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Where are all the Native American medical students?

One of two Indigenous students in his Harvard Medical School class on the lack of representation and why it matters.

Victor A. Lopez-Carmen

After a rough go on an exam last May, I texted a chief from my nation for advice.

Me: Hey Chief . . . I failed my first exam in the Harvard Medical School course I’m in, and need to score high on the last two to pass the class. I’m wondering if there are any teachings on what Lakota and Dakota people do during times of failure?

Chief: I don’t know about failure, ‘cause we always won!

Me: Well I guess I gotta win then.

Chief: Good start.

Sometimes, the pressure of being one of the few from my tribe to go to medical school makes the weight of every evaluation feel that much heavier. One failed exam might seem insignificant in the long run (and it was), but no one can deny that the stakes are high for Native Americans studying medicine.

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According to the American Medical Association, of the roughly 5.2 million American Indians and Alaska Natives in the United States, approximately 3,400 are physicians. Put another way, Native Americans, at 2 percent of the US population, make up just two-fifths of 1 percent of physicians working in America today. And there aren’t enough of us in the pipeline. Only 9 percent of medical schools have more than four Native medical students, 43 percent don’t have any, and Native Americans make up one-tenth of 1 percent of medical school faculty nationwide. These statistics are especially troubling given that Native Americans have higher than average rates of 15 of the 16 leading causes of death, including heart disease, cancer, diabetes, and stroke.

Success in medical school confers a life of stability and an opportunity to measurably improve people’s lives. For me, success means that one day, I will be able to help Indigenous youth become doctors; speak to patients in our mother tongue; invest in community gardens and traditional nutrition; advocate for policy changes that will help lower Indigenous mortality rates; attend traditional ceremonies with the community I care for; and help lay down foundations for sovereign Indigenous health care delivery models, such as tribal-owned and operated hospitals and clinics. My aspirations are just the beginning. Imagine what Native American medical students across the country dream of doing as physicians. And imagine the indescribable potential that is being lost by tribes’ unjustifiable underrepresentation in medicine.

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Dr. Charles Alex Eastman
Dr. Charles Alex EastmanGlass Negatives of Indians (Collected by the Bureau of American Ethnology)

I am not the first of my nation to have such dreams. My Tunkasidan, or great-grandfather in Dakota tradition — whose name was Ohiyesa (“Always Victorious”) — pursued them more than a century before me. Often known as Dr. Charles Eastman, he graduated from Boston University School of Medicine in 1890 and was the first Native American man to become a medical doctor in the United States.

Upon Eastman’s graduation, he worked at the Pine Ridge Indian Reservation in South Dakota, where he visited the Oglala Lakota in their tipis, treated them alongside traditional healers, and spoke to them in Dakota. After US Army soldiers slaughtered nearly 300 Lakota men, women, and children in the Wounded Knee Massacre in December 1890, Eastman was the only physician the survivors trusted to help them. He spoke their language and knew their traditions, and he shared their grief.

In addition to his career in medicine, Eastman was a political lobbyist for the Dakota people in Washington, D.C. As he documented in his 1920 autobiography, “From the Deep Woods to Civilization,” he fought to ensure that the US government upheld its promise to deliver health care to Native peoples. He founded 32 Native American chapters of the YMCA and co-founded the Boy Scouts of America. His journey as a writer and social reformer led to friendships with Presidents Harrison, Cleveland, McKinley, and Theodore Roosevelt, and with other notable figures of his day, including Mark Twain, who invited Eastman to his 70th birthday banquet.

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One hundred and thirty years after Eastman trod the streets of Boston as the only Native American medical student in his class, I walk in his footsteps, one of only two Native American students in my own class. Is this really the best we can do? Eastman’s fight for Native people to get the health care they were owed now falls upon the shoulders of this generation’s Indigenous medical professionals and non-Indigenous allies.

Today, I see powerful examples of Indigenous inclusion in medicine, led by Native American physicians like Dr. Lori Alvord, of the Dine Nation, who wrote a book about being the first woman from her nation to become a surgeon; Dr. Donald Warne, an Oglala Lakota who directs the Indians Into Medicine Program at the University of North Dakota; and Pueblo physician Dr. Thomas Sequist, one of two Native American faculty at Harvard Medical School. While he was still a medical student, Sequist co-founded the Four Directions Summer Research Program, which has given hundreds of Native American pre-med undergraduates, including me, the opportunity to conduct research at Harvard Medical School and to learn what makes a successful medical school applicant.

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Six US medical schools enroll 40 percent of all Native American medical students. If the other American medical schools are to level the playing field and expand their ranks of Native American students, they must invest in pipeline programs that give more Native youth a shot, actively recruit Indigenous medical students and faculty, and be guided by the solutions and ideas they bring to the table. These goals should be framed in an appreciation for the unique political status of Native Americans as members of sovereign and distinct Indigenous nations — of which there are 574 in the United States. Each grapples still with the consequences of colonization and broken treaties with the US government.

Over the past 500 years, the US government’s brutal policies toward Indigenous nations ravaged them. Faced with starvation and death, many tribes signed treaties that, in exchange for cooperation, guaranteed access to health care through the Indian Health Services (IHS), as well as food commodities, all funded and provided by the federal government as compensation for the loss of their original lands and food systems.

The government has not upheld its end of the deal. Take health care. In 2017, IHS spending per person was $4,078. In comparison, that year the government spent more than twice that nationally, at $9,726, for each person covered by Medicare, Medicaid, or another federally funded program. That same year, the United States spent more than five times as much on federal prison health care per capita as it did on Native American health care. It is no wonder that from 1980 to 2014, Oglala Lakota County, home of the Pine Ridge Reservation in South Dakota, reported the second-shortest lifespan in the entire Western hemisphere.

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Today, Native Americans are 3.5 times more likely to be diagnosed with COVID-19 than are white people, a burden of disease worsened by our lack of representation in the medical field and the failure of one-size-fits-all approaches to combating the virus. For example, CDC guidelines for handwashing do not account for the fact that many Native Americans still don’t have access to running water.

As physicians, we are taught that each patient presents to the clinic with a unique set of environmental, social, cultural, genetic, political, and medical factors that are integral to their health. When it comes to Native Americans, there is no such context. The majority of medical schools don’t teach about the systemic factors at the root of Indigenous health: Indigenous rights, the IHS system, the oppressive policies that left us impoverished, or the US treaty obligations to ensure equitable health care for federally recognized tribes. As of 2017, only 11 percent of medical degree-granting institutions reported that they included Native American health content in their curricula. Contextual care for Indigenous peoples requires contextual education of future care providers.

A model that recognizes Indigenous self-determination, creates space for partnerships with tribes, fosters understanding of our history and treaty rights to health, and promotes recruitment into medicine and that is applied to every Indigenous nation will lead to more effective and contextual solutions like the Indians Into Medicine program at North Dakota and the Harvard summer research program I joined.

We have seen some positive change since Eastman made it his personal mission to expand representation and raise awareness around Indigenous rights in health care, but we are not done. The journey forward weighs heavily on me, yet my chief’s advice reminds me that success is in our DNA. Given the tribulations we have experienced, our very existence is a victory. Each moment our abundant potential in medicine remains untapped is a loss. I have hope that medical schools will begin to treat our struggles as their own and appreciate that each Native American physician is a victory not just for their nation but for the field of medicine too.

Victor A. Lopez-Carmen is a Dakota and Yaqui writer, health policy advocate, and student at Harvard Medical School. His commentary on minority health and human rights has been featured in such outlets as the BBC, Teen Vogue, and the UN News Centre.