Reproductive Justice: The Politics of Health Care for Native American Women

by Barbara Gurr

Feminist sociologists frequently argue that notions of kinship that rely on blood are patriarchal in their essence. This may be so, as ideas of “family” that exclude relationship outside of genetics or marriage serve a heteropatriarchal function, for example by marginalizing other ways of creating family (queer families come to mind; foster and adoptive families;

I didn’t want to research Native women’s lives because I didn’t want to be yet another white scholar who thought she understood Indian Country and made an academic career out of that arrogance.

For this study, entry-level data focusing on the experiences of Native women who utilize the Indian Health Service (IHS) for their reproductive health care derives from participant observations and just over thirty interviews conducted between 2009 and 2011.

These stories and the knowledge these women shared with me prompted my research into reproductive health care for Native women, and particularly my interest in reproductive health care through IHS and on Pine Ridge Reservation.

How do dynamic social and political ideologies of race, gender, sex, sexuality, class, and nation inform the ways in which the State understands reproductive health care and organizes the delivery of this health care? In other words, why are my reproductive health-care experiences so different from those of Native women in general, and women in reservation communities

My reliance on the frame of reproductive justice anchors this study in an intersectional perspective that allows room for the diverse experiences of Native women as they themselves understand them to guide the overall inquiry. However, my research questions are complicated by the extraordinarily complex and fractured bureaucratic organization of IHS as well as the multiple physical and ideological locations from which Native women seek health care.

I focus specifically on three factors salient to Native women’s health-care experiences: the function of race, class, gender, sexuality, and citizenship in reproductive health care as this health care serves the interests of settler colonialism; the organizational neglect and institutional control of reproductive health care within IHS (what I call the “double discourse” of imperialist medicine), which emerges from multiple locations; and the tensions between what Native women want and need and what they can access.

The forces that produce these tensions include not only the decisions of key elite parties (often based on competing interests), but also broad social, political, and economic processes. For example, because IHS is a federal agency that works throughout the contiguous United States and Alaska, the boundaries of IHS are frequently permeated by the national organization of health care as well as the government’s relationship with Native nations. This is particularly relevant when considering reproductive health care, an often contentious area of political debate and one that is frequently used as a political bargaining chip.

when I refer to the State in this book I have in mind the diverse set of institutions subject to management by the ruling apparatuses located in the federal government.

Not only federal apparatuses, but also regional states (such as South Dakota, where Pine Ridge Reservation is located) and Tribal councils influence the reproductive health care available to Native women. The Indian Health Service is accountable in different ways to all of these. Further, IHS is institutionally linked to and deeply influenced by lateral organizations in the Department of Health and Human Services (HHS) where it is located, particularly the Centers for Disease Control (CDC), the National Institutes of Health (NIH), the commissioned corps of the US Public Health Service (USPHS), and the Centers for Medicaid and Medicare.

(The term “Indian Country” was statutorily defined in 1948 by 18 U.S.C. 1151 as land within the limits of an Indian reservation, all dependent Indian communities within the United States, and all Indian allotments. The term “Indian Country” has also come to denote not only physical space but also the cultural and intellectual space predominantly influenced by Native America.)

This book considers how mainstream medical practice as it is institutionalized within IHS by the State serves as one mechanism to advance the goals of the settler colonialist State.

Part I offers a brief introduction to Indian Country generally and Pine Ridge Reservation in particular, and considers the development of the reproductive justice paradigm and its relevance for Native women.

No one knows for sure how many people lived here before the arrival of European and other immigrants

Scholarly consensus currently estimates around fifty million across the Western Hemisphere, but some estimates range much higher

Thomas Jefferson was the first US president to propose a reservation system to provide land for Native Americans outside of the growing domain of the young United States. Jefferson enacted policies with the state of Georgia to remove members of the Cherokee Nation almost three decades before Andrew Jackson’s infamous Indian Removal Act; his goal was to make more land available for purchase by the federal government, and specifically to separate Native Americans from the general population

There are currently over 560 federally recognized Native nations, and approximately 300 of these have reservation homelands.

Indian Country is indeed everywhere, because Native people are everywhere.

Unemployment is disproportionately high for Native Americans. In 2011, national unemployment was 8.9 percent, but for Native Americans and Alaska Natives it was 14.6 (Solis 2012). Native Americans are statistically the poorest people in the country; Buffalo County (located on the Crow Creek Reservation in South Dakota) is the poorest county in the country, and Shannon County, which composes two-thirds of nearby Pine Ridge Reservation, is the second poorest. According to the 2010 US Census, seven of the ten poorest counties in the country are located on Native American reservations. Three of the five poorest are on reservations in South Dakota.

Native people are also statistically among the sickest in the nation, with diabetes, tuberculosis, and cardiovascular disease rates well above that of all US races combined (IHS 2008). Rates of sexually transmitted infections are high in Native communities, a disparity that the Centers for Disease Control correlates with poverty and restricted access to health care as well as, potentially, cultural mistrust in health-care–seeking behaviors (CDC 2011b). Native Americ...

Pine Ridge Reservation, located in the southwest corner of South Dakota, is the Tribal center of the Oglala Lakota Oyate, one of the seven council fires of the Lakota nation.

The Native American Housing Assistance and Self-Determination Act of 1996 provides funds to support the construction of homes for Native people through the Department of Housing and Urban Development.

There is a severe housing shortage on the reservation, and approximately one-third of the homes are substandard, without regular access to water, electricity, adequate insulation, and sewage systems

approximately 55 percent of the homes on Pine Ridge are infected with Stachybotrys, also known as black mold, a potentially lethal infestation

communities. In 2010 the Environmental Protection Agency released a report analyzing water access on Diné’tah, home of the Navajo people, which covers twenty-seven thousand square miles across the states of Arizona, New Mexico, and Utah (Diné’tah is the largest reservation homeland in the United States). They found approximately 56 percent of homes lacked regular access to adequate water and sewage facilities.

Journalist Erik Eckholm (2009) estimates that there are approximately five thousand young men involved in over thirty-nine gangs on the reservation; he offers no estimate of young women’s involvement,

Rates of sexual violence are particularly high across Indian Country, and the legal, medical, and social resources needed to address these crimes and serve the survivors and their families are sorely lacking, due in part to federal and regional state underfunding and judicial policy

that the only domestic violence shelter on the reservation had been closed by the Tribal council due to allegations of corruption,

“activism” is not just what we see on the streets or on the Internet or in the news; sometimes, “activism” is the simple act of doggedly, determinedly surviving.

Sometimes resilience is really resistance, and survival is defiance.

It also means that we must question not only how but also why women’s reproductive bodies are used as mechanisms of oppression against whole communities.

patriarchy seeks to control women’s bodies and opportunities around sexuality, parenting, and even labor based on presumptions about the female reproductive body. Many scholars assert that the State is essentially patriarchal, producing and reifying structures of inequality that rely on binary, essentialist, and hierarchical constructions of sex and gender (see Connell 1990; Eisenstein 1981; Haney 2000). In the patriarchal State, they argue, sexuality, and particularly women’s sexuality, is regulated by the State through its policies, laws, and allocation of resources, and reproduction becomes a primary defining characteristic of women.

The settler State requires indigeneity, at least ideologically and in the terms it dictates.

In this country, all women experience reproductive oppression, but we don’t all experience it in the same ways.

Whereas the State has historically used women’s reproductive bodies as a means of population and community control in its quest to build an exclusive national collectivity, reproductive justice relies on women’s reproductive bodies to address the diverse health needs of whole communities.

The reproductive justice framework, which is both a theoretical paradigm and an activist model, brings together in cogent ways theories of human rights and inequality with intersectional examinations of women’s embodied experiences, and locates these in local social contexts. This grounding of international human rights law in locally driven conceptualizations of women’s health needs expands understandings and applications of the fundamental right to health. By situating women’s fundamental right to health in the broad social contexts of spiritual, environmental, and economic well-being, reproductive justice asserts the links between all of these areas and resists false isolation of the right to health from the conditions for health.

Loretta Ross confirmed this intention in her lecture at TWU on 10/12/16

stringent admission requirements and the extended course of study now required to become a physician inhibited economically disadvantaged students from pursuing careers in medicine, a problem with which IHS continues to struggle as it seeks to increase the number of Native American medical students through grants and scholarships. Thus diverse types of knowledge about health, wellness, and the body were increasingly marginalized and discredited, as a single model, emerging from an exclusively elite education, became progressively established.

A form of cultural genocide?

The linkage of women’s health and well-being to their presumed reproduction and the potential use of this presumed reproduction as a bargaining chip for improved public health reflects in complicated ways both the work of the State as it relies on women’s reproductive bodies to produce structures of oppression, and reproductive justice efforts as they rely on women’s reproductive bodies to argue for community well-being.

Even as women’s bodies have served as a primary resource for knowledge construction and professionalization, women’s diverse needs and experiences—and especially those of women of color and poor women—have been marginalized and neglected.

per capita spending on all Native American programs was higher than spending for the general population. However, President Ronald Reagan’s election in 1980 signaled a reversal for Native programs as his administration sought to reduce federal fiduciary responsibilities. After 1985, per capita spending on Native American programs was less than on the general population, resulting in a wide gap that persists today.