Board for Mental Health Practitioners as an approved provider of continuing education for licensed marriage and family therapists. #MFT-0015.This course is considered self-study by the New York State Board of Marriage and Family Therapy. Materials that are included in this course may include interventions and modalities that are beyond the authorized practice of licensed master social work and licensed clinical social work in New York. As a licensed professional, you are responsible for reviewing the scope of practice, including activities that are defined in law as beyond the boundaries of practice for an LMSW and LCSW. A licensee who practices beyond the authorized scope of practice could be charged with unprofessional conduct under the Education Law and Regents Rules.

Designations of Credit

This activity was planned by and for the healthcare team, and learners will receive 3 Interprofessional Continuing Education (IPCE) credit(s) for learning and change. NetCE designates this continuing education activity for 3 ANCC contact hour(s). NetCE designates this continuing education activity for 3.6 hours for Alabama nurses. NetCE designates this continuing education activity for 1 NBCC clock hour(s). Social workers participating in this intermediate to advanced course will receive 3 Cultural Competency continuing education clock hours. NetCE designates this continuing education activity for 3 credit(s). NetCE is authorized by IACET to offer 0.3 CEU(s) for this program. AACN Synergy CERP Category B.

Individual State Nursing Approvals

In addition to states that accept ANCC, NetCE is approved as a provider of continuing education in nursing by: Alabama, Provider #ABNP0353 (valid through July 29, 2025); Arkansas, Provider #50-2405; California, BRN Provider #CEP9784; California, LVN Provider #V10662; California, PT Provider #V10842; District of Columbia, Provider #50-2405; Florida, Provider #50-2405; Georgia, Provider #50-2405; Kentucky, Provider #7-0054 through 12/31/2025; South Carolina, Provider #50-2405; West Virginia RN and APRN, Provider #50-2405.

Individual State Behavioral Health Approvals

In addition to states that accept ASWB, NetCE is approved as a provider of continuing education by the following state boards: Alabama State Board of Social Work Examiners, Provider #0515; Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling, CE Broker Provider #50-2405; Illinois Division of Professional Regulation for Social Workers, License #159.001094; Illinois Division of Professional Regulation for Licensed Professional and Clinical Counselors, License #197.000185; Illinois Division of Professional Regulation for Marriage and Family Therapists, License #168.000190;

Special Approvals

NetCE is approved as a provider of continuing education by the California Consortium of Addiction Programs and Professionals. Provider Number 5-08-151-0626.

Course Objective

The purpose of this course is to provide Health and mental health professionals with the information necessary to provide the best possible care to Alaska Natives.

Learning Objectives

Upon completion of this course, you should be able to:

1. Identify relevant terms and demographic trends affecting Alaska Natives.

2. Outline the history of Native peoples in Alaska and interaction with the U.S. government.

3. Identify sources of discrimination experienced by Alaska Natives.

4. Describe unique health and mental health needs of Alaska Natives.

5. Discuss barriers to Alaska Natives accessing and receiving appropriate care and resources.

6. Apply best practice guidelines when creating assessment and treatment plans for Alaska Natives.

Faculty

Lauren E. Evans, MSW, received her Master’s degree in Social Work from California State University, Sacramento, in 2008. Her focus was on political and community social work. She has also been a Registered International Instructor of Therapeutic Horseback Riding through the Professional Association of Therapeutic Horsemanship International (PATH Intl.) since 2006. She currently works as a mental health practitioner with the homeless population.

Faculty Disclosure

Contributing faculty, Lauren E. Evans, MSW, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planners

Mary Franks, MSN, APRN, FNP-C

Alice Yick Flanagan, PhD, MSW

Margaret Donohue, PhD

Division Planners Disclosure

The division planners have disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Director of Development and Academic Affairs

Sarah Campbell

Director Disclosure Statement

The Director of Development and Academic Affairs has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

Implicit Bias in Health Care

The role of implicit biases on healthcare outcomes has become a concern, as there is some evidence that implicit biases contribute to health disparities, professionals' attitudes toward and interactions with patients, quality of care, diagnoses, and treatment decisions. This may produce differences in help-seeking, diagnoses, and ultimately treatments and interventions. Implicit biases may also unwittingly produce professional behaviors, attitudes, and interactions that reduce patients' trust and comfort with their provider, leading to earlier termination of visits and/or reduced adherence and follow-up. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals' implicit biases can further exacerbate these existing disadvantages.

Interventions or strategies designed to reduce implicit bias may be categorized as change-based or control-based. Change-based interventions focus on reducing or changing cognitive associations underlying implicit biases. These interventions might include challenging stereotypes. Conversely, control-based interventions involve reducing the effects of the implicit bias on the individual's behaviors. These strategies include increasing awareness of biased thoughts and responses. The two types of interventions are not mutually exclusive and may be used synergistically.

1. INTRODUCTION

Before Russians settled on the land now known as Alaska, the Native people lived and thrived there for thousands of years. Today, Alaska Natives make up approximately 16% of the population of Alaska[2]. This course will offer a brief history of the State of Alaska and Alaska Natives, as well as the relationship between the U.S. Government and Alaska Natives. The particular health and mental health concerns facing Alaska Natives will be discussed at length. Sources of discrimination and barriers to the care of the Native population will also be explored.

2. DEFINITIONS AND DEMOGRAPHICS

Between 1960 and 2000, the population of American Indians and Alaska Natives increased by 250%, due partly to improved birth rates, more people identifying as Native American, and better data collection from the Census Bureau. In the 2020 Census, further improvements and changes to questions regarding race and ethnicity were implemented to enable a more thorough and accurate depiction of how people self-identify, especially those who identify as multiracial [3]. As a result, the number of individuals identifying as American Indian or Alaska Native alone or in combination with another race group increased 160%, from 5.2 million people in 2010 to 9.7 million in 2020. In 2020, the American Indian and Alaska Native alone population (3.7 million) accounted for 1.1% of all people living in the United States [3]. Even with greater numbers of individuals being identified, the group is still one of the smallest and most underserved in the country. American Indians and Alaska Natives in the United States consistently rank at or near the bottom of nearly every social, health, and economic indicator [34].

The U.S. Office of Management and Budget defines an American Indian or Alaska Native individual as a "person having origins in any of the original peoples of North and South America (including Central America) and who maintains tribal affiliation or community attachment" [35]. In this course, "Alaska Native" will be used to refer to the indigenous population of Alaska, more specifically, to describe individuals who identify themselves as whole or part Native. Alaska "native" (no capitalization) refers to persons born in the state who are not descendants of original inhabitants. Alaskans, generally, refers to all inhabitants of the state, whether Native or not [5]. The term Native American may be used to refer to American Indians and Alaska Natives when referring to statistics or issues concerning both groups. In addition, many studies and federal data refer to American Indians and Alaska Natives together, without discerning between them or describing how statistics may apply specifically to Alaska Natives.

Alaska Natives and American Indians share some similar experiences. For example, both Alaska Natives and American Indians are culturally diverse, consisting of different tribes with different languages and customs. Both American Indians and Alaska Natives were also, and to some extent continue to be, subsistence economies, an important part of Native American identity and culture. Alaska Natives and American Indians also both experienced population devastation due to diseases introduced by Europeans [1]. However, the relationship that Alaska Natives have had with the U.S. Government differs slightly from the experiences of American Indian tribes. This relationship will be discussed later in this course.

3. HISTORY OF ALASKA AND ALASKA NATIVES

It is clear through anthropology and Native history that the territory that is now known as Alaska has been inhabited for at least 10,000 years. Its first inhabitants, and the ancestors of the Native people of Alaska, arrived from Asia, though it is not clear if by land or by sea [2]. As noted, Alaska Natives have a distinct history from American Indians, although the similarities between some Alaska Native languages and the language of the Navajo and Apache, for example, are evidence of their connection [1,2].

Different Alaska Native cultures and tribes were found, and continue to be recognized, throughout the state of Alaska. According to the Alaska Federation of Natives, 11 distinct cultures can be described geographically: Eyak, Tlingit, Haida, and Tsimshian peoples in the southeast; the Inupiaq and St. Lawrence Island Yupik in the north and northwest; Yup'ik and Cup'ik Alaska Natives in southwest; the Athabascan peoples in Alaska's interior; and Alutiiq (Sugpiaq) and Unangax̂ peoples in south-central Alaska and the Aleutian Islands [54]. Today, the federal government recognizes 228 tribes in Alaska [6].

In general, although differences between tribal customs and culture exist, Alaska Natives were skilled hunters and fishermen and depended on a subsistence way of life [9]. Depending on the location of the particular tribe and the animals that were native to the region, they hunted duck, otters, seals, polar bear, and walrus and harpooned whales. Tribes that lived inland hunted caribou and moose, sometimes tracking them for long distances. Certain tribes and cultures struggled more than others because of the region in which they lived. The tribes living in southeast Alaska, for example, lived in a more mild climate, where there was ample fish, game to hunt, and edible plants. The Athabascan Indians, on the other hand, suffered more famine than other tribes because of the harsh weather conditions in which they lived. However, no matter the region in which the tribe lived, the subsistence way of life was, and continues to be, an important part of Alaska Native identity [2]. Alaska Native tribes were also skilled artists, excelling in garment and blanket making and perhaps best known for the distinctive form of Pacific Northwest Native art: totem poles [2].

In 1741, a Russian expedition sighted the Alaska mainland, and in 1784, Russia founded the Three Saints Bay Colony on Kodiak Island [4]. The Aleuts were particularly affected by the arrival of the Russians. Before their arrival, the population of the Aleuts was estimated to be 80,000; because of the new diseases introduced by the Russians, their population was reduced to 25,000 by 1909 [1]. Alaska was used by the Russians for hunting and especially by fur traders, who enslaved the Native population and used them to procure furs [1,4,5]. After the Crimean War in the 1850s, which left Russia nearly bankrupt, Russia sought to sell Alaska [4]. In a decision controversial at the time, the United States purchased the land from Russia in 1867 for $7.2 million (2 cents per acre), signing the Treaty of the Cession [4,5].

Article III of the Treaty of the Cession stated, "uncivilized [Native] tribes will be subject to such laws and regulations as the United States may, from time to time, adopt in regard to aboriginal tribes of that country" [1]. However, the United States government did not immediately attempt to control or force the Native population of Alaska onto reservations [1]. Rather, Alaska was somewhat forgotten and neglected by the U.S. Government. The gold rush of the 1890s once again brought many new settlers to Alaska, this time from the United States, and gave rise to the urban cities of Juneau, Fairbanks, and Anchorage. However, much like the Russians, the newcomers had little respect for Alaska Natives, their customs, or traditions [5]. Throughout the years, Alaska continued to be used for its many natural resources [4].

Alaska became the 49th state of the United States of America in 1959 [4,5]. The following two decades were considered a time of turmoil for Alaska Natives, as land ownership and land rights were disputed [5,10]. In 1971, oil was discovered in Prudhoe Bay, and it became necessary that the oil companies procure a clear title to the land in order to begin construction of the Trans-Alaska Pipeline System [1,5]. In response, Congress passed the Alaska Native Claims Settlement Act (ANCSA) in 1971, organizing Alaska Natives into regional and village corporations, returning more than 44 million acres of land and providing nearly $1 billion. In exchange, however, Alaska Natives were required to waive their rights to much of their original land [1,5]. More specific repercussions, both positive and negative, from ANCSA will be discussed in the next section of this course.

4. ALASKA NATIVES AND THE U.S. GOVERNMENT

ALASKA NATIVE ALLOTMENT ACT OF 1906

As an answer to the many land disputes in Alaska, Congress passed the Alaska Native Allotment Act in 1906. This Act entitled Alaska Natives to up to 160 acres of land, so long as it was non-mineral and unappropriated [10]. However, allotments were provided to individual Natives, contradicting the idea of collective ownership of the land that Alaska Natives had held and passed down for generations [11].

ALASKA NATIVE CLAIMS SETTLEMENT ACT (ANCSA)

The Alaska Native Claims Settlement Act (ANCSA) was passed by Congress in 1971 in order to begin the construction and development of the Trans-Alaska Pipeline System. In exchange for waving their claim to Native lands, Alaska Natives received $962 million and more than 44 million acres of land [1,5]. ANCSA had some positive effects for the Alaska Native population. For example, much of the land that had been allotted to them was inhabitable and rich in resources. Also, the settlement created 13 regional, 4 urban, and more than 200 village Native corporations, setting up regional and statewide structures that would give Alaska Natives political and economic power. However, in the early 1970s, the state legislature was reapportioned based on population; rural, mostly Native regions of the state lost a significant amount of power on the state level [5].

Under ANCSA, Alaska Native Regional Corporations can obtain the title to land that contains Native historical sites or cemeteries. Over the past 30 years, the Bureau of Indian Affairs has documented 2,300 historical Alaska Native sites [6].

MARINE MAMMAL PROTECTION ACT (MMPA) OF 1972

Originally passed in 1972, the Marine Mammal Protection Act (MMPA) protects all marine mammals, including dolphins, whales, manatees, seals, otters, walruses, and polar bears. The Act protects the "taking" of these mammals in U.S. waters and by U.S. citizens, with certain exceptions [12]. One of the exceptions to the MMPA gives the right to Alaska Natives to "take" marine mammals for subsistence purposes and for the creation and sale of Native handcrafts and clothing, allowing Natives to continue many cultural traditions [12,13].

TITLE VIII OF ALASKA NATIONAL INTEREST LANDS CONSERVATION ACT (ANILCA)

The Alaska National Interest Lands Conservation Act (ANILCA) of 1980 created the majority of the national parks in Alaska. ANILCA stipulates the designation of wilderness, subsistence management, transportation in and across parklands, use of cabins, mining, archaeologic sites, scientific research studies, and more [7]. Under Title VIII of ANILCA, rural residents of Alaska have priority subsistence use of federal public lands [8]. The federal management of subsistence harvests of fish and wildlife on federal land is unique to Alaska and does not exist elsewhere in the United States [9].

5. SOURCES OF DISCRIMINATION

As with any minority population, and particularly with Native or aboriginal communities, discrimination and oppression have historical roots and continue today. There are many sources of discrimination, with various effects and related trauma.

LOCAL SUBSISTENCE ECONOMY

The subsistence way of life is of great cultural and traditional importance to Alaska Natives and American Indians. Subsistence includes the gathering, harvest, processing, consumption, and use of wild resources, including birds, mammals, fish, and plants, from the natural environments of Alaska [8]. While this is the literal meaning of the word, subsistence is considered to be much more than feeding one's family. Many Alaska Natives prefer the phrase "our way of life" over "subsistence," feeling that it describes better the importance of continuing cultural traditions, including the social and economic ties of family and community in Alaska [8,9]. In some places in Alaska, subsistence food still makes up more than 50% of Native diets [2].

ANCSA gave Alaska Natives rights to about 10% of Alaska's land, ending their ability to live a complete subsistence lifestyle [2]. Also, in general, the Alaska Legislature has not recognized the cultural importance of subsistence and has passed policies that force Natives to assimilate. People who oppose subsistence claim that it is unfair to give hunting and fishing preference to rural and Native Alaskans. The issue of subsistence in Alaska has further divided rural and urban Alaska. In general, there are racial and cultural misunderstandings of Alaska Natives' subsistence way of life [5].

RACISM

Racism in Alaska today can take many forms, from blatant hate crimes against Alaska Natives to a general failure to acknowledge or celebrate Alaska Native culture to systematic racism perpetuated by the state and federal government through biased policies and distribution of wealth [5]. While there is a lack of research about the relationship between experiencing racism and physical health problems of Native Americans, racism has been shown to linked to physical harm (e.g., hypertension, heart disease) among other racial/ethnic groups, such as African Americans and Latinos [15].

Racism against Native Americans can take the form of social and cultural isolation as well as a general lack of acknowledgement [5]. This can be seen in the mainstream and commercial use of Native American imagery and Tribal names or words, while also having a general ignorance about Native life and Native people. Native people as individuals and as a community are not properly recognized while the symbols used can often be stereotypical and offensive—for example, the symbol of an American Indian as a sport team mascot [18].

It is important to also consider the long-term effects of colonialism on indigenous people [16]. For mental health practitioners, using the construct of historical trauma can help to understand the suffering and struggle of a culture as a whole [17]. Looking at the experiences of Native people in Canada, the United States, Australia, and New Zealand, historical trauma has been shown to impact health, impact children through parenting practices, and increase substance abuse, and it has been associated with higher levels of self-reported racism [16]. Historical trauma is connected with and caused by the 4Cs: colonial injury with the collective experience, cumulative effects, and cross-generational impacts of injuries [16].

THE URBAN/RURAL DIVIDE

The State of Alaska is unique in many ways from the lower 48 states. It is by far the largest state in area. It is a total of 571,641 square miles of land, or one-fifth the size of the entire continental United States, yet it has one of the lowest populations of any state. Also, the majority of the population lives in the three largest cities in Alaska: Anchorage, Fairbanks, and Juneau. Traditionally, city dwellers are more likely to be White, while Alaska Natives make up a large percentage of rural Alaskans. However, shifts in demographics have been occurring, and in the 2020 census, 60% of persons identifying as Alaska Natives resided in cities rather than rural areas [3,54]. In some cases, rural communities do not have basic infrastructure, such as road systems, and can only be reached by plane, boat, or snowmobile. Federal and state services, such as education, law enforcement, and employment, are inferior to those received by city dwellers [5].

The Alaska Federation of Natives, a statewide organization that advocates for Alaska Natives, identifies the urban/rural divide as one of the key issues affecting the socioeconomic and political status of Alaska Natives, stating, "the urban/rural divide is rooted in the unequal treatment accorded to Native villages in terms of education, law enforcement, clean water and sanitation, and the double-digit unemployment in rural communities" [5]. The urban/rural divide is not only geographic, but also cultural, affecting the way in which Alaskans may or may not understand each other due to such stark differences between the urban and rural ways of life [5].

6. HEALTH AND MENTAL HEALTH

SPECIFIC HEALTH ISSUES

Alaska Natives are at risk for certain physical and mental health conditions, several of which are described in this course. It is important to remember that many health conditions are interconnected and cannot be viewed as independent problems. Changes to and loss of traditional ways of life of the Alaska Native people appear to negatively affect health. In some cases, because studies or surveys have combined data about American Indians and Alaska Natives, it is difficult or impossible to know if statistics accurately reflect the health issues of Alaska Natives.

Suicide

American Indians and Alaska Natives have the highest rates of suicide of any racial or ethnic group in the United States, with suicide rates increasing nearly 20% from 2015 to 2020, compared with a less than 1% national increase among the overall U.S, population. Nearly 75% of American Indian and Alaska Native suicide victims are younger than 44 years of age. Among American Indian and Alaska Natives, men are three times more likely to commit suicide than women [19].

One theory about the high rates of suicide among Alaska Natives is the loss of culture and tradition due to modernization [20]. For example, psychologists and sociologists in Greenland, which has some of the highest suicide rates in the world for young men 15 to 24 years of age, assert that disruption of community leads to a breakdown of the family, which can cause higher levels of alcohol and substance use disorders, child abuse, and physical abuse [20,22]. The Inuit people of Greenland suffered a loss of cultural identity when their way of life was erased by modernization [20]. This theory could also be applied to the loss of the traditional way of life for many Alaska Natives.

Homelessness

While American Indians and Alaska Natives (alone or in combination) make up only 2.6% of the U.S. population, nearly 3.5% of all people experiencing homelessness identify as American Indian, Alaska Native, or Indigenous. Furthermore, between 2022 and 2023, an 18% increase in homelessness rates occurred among American Indian and Alaska Natives, the greatest increase of any racial/ethnic group [27,55]. In the State of Alaska, 36 out of every 10,000 people in the general population are homeless [27]. In the city of Anchorage alone, Alaska Natives make up nearly 50% of the homeless population [28,29]. Reported reasons for homelessness include unemployment, substance use, poor mental health, relationship/family issues, eviction, and/or experiencing a behavioral or medical emergency [29].

In a qualitative study of Alaska Natives experiencing homelessness, social workers who interviewed the subjects reported that, apart from some of the more common reasons for homelessness (e.g., substance use disorder, job loss), Alaska Natives often reported discrimination as a cause. The study concluded that perceived discrimination stemming from being Native may have created a sense of fatalism in the individuals interviewed, causing binge drinking, alcohol use disorder, and a feeling of lack of self-worth. Furthermore, because the Alaska Natives interviewed held only temporary, low-paying, and low-skill jobs, they felt anger, depression, and hopelessness. There was a feeling that they had fulfilled a negative stereotype of Alaska Natives held by White Alaskans, causing low self-esteem. Finally, the study reported that subjects were often anxious, perhaps because many felt that the system had failed them and could not help them in the future [26]. This information is echoed in additional studies, in which systemic failures (e.g., inaccessible housing, economic inequality, racial inequities) are seen as the root causes of homelessness, rather than individual factors [29].

Cardiovascular Disease

It was once thought that Alaska Natives and similar groups of people were protected from developing heart disease. Early Danish researchers found low rates of cardiovascular disease among the Inuit people of Greenland, most likely due to their diets of marine mammals being high in omega-3 fatty acids. This idea was generalized to Alaska Natives, who share ancestral roots and similar diets with Greenland Inuits [32]. Studies have shown that high levels of omega-3 fatty acids help to reduce the risk of coronary heart disease [14].

A more recent review of cardiovascular disease among Alaska Natives found that the rates at which Alaska Natives are developing the disease is increasing. The review concluded that the higher prevalence of the disease was most likely due to the change in diet, from traditional foods high in omega fatty acids to more processed foods, increased rates of smoking, and inactivity [32]. Increased rates of obesity and diabetes among Alaska Natives also contribute to being at risk for heart disease and stroke [33].

Smoking and Tobacco Use

Smoking and tobacco use are also known causes of heart disease and stroke [33]. American Indian/Alaska Native adults have the highest prevalence of cigarette smoking among all racial/ethnic groups in the United States (nearly 25%), and quitting rates are lower than other ethnic/racial groups [33]. Tobacco use among Alaska Natives living in Alaska is higher than among non-Native Alaskans, White Americans, and American Indians and Alaska Natives living in the lower 48 states. Smoking was not part of the traditional way of life for the Native people of Alaska, as it was for some American Indian tribes, but was introduced by European settlers [32,33]. Tobacco companies target American Indian/Alaska Native communities through extensive promotions, sponsorships, and advertising campaigns. Historically, tobacco industry product promotions to American Indians/Alaska Natives featured symbols and names with special meanings to this group. For example, the American Spirit cigarettes were promoted as "natural" cigarettes, and their packaging featured an American Indian smoking a pipe [33].

Cancer

Cancer is the leading cause of death among Alaska Natives, with more than 50% of diagnosed cancers being breast, colorectal, lung, and prostate. In addition, lung cancer, colorectal cancer, cancer of the kidney, stomach cancer, and nasopharynx cancer are all more common in Alaska Natives than in the White population [24]. While cancer rates of Alaska Native women and White women were similar in the past, since the 1980s, cancer rates for Alaska Native women have increased, even as cancer rates among White women have decreased. Some risk factors, including smoking, may contribute to cancer rates; it has been found that approximately 90% of lung cancer cases are related to smoking. Additionally, an estimated 32% of Alaska Natives are current smokers,—more than twice the rate in White Americans [24].

Research has also shown that one's diet, namely eating more fruits and vegetables, can help to decrease the risk of cancers of the mouth, throat, stomach, esophagus, and lungs. There is also evidence that consumption of calcium supplements, dietary fiber, and milk can help to decrease the risk of colorectal cancers. While there have been few studies on the diet of Alaska Natives, one study, supported by a separate statewide survey, showed that 83% of Alaska Native adults do not eat five servings of fruits and vegetables per day [14]. The same study also reported low levels of calcium intake of Alaskan Natives living in two different regions [14].

Diabetes and Obesity

Studies show that 33.1% of American Indian and Alaska Native adults 18 years of age and older are overweight, and an additional 48.1% are obese; 4 out of every 5 adults in the group are outside of the healthy weight range [23]. Also, Native Americans have the highest rates of type 2 diabetes in the United States and are three times more likely to be diagnosed with diabetes compared with Non-Hispanic White adults [25]. In the case of Alaska Natives, this may be connected to a change in diet from traditional to processed, store-bought foods.

The traditional foods of Alaska Natives are somewhat varied, depending on the region in which the tribe lives. In general, however, Native foods include fish, land and sea mammals, berries, and plants. Native foods are considered to be very nutritious, being high in protein, iron, unsaturated fats, fatty acids, and vitamin B12. The traditional Alaska Native diet offers some important health benefits. Studies have shown, for example, that daily intake of salmon and seal oil was linked with lower levels of glucose intolerance. While Native foods still make up a portion of the Alaska Native diet, there is a growing dependency on processed, store-bought foods. Studies have found that Native foods make up only 15% of the typical Alaska Native diet [14,21].

Before the introduction of European foods by settlers, the Alaska Native diet was very low in carbohydrates, most likely consisting of no more than 10 grams per day. One recent study that examined the dietary habits of Alaska Natives in two regions of Alaska found that the carbohydrate intake of the study participants ranged from 180–330 g per day. At the same time, cases of diabetes and obesity among Alaska Natives have increased over the past decades, with some experts suggesting that the increased intake of carbohydrates, diabetes, and obesity are closely connected. Also, according to the study, most of the carbohydrate intake from the modern diet consisted of simple sugars, such as fructose and sucrose, two types of sugar thought to be related to type 2 diabetes and obesity. The study also recorded low levels of dietary fiber intake. Low intake of dietary fiber is also thought to be a risk factor for obesity and type 2 diabetes as well as heart disease and cancer [14,21].

Hepatitis and Liver Disease

In the 1970s, Alaska Native children were dying in large numbers from liver cancer caused by hepatitis B. In 1983, the Liver Disease and Hepatitis Program was launched and began a vaccination program to protect the population against viral hepatitis. The program was very successful and helped to vastly reduce liver disease and cancers caused by acute hepatitis B. In the 1990s, the program focused on preventing hepatitis A, and today, the program is working to eliminate the risks from hepatitis C [36]. Despite the efforts by the Liver Disease and Hepatitis Program, American Indians and Alaska Natives were 2.7 times more likely to die from hepatitis C and 3.9 times more likely to die from chronic liver disease and cirrhosis compared with Non-Hispanic White Americans in 2018 [39,41].

Substance Use Disorders

Much of the data on substance abuse refer to both American Indians and Alaska Natives together and not to Alaska Natives specifically. Keeping this in mind, the premature death rate of Native Americans is 90% higher than all other races and ethnicities in the United States. This is considered to be due, in part, to alcohol use [49].

There is a misconception that genes that increase risk of substance misuse and related factors (e.g., tolerance, craving) are more common in American Indians and Alaska Natives than in White Americans—this is untrue [52]. Alcohol is the most misused substance among American Indians and Alaska Natives, as well as among the general population. Many American Indians and Alaska Natives do not drink at all, but binge drinking and alcohol use disorder occur among Native populations at relatively high rates [52]. In one study exploring the connection between alcohol use disorders and comorbid psychiatric disorders, Native men and women with alcohol use disorders and those who participated in binge drinking were more likely to suffer from another psychiatric disorder [1,49].

American Indians and Alaska Natives start drinking and using other substances at a younger age than do members of other major racial or ethnic groups. Early use of substances has been linked with greater risk for developing substance use disorders [52]. In a survey on prevalence of alcohol use among Native youth, it was found that, while the number of Native American youth who had tried alcohol was similar to that of non-Native youth, Native American youth drank in greater quantities than their non-Native counterparts and often faced more serious consequences as a result. Mental health problems were also found to be more common among Native American youth partaking in alcohol [1].

Due to the increased use of alcohol among Native Americans, fetal alcohol syndrome is also a serious problem. Between 1980 and 1986, the CDC monitored the rate of fetal alcohol syndrome in the United States and found a fetal alcohol syndrome rate of 2.97 per 1,000 births for Native Americans, 0.6 for African Americans, 0.09 for White Americans, 0.08 for Hispanics, and 0.03 for Asians. Fetal alcohol syndrome is known as the leading cause of developmental delays [1].

Teen Pregnancy and Infant Mortality

While the teen birth rate in Alaska has decreased significantly, from 65.6 births per 1,000 females in 1990 to 15.7 births per 1,000 females in 2022, it remains higher than the national average of 13.5 births per 1,000 females [37]. The teen birth rate among Alaska Native teens was 34.4 per 1,000 females in 2022, more than double the state average and higher than any other racial/ethnic group in Alaska [37].

At the same time, infant mortality rates among American Indians and Alaska Natives are significantly higher when compared with infant mortality in White populations. Infant mortality is the most widely used measure of population health and quality of health care. The infant mortality rate is not only seen as a measure of the risk of infant death but is used more broadly as a crude indicator of community health status, poverty and socioeconomic status levels in a community, and availability and quality of health services and medical technology [38,40]. The infant mortality rate for infants born to an Alaska Native individual was 10.9 per 1,000 births in 2021, and while that number has decreased since 2015, it is still 1.5 times higher than the average infant mortality rate in the State of Alaska and the United States in general [40].

IMPACT OF CLIMATE CHANGE

The effects of climate change can and will increasingly be seen in the Alaska Native population, affecting both physical and mental health, as well as Native communities, homes, and the subsistence way of life [46,47]. Flooding and other natural disasters related to climate change will continue to lead to the displacement of people living in rural Alaska, many of whom are Alaska Natives. With climate change comes increased exposure to infectious disease due to rising temperatures and traditional ways of storing food. Water and food sources will also be more limited, and poor water quality is already a concern for rural Native communities. In addition, the cultural importance of the subsistence way of life will be endangered, as well as the relationship that Alaska Natives have historically had with their environment [46].

Natural disasters and environmental changes caused by climate change can also be the cause of solastalgia, the distressing sense of loss that people experience as a result of unwanted environmental changes that occur close to one's home [47]. Climate change has also been linked to anxiety, depression, and post-traumatic stress disorder following extreme weather or natural disasters (e.g., erosion, fires, flooding, storms) [47]. Permafrost (defined as occurring when the ground remains frozen at 32 degrees or colder for at least two years) is found in 80% of the State of Alaska. With the thawing of permafrost in some areas, the landscape will ultimately change, possibly causing permanent damage to roadways or creating the need of some remote villages to relocate [47].

TRADITIONS AND BELIEFS THAT AFFECT HEALTH

American Indians and Alaska Natives often have a general mistrust of the healthcare system, particularly when the medical practitioner is culturally discordant [1,43]. In particular, elderly Alaska Natives may have suffered many injustices at the hands of the government, including separation from family and culture in boarding schools or institutionalization [1,43]. These separations are often viewed as an attempt by the government to eradicate Native culture and have resulted in past and current mistrust, with many assuming that the healthcare system will not approve of Native culture or traditional healing beliefs [43].

Alaska Native culture includes many natural healing methods dating back thousands of years. Although these practices became less common because of European settlers and missionary influence, they still exist today and they are regaining popularity. There is much diversity in the beliefs and practices of natural healing methods. However, traditional Alaska Native healing methods include, but are not limited to, therapeutic massage, prayer, cleansing by the burning of sage, drumming circles, traditional plant medicine, and talking circles [43].

Modern medicine and traditional healing have, in some cases, adopted a middle ground whereby patients may get their necessary treatments from medical professionals and healers who use methods with which they feel more comfortable. For example, tribal doctors may have a certificate from a credentialing organization or may have completed an apprenticeship with a more experienced tribal doctor. They may be employed by an Alaskan tribal health organization, while traditional healers work informally, typically without pay, within the community and are recognized as having a gift of healing. Tribal doctors can refer patients to regional or state hospitals or clinics for treatment [43].

7. BARRIERS TO OPTIMAL HEALTH AND CARE

CULTURAL BARRIERS

There are several aspects of Alaska Native culture that may cause misunderstandings or barriers for health or mental health providers or people in the helping professions. Language differences between English and Native languages may present difficulties in communication and mutual understanding. For example, research into language patterns of English and Athabascan shows that English speakers may find Athabascan speakers to be incommunicative, not wishing to answer questions or participate in conversations, while Athabascan speakers may find English speakers to be too pushy in conversation, asking too many questions, speaking too much in general, and ignoring turn-taking in conversation [43,44]. Because many Alaska Natives speak a language other than English, health assessments may need to be done in the patient's native language. Healthcare professionals benefit from collaboration with translators to be sure that the health assessment is done correctly, as there may exist important differences between the meanings of words related to health [1].

In addition, the way in which American Indians and Alaska Natives may describe symptoms, distress, and mental health conditions may differ greatly from how they are described in Western medical literature. Mental health professionals should therefore find ways of eliciting and understanding the information in order to make the correct assessment [1].

The perception of the elderly population can also differ in Alaska Native culture compared with White populations. For example, Alaska Native elders are never thought to reach an age when their opinions, stories, and experiences are unimportant. They continue to be a vital part of the Native community, passing culture to the younger generations. Therefore, when elder Alaska Natives have a medical condition that may require treatment or institutionalization outside of the community, it is to the detriment of the health of the elder and to the community as a whole [43]. While disengagement theory states that it is normal for elderly people to separate and disengage from society at a certain age, it is thought that in the case of Alaska Natives, it is a "forced disengagement" and not in line with Native customs and culture. In general, families and Tribes believe the best place for Native elders to be cared for is in a family home and that care should never be so restrictive as to limit elders from participating in community activities [43].

GEOGRAPHIC ISOLATION

Alaska Natives who live in rural areas face challenges unique from those experienced by Natives living in urban areas. Unemployment rates are higher in rural areas, as is the percentage of people without a high school diploma. The poverty rate is also higher in rural areas than in Alaskan cities [45]. In a national survey on services provided by mental health and substance abuse centers in Alaska, rural centers were less likely to have nurses and healing consultants on staff. Rural clinics were also less likely to have planning in place to improve the quality of the clinic program [42].

INADEQUATE PLUMBING AND SEWAGE DISPOSAL

In the State of Alaska, 6% of the population lives without basic plumbing, more than any other state. Because of permafrost, some villages lack piped water and sewage and outhouses and septic tanks do not function and, therefore, cannot be used. Looking for other ways to dispose human waste, sewage is often tracked around, disturbed by animals, spilled, spread by vehicles, or blown by the wind once dry. While this is a serious hazard to community health, another more serious problem for health is the lack of clean, running water [31].

In rural Alaskan communities where there is no running water, people must buy their water or haul in water or ice from lakes and rivers. Because water is not as readily available to these communities, people tend to use it sparingly or overuse the same water—for example, washing hands throughout the day with the same bucket of water in order to save water for other uses. This can lead to the spread of bacteria, viruses, and skin and respiratory infections [31]. In rural communities, respiratory infections can be up to 11 times higher than for other Alaskans [30,31]. Infants in villages without access to clean water have five times more hospitalizations for respiratory infections than the U.S. population in general [30].

In some cases, proper plumbing and piping systems in rural and remote communities are not a viable option, either because of high costs or because of land erosion, often attributed to climate change [30,31]. Several sanitation systems are being researched and developed with the specific requirements and needs of rural Alaskan communities in mind, including systems that can catch and store rainfall and melted snow, systems that are mobile and can move with the home, and systems that use gravity flow from a large cistern and can serve several homes at once [30]. There are also programs in place to help provide access to water and sanitation to Alaska Natives and American Indians, such as the Alaska Native Tribal Health Consortium's (ANTHC) Individual Sanitation Facilities Scattered Sites Program and the National Tribal Water Center [30].

EDUCATION

Brief History of Education in Alaska

Like many Native Americans, Alaska Natives have a complicated history with the formal education system. In 1784, education was first imposed upon young Alaska Natives by Russian fur trader Grigory Shelikhov, and the curriculum included Christianity, Russian, and arithmetic. This first school was followed by mission schools, first operated by the Russian Orthodox Church and later by the American Protestant and Roman Catholic Churches, whose objectives were to Christianize Alaska Natives, to phase out Native traditions, and to teach students trades that would make them useful servants to the settlers. The last of the mission schools did not close until 1916 [51].

The federal government did not officially fund education in Alaska until 1884, and schools were not separated from churches until 1894. "Civilizing" Alaska Natives and teaching Christianity remained the objectives of education in Alaska for decades. In the 1930s, when the responsibility of the education of Alaska Natives was transferred to the Bureau of Indian Affairs (BIA), it was found that the schools in Alaska were failing to meet federal policy goals of integrating Natives into white society and preserving Native culture. As a result, and in an attempt to help young Alaska Natives assimilate, Native youth were sent from all over Alaska to a high school in Sitka. When the school reached capacity, students were sent to BIA boarding schools in other states. The BIA program sought to remove students from their communities and encourage them not to return [51].

When Alaska became a state in 1959, the school system changed once again, first with the State-Operated School System and then with regional high schools. This system was discontinued when it was found that Native students struggled to incorporate back into life in their villages after returning from regional schools. Alcohol use and suicide rates were high among Native students attending regional schools. In 1975, it was argued that having a K–12 education in one's home community was a constitutional right, and the State of Alaska agreed to provide a high school in every community with an elementary school. A study on the federal and state schools of Alaska between 1867 and 1970 concluded that, throughout history, policies and programs have been established by non-Natives deciding on what they thought was best for the Alaska Native community [51].

Barriers to Education

There are several barriers to education for Alaska Natives in the State of Alaska. First, many policies and programs around education are based on models used in the "lower 48" and do not translate well to the unique situation in Alaska, including geographically remote communities [48]. Also, there can be a lack of cultural understanding between students, parents, teachers, and school staff. This can also include difficulties in communication due to language differences [48,50]. School materials, standardized tests, curriculum, and teaching styles may also not take into consideration Native culture, and research has shown that Native Americans have different learning styles from non-Natives, making classroom learning more challenging [1,50]. Finally, systemic and community issues, such as poverty, alcohol use disorder, lack of educational role models, and lack of parental support, can present significant barriers to education [50]. Including Native culture and language in the classroom can help Alaska Native students be more successful and to continue education longer [50].

LACK OF REPRESENTATION IN HEALTH RESEARCH

Because American Indians and Alaska Natives make up a small percentage of the general population, they are often under-represented in medical or mental health research, and even when an attempt is made to include Native American subjects, inter-tribal diversity cannot be accurately reflected [1]. In 1993, legislation was passed in Congress to require more active recruitment of Native Americans in clinical trials. In the past, researchers have performed studies in Native communities without respect for or inclusion of the people themselves. These negative historical examples led to deeply seated fears and negative beliefs about research and have resulted in many Native people being unwilling to participate in research. Furthermore, some trials may involve invasive assessments or questioning contrary to cultural beliefs [44].

8. BEST PRACTICES WHEN WORKING WITH ALASKA NATIVE CLIENTS

With increased knowledge and improved awareness of the issues faced by Alaska Natives, clinicians should take steps to provide care that is culturally sensitive and appropriate. The Substance Abuse and Mental Health Services Administration emphasizes the following key points when providing care to American Indians and Alaska Natives [52]:

- Importance of historical trauma. Providers should learn about, acknowledge, and address the effects of historical trauma when working with American Indian and Alaska Native clients. Most American Indians and Alaska Natives believe that historical trauma, including the loss of culture, lies at the heart of substance use and mental illness within their communities.

- Acceptance of a holistic view of behavioral health. Among many American Indian and Alaska Native cultures, substance use and mental illness are not defined as diseases, diagnoses, or moral maladies, nor are they viewed as physical or character flaws. Instead, they are seen as symptoms of imbalance in the individual's relationship with the world. Thus, healing and treatment approaches must be inclusive of all aspects of life—spiritual, emotional, physical, social, behavioral, and cognitive.

- Role of culture and cultural identity. Providers need to understand how clients perceive their own cultural identity and how they view the role of traditional practices in treatment. Not all American Indian and Alaska Native clients recognize the importance of culture or perceive a need for traditional practices in their recovery. Nonetheless, providers and administrators must be ready to address their clients' cultural identity and related needs. Helping clients maintain ties to their Native cultures can help prevent and treat substance use and mental disorders. Through reconnection to American Indian and Alaska Native communities and traditional healing practices, an individual may reclaim the strengths inherent in traditional teachings, practices, and beliefs and begin to walk in balance and harmony.

- Recognition of sovereignty. Tribal governments are sovereign nations. Each nation adopts its own tribal codes and has a unique history with the U.S. federal government. Providers in Native and non-Native programs need to understand the role of tribal sovereignty and governance systems in treatment referrals, planning, cooperative agreements, and program development.

- Significance of community. American Indian and Alaska Native clients and their communities must be given opportunities to offer input on the types of services they need and how they receive them. Such input helps match services to clients, increase community use of services, and use agency and tribal financial resources efficiently. Providers must involve themselves in Native community events and encourage Native community involvement in treatment services.

- Value of cultural awareness. If providers are aware of their own cultural backgrounds, they will be more likely to acknowledge and explore how culture affects their interactions, particularly their relationships with clients of all backgrounds. Without cultural awareness, providers may discount the influence of their own cultural contexts—including beliefs, values, and attitudes—on their initial and diagnostic impressions of clients and selection of healing interventions.

- Commitment to culturally responsive services. Organizations have an obligation to deliver high-quality, culturally responsive care across the behavioral health service continuum at all levels—individual, programmatic, and organizational. Not all American Indian or Alaska Native clients identify or want to connect with their cultures, but culturally responsive services offer those who do a chance to explore the impact of culture, history (including historical trauma), acculturation, discrimination, and bias on their behavioral health.

- Significance of the environment. An environment that reflects American Indian and Alaska Native culture is more engaging for, and shows respect to, clients who identify with this culture. Programs can create a more culturally responsive ethos through adapted business practices, such as using Native community vendors, hiring a workforce that reflects local diversity, and offering professional development activities (e.g., supervision, training) that highlight culturally specific American Indian and Alaska Native client and community needs.

- Respect for many paths. There is no one right way. Providing direction on how something should be done is not a comfortable or customary practice for American Indians and Alaska Natives. For them, healing is often intuitive; it is interconnected with others and comes from within, from ancestry, from stories, and from the environment. There are many paths to healing.

Alaska Native traditions and history are largely passed down orally, and it is important to let these clients tell their stories fully [53]. Some individuals will be more willing to discuss their cultural and health practices with a nonindigenous person than others.

9. CONCLUSION

Due in part to changes of the traditional way of life that Alaska Natives practiced for thousands of years before Europeans settled in Alaska, Alaska Natives have several unique health and mental health challenges. Cultural understanding and respect on the part of the health or mental health professional can help to ensure that Alaska Natives receive optimum care.

Works Cited

1. Office of the Surgeon General. Mental Health: Culture, Race, and Ethnicity: A Supplement to Mental Health: A Report of the Surgeon General. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2001.

2. State of Alaska. Alaska Natives. Available at https://alaska.gov/kids/learn/nativeculture.htm. Last accessed May 1, 2024.

3. Jones N, Marks R, Ramirez R, Ríos-Vargas M. Improved Race and Ethnicity Measures Reveal U.S. Population Is Much More Multiracial. Available at https://www.census.gov/library/stories/2021/08/improved-race-ethnicity-measures-reveal-united-states-population-much-more-multiracial.html. Last accessed May 1, 2024.

4. History.com. Russians Settle Alaska. Available at https://www.history.com/this-day-in-history/russians-settle-alaska. Last accessed May 1, 2024.

5. U.S. Commission on Civil Rights. Racism's Frontier: The Untold Story of Discrimination and Division in Alaska. Available at https://www.usccr.gov/pubs/sac/ak0402/ch1.htm. Last accessed May 1, 2024.

6. U.S. Department of the Interior, Bureau of Indian Affairs. ANCSA Program. Available at https://www.bia.gov/regional-offices/alaska/ancsa-program. Last accessed May 18, 2024.

7. National Park Service. Alaska National Interest Lands Conservation Act. Available at https://www.nps.gov/locations/alaska/anilca.htm. Last accessed May 1, 2024.

8. U.S. Department of the Interior, Bureau Indian Affairs. Subsistence Branch. Available at https://www.bia.gov/regional-offices/alaska/subsistence-branch. Last accessed May 1, 2024.

9. National Park Service. Subsistence in Alaska. Available at https://www.nps.gov/subjects/alaskasubsistence/subsistence-learn.htm. Last accessed May 1, 2024.

10. University of Alaska Fairbanks. Early Alaska Native Land Cases and Acts. Available at https://www.uaf.edu/tribal/112/unit_2/earlalaskanativelandcasesandacts.php. Last accessed May 1, 2024.

11. National Library of Medicine. 1906: Allotments Take Land from Alaska Native Villages. Available at https://www.nlm.nih.gov/nativevoices/timeline/401.html. Last accessed May 1, 2024.

12. U.S. Fish and Wildlife Services. Marine Mammal Protection Act. Available at https://www.fws.gov/law/marine-mammal-protection-act. Last accessed May 1, 2024.

13. Langdon SJ. Determination of Alaska Native Status Under the Marine Mammal Protection Act. Available at https://www.sealaskaheritage.org/sites/default/files/MMPAFinalReport.pdf. Last accessed May 1, 2024.

14. Johnson JS, Nobmann ED, Asay E, Lanier AP. Dietary intake of Alaska Native people in two regions and implications for health: the Alaska Native Dietary and Subsistence Food Assessment Project. Int J Circumpolar Health. 2009;68(2):109-122.

15. Kaholokula JKA, Grandinetti A, Keller S, Nacapoy AH, Mau MK. Association between perceived racism and physiological stress indices in Native Hawaiians. J Behav Med. 2012;35(1):27-37.

16. Paradies Y. Colonisation, racism and indigenous health. J Pop Res. 2016;33(1):83-96.

17. Kirmayer LJ, Gone JP, Moses J. Rethinking historical trauma. Transcult Psychiatry. 2014;51(3):299-319.

18. National Geographic. Native Americans Are Recasting Views of Indigenous Life. Available at https://www.nationalgeographic.com/magazine/article/native-americans-recasting-views-indigenous-life. Last accessed May 1, 2024.

19. Stone D, Trinh E, Zhou H, et al. Suicides among American Indian/Alaska Natives—National Violent Death Reporting System, United States, 2015–2020. MMWR. 2022;71(37):1161-1168.

20. National Public Radio. The Arctic Suicides: It's Not the Dark that Kills You. Available at https://www.npr.org/sections/goatsandsoda/2016/04/21/474847921/the-arctic-suicides-its-not-the-dark-that-kills-you. Last accessed May 1, 2024.

21. Redwood DG, Day GM, Beans JA, et al. Alaska Native traditional food and harvesting activity patterns over 10 years of follow-up.Curr Dev Nutr. 2019;3(11):nzz114.

22. Sargeant H, Forsyth R, Pitman A. The epidemiology of suicide in young men in Greenland: a systematic review. Int J Environ Res Public Health. 2018;15(11):2442.

23. U.S. Department of Health and Human Services, Office of Minority Health. Obesity and American Indians/Alaska Natives. Available at https://minorityhealth.hhs.gov/obesity-and-american-indiansalaska-natives. Last accessed May 1, 2024.

24. Alaska Native Tribal Health Consortium. Cancer Among Alaska Native People: An Executive Summary of the Alaska Native Tumor Registry's 50-Year Report. Available at http://anthctoday.org/epicenter/antr/Alaska_Native_Cancer_Report_50_Year_Executive_Summary.pdf. Last accessed May 1, 2024.

25. U.S. Department of Health and Human Services, Office of Minority Health. Diabetes and American Indians/Alaska Natives. Available at https://minorityhealth.hhs.gov/diabetes-and-american-indiansalaska-natives. Last accessed May 1, 2024.

26. Travis R. Homelessness, Alcoholism, and ethnic discrimination among Alaska Natives. Arctic. 1991;44(3):247-253.

27. U.S. Department of Housing and Urban Development. The 2023 Annual Homelessness Assessment Report (AHAR) to Congress. Available at https://www.huduser.gov/portal/sites/default/files/pdf/2023-AHAR-Part-1.pdf. Last accessed May 1, 2024.

28. National Alliance to End Homelessness. State of Homelessness: 2023 Edition. Available at https://endhomelessness.org/homelessness-in-america/homelessness-statistics/state-of-homelessness. Last accessed May 1, 2024.

29. Anchorage Coalition to End Homelessness. Data Snapshot. Available at https://www.aceh.org/data. Last accessed May 1, 2024.

30. Alaska Native Tribal Health Consortium. Clean Water and Sanitation. Available at https://anthc.org/clean-water-and-sanitation. Last accessed May 1, 2024.

31. Mattos K, Blanco-Quiroga T. Water Infrastructure Brief: Opportunities and Challenges for Washeterias in Unpiped Alaska Communities. Available at https://www.anthc.org/wp-content/uploads/2021/04/Washeteria-Technical-Brief.pdf. Last accessed May 1, 2024.

32. Jolly SE, Howard BV, Umans JG. Cardiovascular disease among Alaska Native peoples. Curr Cardio Risk Rep. 2013;7(6):10.1

33. Centers for Disease Control and Prevention, National Center for Health Statistics. Health of American Indian and Alaska Native Population. Available at https://www.cdc.gov/nchs/fastats/american-indian-health.htm. Last accessed May 1, 2024.

34. International Association for Indigenous Aging. American Indians and Alaska Natives: Key Demographics and Characteristics. Available at https://www.ncoa.org/article/american-indians-and-alaska-natives-key-demographics-and-characteristics. Last accessed May 1, 2024.

35. Congressional Research Service. American Indian, Alaska Native, and Tribal Population Data. Available at https://crsreports.congress.gov/product/pdf/IF/IF12612/2. Last accessed May 1, 2024.

36. Alaska Native Tribal Health Consortium. Hepatitis History among Alaska Native People. Available at https://anthc.org/news/hepatitis-history-among-alaska-native-people-part-1-in-a-series-on-anthc-support-and-prevention-against-liver-disease-and-hepatitis. Last accessed May 1, 2024.

37. Alaska Department of Health and Social Services. Teen Birth Rates in Alaska. Available at https://alaska-dhss.hub.arcgis.com/pages/4b2085a2feff4c67bd12efe96d15cacc. Last accessed May 1, 2024.

38. U.S. Department of Health and Human Services, Office of Minority Health. Infant Mortality and American Indians/Alaska Natives. Available at https://minorityhealth.hhs.gov/infant-mortality-and-american-indiansalaska-natives. Last accessed May 1, 2024.

39. U.S. Department of Health and Human Services Office of Minority Health. Chronic Liver Disease and American Indians/Alaska Natives. Available at https://minorityhealth.hhs.gov/chronic-liver-disease-and-american-indiansalaska-natives. Last accessed May 1, 2024.

40. March of Dimes. 2023 March of Dimes Report Card for Alaska. Available at https://www.marchofdimes.org/peristats/reports/alaska/report-card. Last accessed May 1, 2024.

41. U.S. Department of Health and Human Services Office of Minority Health. Hepatitis and American Indians/Alaska Natives. Available at https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlID=35. Last accessed May 16, 2021.

42. Rieckmann T, Moore LA, Croy CD, Novins DK, Aarons G. A national study of American Indian and Alaska Native substance abuse treatment: provider and program characteristics. J Subst Abuse Treat. 2016;68:46-56.

43. Stanford School of Medicine. Traditional Healing. Available at https://geriatrics.stanford.edu/ethnomed/alaskan/fund/traditional_healing.html. Last accessed May 1, 2024.

44. Hodge FS, Weinmann S, Roubideaux Y. Recruitment of American Indians and Alaska Natives into clinical trials. Ann Epid. 2000;10(8):S41-S48.

45. Rural Health Information Hub. Alaska. Available at https://www.ruralhealthinfo.org/states/alaska. Last accessed May 1, 2024.

46. Ford JD. Indigenous health and climate change. Am J Pub Health. 2016;102(7):1260-1266.

47. Alaska Department of Health and Social Services, Department of Public Health. Assessment of the Potential Health Impacts of Climate Change in Alaska. Available at http://www.epi.alaska.gov/bulletins/docs/rr2018_01.pdf. Last accessed May 1, 2024.

48. Alaska Native Knowledge Network. A History of Schooling for Alaska Native People. Available at http://www.ankn.uaf.edu/Curriculum/Articles/CarolBarnhardt/HistoryofSchooling.html. Last accessed May 1, 2024.

49. Whitesell NR, Beals J, Crow CB, Mitchell CM, Novins DK. Epidemiology and etiology of substance use among American Indians and Alaska Natives: risk, protection, and implications for prevention. Am J Drug Alc Abuse. 2012;38(5):376-382.

50. First Alaskans Foundation. Alaska Native Education Study: A Statewide Study of Alaska Native Values and Opinions Regarding Education in Alaska. Available at http://www.alaskool.org/native_ed/McDowell.pdf. Last accessed May 1, 2024.

51. Alaska Native Education. Report of the Education Task Force. Available at http://www.alaskool.org/resources/anc2/ANC2_Sec4.html. Last accessed May 1, 2024.

52. Substance Abuse and Mental Health Services Administration. Treatment Improvement Protocool (TIP) 61: Behavioral Health Services for American Indians and Alaska Natives. Available at https://store.samhsa.gov/sites/default/files/d7/priv/tip_61_aian_full_document_020419_0.pdf. Last accessed May 1, 2024.

53. Hasbah Roessel M. Working with Indigenous/Native American Patients. Available at https://www.psychiatry.org/psychiatrists/diversity/education/best-practice-highlights/working-with-native-american-patients. Last accessed May 1, 2024.

54. Alaska Federation of Natives. Alaska Native Peoples. Available at https://www.nativefederation.org/alaska-native-peoples. Last accessed May 1, 2024.

55. Gardner B. Addressing Native Homelessness with Culturally Appropriate Housing. Available at https://datasmart.hks.harvard.edu/addressing-native-homelessness-culturally-appropriate-housing. Last accessed May 1, 2024.