Citation
Thinking in pictures

Material Information

Title:
Thinking in pictures
Creator:
Bennish, Jeffrey E
Place of Publication:
Denver, CO
Publisher:
University of Colorado Denver
Publication Date:
Language:
English
Physical Description:
v, 193 leaves : ; 28 cm

Subjects

Subjects / Keywords:
Indians of North America -- Medical care -- Colorado -- Denver Metropolitan Area ( lcsh )
Indians of North America -- Urban residence -- Colorado -- Denver Metropolitan Area ( lcsh )
Indians of North America -- Social life and customs -- Colorado -- Denver Metropolitan Area ( lcsh )
Indians of North America -- Medical care ( fast )
Indians of North America -- Social life and customs ( fast )
Indians of North America -- Urban residence ( fast )
Colorado -- Denver Metropolitan Area ( fast )
Genre:
bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

Notes

Bibliography:
Includes bibliographical references (leaves 185-193).
Thesis:
Anthropology
General Note:
Department of Anthropology
Statement of Responsibility:
by Jeffrey E. Bennish.

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Source Institution:
|University of Colorado Denver
Holding Location:
|Auraria Library
Rights Management:
All applicable rights reserved by the source institution and holding location.
Resource Identifier:
62783193 ( OCLC )
ocm62783193
Classification:
LD1193.L43 2005m B46 ( lcc )

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westem biomedical experience for Native peoples to the Denver area can be an extremely fragmented difficult encounter. Many Native peoples not the familiarity prior experience to rely on to successfully navigate the bureaucracy. Issues with self-esteem living in an unfamiliar place with a population primarily by leaves many Native peoples positioning themselves as second class citizens. This positioning is evident in and outside biomedical institutions whether city hospital or neighborhood clinic. Through interaction discussions with Native Americans, specifically on this topic, who worked in the healthcare field both on reservations in Denver, I come to understand the breakdown at the cultural crossroads better. cultural framing becomes visible through insecure behavior where proud will not admit that they know they are accept unsuccessful attempts at getting healthcare rather than beggingfor help. One Native clinician shares their below on the communication navigation dilemma that is the starting point for most Natives seeking biomedical care in Denver jumping offpoint my discovery of issues facing urban Native peoples' access to implementation of healthcare.

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A collaborator who has spent over twenty years as a biomedical practitioner working in the Denver area gaining a knowledge skill set that is far from common among area Native Americans elaborates on their experiences navigating a persona/family health issue.

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According to another collaborator many Native American Denver area residents who retain strong connections to and practice their indigenous cultural pathways while also maintaining relations with relatives and.friends on the re_rvation benefit from this duplication of healthcare environments in comparison

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to other Native residents who do not have these relationship. I discuss these topics with them below. Many Native Americans living in metropolitan areas struggle become advocates for their health in highly individualistic deantralized settings offered in urban medical environments like Denver. Miscommunication discord between healthcare clinicians Native patients are often driven by cultural disconnections between illness causation and cultural time/space continuums reflected in cosmology (Quintero Csordas Deloria 2002). This is often coupled geographic disparity, economic disenjranchise1lllmt inexperience among generations of family members in navigating complex urban healthcare bureaucracies. A Jack knowledge on how to navigate the urban healthcare bureaucracy is not an isolated issue many indigenous North American peoples living in Denver. Many hod no role models providing insight erper;ence on how navigate a mortgage office let alone a hospital or clinic.

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withheld), Another collaborator comments on how economic illiteracy constrains urban Native peoples' ability to functionally maneuver through developed world of capitalistic medicine.

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One Native American person with of experience living in Denver as both a health care worker as a patient touches on the problems of navigation how that impacts often restricts peoples' abilities communication that many Native people experience when attempting to seek healthcare Denver.

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Communication issues within the urban Native connmmity and communication differences between this community and larger dominant Euro-American society strongly affect Native community's ability to access receive care. According to one collaborator, due to racism, many Euro-American clinicians interpret the or pan-Indian communication style with its emphasis preSl!1lt the circularity 0/ as evidence that Native people are slow. dimwitted and not as intelligent as members their Euro-AmeriCllll cultural group.

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In opposition to this Native communication style one collaborator believes that Euro-Amerlcans con more Ii. aflushing sewer when they speak than someone with intelligence. This observation based on their experience listening to -Whites' speed talk. One QIIthropologist has commented in discussions on his

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work on the Navajo reservation I.R.S. hospitals on the cultural distinctiveness of Navajo of silence a communication tool in direct comparison to the American clinicians observed discomfort with lapse in spealdng during patient eram;nes (Csordas Similar observations are given bya collaborator below. (name Withheld)

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In reference communication in biomedical settings one Native American researcher concluded "many sociolinguists noted the differences between physician and client communication practices. Providers their clients tend to form two speech communities. Agreement on the interpretations of on associated social values may be limited. "This disagreement may be due in to the marginalization of social conterts during patient-provitier interactions" (Weiner 2001: 120). Several examples of the breakdown between communication systems with diJferent cultural origins are given by collaborators later in this ttrl. One example from ethnographic literature on this subject can be found in the interactions with Alcoholic Anonymous Native peoples. When corifronting health issues like alcoholism Alcoholics Anonymous hod some success Native peoples. but it often fails from the because it is oriented around western not Native cultural values. It is an individualistic health model (Fir/co 2000:103). "You look at alcohol say. what is it a symptom of! It looks like a symptom of cultural conflict: American Indians cultural values quite different from those being imposed on us. Nobody ever stopped thinlc of this before" (Fixico 2000:96). It is the opinion several collaborators that many urban biomedical physicians not the time to develop the relationships many Native patients need, a discourse of trust. This dialogue shares one Native's feelings for the fast paced in and out nature many urban medical clinics

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A non-Native American medical clinician who works at the Denver Indian Health and Family Services center comments on their experience as someone who has cared for Native people here in the Denver area for many years as one of the only non-Native staff members of the clinic. These experiences are on a history of refe"ed patients out to area hospitals and specialists for medical services and witnessed first the difficulties patients have in accessing utilizing healthcare in this metropolitan area. A collaborator erplains differences in reservation biomedicine through I.RS. versus their experiences with Denver based biomedical facilities.

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A second collaborator comments on the issues of communication navigation Health as a recognized issue that was addressed by community voices program more aggressively in the past when the 10 vision collaboration was ongoing between Denver Indian Health Family Services or D.l.H.F.S. which is a small outpatient Indian Health Service funded clinic in Denver area Denver Health. D.l.H.F.S. is discussed more thoroughly in Chapter community voices program still exists partially with one part-time Native employee. In the community voices program was staffed by two full-time one part time Native employee with a budget community events outreach programs.

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No budget cun'ently exists. During the 10 Year Program time period in the late 1990s community voices program contributed extensively to researching providing specialized services exclusively for Denver's Native community in opinion was on the verge of creating some exciting protocols procedures for improving urban Native health in Denver. Native American urban health can benefit from continued improvements in communication in hospitals a reinvigoration of the roles filled previously through grant money formerly at Denver Health. It cannot be overstated that Euro-Americans are more likely to inherently trust western institutional representatives like physicians than Native patients according to several collaborators.

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Many Native Americans leave the reservations for urban areas seeking improvements for their jamilies through city work opportunities, but often get economically trapped along the way paying health care related expenses that turn to debt before they can get over the hump this geographically culturally transitional journey (Sorkin Rhoades 2002). It can't be overstated lack of experience with privatelpublic insurance ver.s walking in the LH.S. facility with empty pockets receiving care ill-equips many Native patients with the skill set necessary for accessing care in Denver.

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A collaborator explains memories of visiting an l.H.S. facility with their father on the reservation comparison to the healtheare experiences ofmany Native living in Denver. (He hod a navigator, translator, (the doctor)

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According to some collaborators who are extremely familiar with the Denver Indian Health Family Services center many urban Native who become aware of this facility assume that DJ.H.F.S. operates an off-reservation facility.

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II

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The ability to access reservation healthcare services once someone has become an urban resident is often dependent on connections that been with

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the reservation through family still living there. An entire generation of Native born after World War II lost connections to the reservations through urban displacement (Sorkin Fixico 2000). In addition to being removedfrom their Nattve families by state social service, children in this era have they have been disploced because their parents married a Native from another tribe or a Non-Native person. Although different tribes different rules, the end results tends to the same when it comes to the rules of blood quantum qualificationfor tribal membership. Blood quantum can be most easily explained in the followingfashion you mother is afull blood Navajo and your father a Euro American than you are only half Navajo. your mother is half Ottawa half Chippewa father is half Sioux and a quarter Flathead a quarter B1aclcfoot than you as their offspring might not be enough of any one tribe at the blood quantum level for membership. For many urban Native people who have lost these personal connections through losing blood quantum levels necessary to maintain membership through intermarriage, adoption or their own family's lack of record keeping these connections become difficult to resurrect A coauthor comments specifically on this issue directly to me.

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Biomedicine, often refe"ed to as westem medicine (Rhoades 2002:401) generally designates the application of scientific principles that were originally constructed from within Euro-America 's epistemological foundation of GrecoRoman historical cultures (Scheper-Hughes and Lock Traditional Native American medicines or indigenous medical systems are healing practices beliefs constructedfrom within Native tribal knowledge systems. Between the two "biomedicine stands alone by its insistence on materialism as the grounds of knowledge and by its discomfort with dialectical modes of thought and particularly because of its peculiarly powerful commitment to an idea nature excludes the teleological (Kleinman Foremost among the characteristics of Native A.merican medicine its inclusion ojwhat in Euro-American terminology ;s called religion (Brito A recent study conducted by a Native American scholar physician concluded that Native medicine, taking into account the diversity of this term depending on the tribe, is centered on a theological-physical dualism focused on power that includes realms of spirits capable of doing both benevolent and negative actions (Rhoades 2002:402). Colonial governments historically often feared indigenous medical systems because their communal orientation held the potential for populations to organize opposition movements. "Biomedicine played a central role in capitalist imperialism, specifically in its efforts to maintain control of erploited populations" (Boer 2000:212). While biomedicine's dominance over rival medical systems hDs never been absolute its connection with political economic power positioned Native A.merican healing systems as everything unimportant to a direct threat (Csordas This is because altemative medical systems often exhibit counter hegemonic elements that resist, often in subtle forms, the elitist, hierarchical bureaucratic patterns (Baer 2000). A common observation contemporary Native American intellectuals is that wars against Indian people conducted by the Federal government in the nineteenth century, the forced displacement to reservations, often on that were not traditionally those which the people were previously living, alongside boarding school cultural reprogramming and relocations o/middle twentieth centrny reservation young men their families, together created a genocidal black swallowing traditional Native American medical browledge (Deloria 2002, Fixico 2002). roots of Native American socio-cultural economic devastation can be attributed not to warfare oppression, but also to other efforts by the

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dominant society, including its system of biomedicine to control and suppress Native peoples (Hassin Young 2001). Beginning in the second half of the nineteenth century, government officials viewed Western medical services as an instrument of assimilation (Reifel 2001). According to one scholar, liUle is still known about what Native people consider when choosing between traditional medicine and biomedicine. Nor is there an untkrstanding how people perceive the role of the two systems of medical practice fReiJeI2001). has been documented previously is that, "Eighty percent of the world's population relies on traditional healthcare based on medicinal plants and seventy four percent of contemporary drugs the same or related uses in western medicine as they in traditional medical systems. '/he pharmaceutical knowledge medicinal skills of indigenous peoples are neither acknowledged nor rewarded" (Cook-Lynn The cultural politics of ownership in healthcare is played out in a theater of oppression that reflects the track record of colonialism's impact on indigenous peoples. An example this phenomenon can be found in the history of the Indian Health Service (I.B.S.), federal government's biomedical facilities on or near Indian Reservations the sterilization of Native American women (Lawrence 2000). Native American women throughout the twentieth century into 1970s were given I.H.S. approved hysterectomies tubal ligations to treat such diagnoses as alcoholism as of a eugenics movement the Bureau Indian Affairs (Lawrence 2000:400). '/he functional aspect of this practice was similar to that which OCCIm'ed during the the Indian wars in the nineteenth century when the federal government knowingly distributed blankets itifected with smallpox duringforced relocations under the pretat keeping them warm (Deloria 1995). Native women were routinely lied to by biomedical personal at I.R.S. facilities who said that sterilizations were reversible (Lawrence 2000:400). Broken medical promises mirror broken treaties for Native Americans. Women going into I.HS. facilities to undergo appendectomies received tubal ligations, aform o/sterilization, without Icnowledge or consent habitually (Lawrence 2000:400). It;s estilllflred that 1970s a/one between thirty tofarty percent all Native women between the ages of fifteen andforty through coercion, misinformation, deceit andforgery were sterilized I.H.S.facilities without medical justification a systematic biomedical enactment of politically motivated eugenics (Lawrence 2000:401). Many clinicians testified that they thought were helping society and the federal government's fiduciary obligations by limiting the number births to low income minority families (Lawrence 2000:401). A congressional in concluded that in addition to this widespread violence committed against Native women, Native peoples in general were being exposed in I.H.S. facilities to experimental pharmaceuticals as guinea pigs without their Irnow/edge and consent (Lawrence 2000:406). This is 3S

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of the long history of negative relations between biomedicine and Native peoples in North America (Fixico 2000, Rhoades 2002, Lawrence 2000). One personal account from a Lakota woman who lives near the Wounded Knee area of South spealcs volumes about the context of the relationship between biomedicine, LH.S. Native peoples. "I was determined not to go to hospital. I did not want a white doctor looking at me down there. I wanted white doctor to touch me. Always in my mind was how they sterilized my sister how they let her die. baby was going to live" (Fixico 2000: 107). Westem healthcare for many Native Americans has been described with terms such as ''frustration, bureaucracy, expensive, alienation miscommunication (Fixico 2000: Reasons for disconnect in communication and a laclc of efficacy for biomedicine with Native peoples been documented as "afraid of treatment care, lack health care insurance, inodequate means of follow-up/continuity and speed in which people are handled" (Firico 2000: Cosmological differences between biomedical representatives who measure time in seconds minutes related to health status contrast with Native American peoples who see time as a continuum where the present is what is most important since it is both the past and the future (Deloria 2002).

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For many Native American people living in Denver in 2005 there remains a lack cultural understanding regarding American biomedicine. Native people often don't believe that the system is capable of understanding their perspective often retain afear that their beliefs as judged by the clinician standards will not be understood. This leads many urban Natives to not seek help at all especially from mental health biomedical practitioners. There is a feeling among several collaborators that communication issues underwrite mistrust between the Native patient typically white clinician.

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In Several Native Americans intellectuals now the collaborators of this text have attempted to explain historical experiences inform continuously divergent epistemologies between Euro-Americans and Native Americans. makes this background important is the fact that these epistemologies inform guide different conceptions of mediCine, health, healing. illness disease (l'rafter 2001). Curing other kinds of rituals, in so far as they convey a sense of order control are a social psychological response to tM fear that arises from living under unpredictable environmental and social conditions 2001). Sickness, disease healthcare are not simply products of biological pathogens, but ultimately tied to sociopolitical contexts interacting with pathogens (Sontag 1978, Hahn A perfect example of this phenomenon can found in the history of cotiflict over medical religious use of peyote among Native Americans. Western culture, represented in this case by the American federal government, classifies peyote as a dangerous, illegal narcotic. No or consideration is given to other cultural interpretations. No Native religious or medical providers are consulted on the interpretations of medical worthiness of peyote. Westem physicians politicians are allowed comment from their powerful, ethnocentric pedestal of multi-cultural authority. When it comes to governing mediating for Native peoples are often left out of decision making process by design. The American Medical Association, olficial authority of biomedicine in the United States condemned and provided the scientific 'proof' needed to outlaw Peyote use by Congress. The D.E.A., B.IA. and other agencies of the federal government sponsored a at Mayo clinic in The biomedical clinician

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authors in full complicity with the FDA, DEA and BIA were continuing a long history of the colonial project t/econst11lcting indigenous spiritual and cultural resistance and conveniently wrapping it in the language of protecting the American public and Indians from dangerous narcotics (Stewart LeBarre Some states since consulted with Native peoples and acquiesced to the medicinal properties of peyote which been known for of years to Native peoples as a safe, but powerful medicine. As recent as April 2003 ignoring the Federal Religious Freedom Act permits religious consumption of peyote among registered tribal peoples a state judge in Michigan, during a child custody case, a Native American's peyote consumption not as a healthcare treatment, but as a "dangerous iUegai drug which should in general be avoided"(New York Times 2003). The signs symptoms of disease illness do more than signify the functioning our bodies they also can signify the sensitive contradictory components of cultures and social relations (Taussig 1980:3). In westem biomedicine the acquires dualistic as both a thing being, a and a soul (Taussig 1980:3). This is not a cultural universal despite the ethnocentricity that underpins its place in Judeo-Christian or secular Euro American psychology that is shared with most Native Americans. Native peoples who retain a paradigm grounded in their traditional epistemologies a much more integrated view on healing. A great example of how this dichotomy is not natural to other cultures was observed earlier by Evans-Pritchard in his famous ethnography on the A.zande. (Evans-Pritchard in Taussig 1980:3) Questions the ask themselves when confronted with illness, Why me? Why now? underwrite the social relations nexus the Azande constructed for understanding of illness, disease sickness in a way that more closely resembles the Native American metaphysical cosmology than biomedicine's culture of science, seeing disease as a social relation way to address it as a synthesis of moral, social physical protocols. Biomedicine, built generally on a mechanical retiuctionist epistemological model that separates the mind soul from the physical body struggles to find a place for the power of peyote, which acts on the mind to directly cure and address physical and psychological ailments (Quintero Natives peoples based on their epistemological foundations are able to integrate peyote as a mind altering substance capable of healing physical ailments because this mind!body dualistic distinction so familiar to Western culture is not separated in their cu/hlres. A lesson taught to me by the collaborators ;s that Westem Medicine still has not developed an adquate culturally sensitive approach for elucidation the Native American patients' model their iUness. Since Native Americans first were contocted by European colonialists through contemporary times the distinctions between cultures mirrors polarity of their unique epistemologies. The majority of Native Americans have from tribe to

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tribe utilized an indigenous metaphysics for IInIkrstanding the world and their place in it with a seamless transparency and circular philosophy of interdependence that contrasts sharply with the historically polarizing divisions between western science religion including most poignantly the discourse or dialectic concerning health, illness healing (Deloria 2001, Firico 2002). MetaphysiCS is most easily described as the primary set of principles that must possessed in order to make sense of the world in which we live. Indian metaphysical tenets teach that "the world all its possible experiences, constituted a social reality, afabric of life in which everything hod the possibility of intimate knowing relationships ultimately, everything was related" (Deloria 2001). "Indian thinking is seeing things from a perspective emphasizing circles cycles are central to world that all things ore related within universe. For Indian people who are close to their tribal traditions Native values, think within a Native reality consisting of a physical metaphysical world" (Fixico 2002:2). Commenting on the western cultural rejection of Native American metaphysics one scholar observes that Europeans their colonialist relations commit a "fallacy of misplaced concreteness, which is to that after reached conclusions to which their premises led them, they came to believe they accurately described ultimate reality" (Deloria 2001 In contrast to the westernfocus on morphology structure, Indian metaphysical paradigms are underwritten through attention to the psychological characteristics of things. Notwithstanding the proven advancements In pharmaceutical interventions, disease diagnosis, treatments and surgical procedures coordinated with genetic biological analysis westerners in 2005 often for granted when addressing illness, historically western science medicine shown "an inner conservatism that often more energy gathering evidence to bolster outmoded paradigms than supporting ideas" (Deloria 2001:3). While western science medicine become more dynamic flexible through the cultural challenges of postmodernism quantum physics, its roots remain planted in a reductionist stnIcture that seeks to explain natural exjJeriences into pre4i!tennined categories that often describes explains nothing. rise of science propelled man into tunnels of specialized knowledge with every step forward in scientific Irnowledge the less clearly he could see the world as a whole his own self' (Scheper-Hughes Lock In generalized terms the science Euro-American epistemology of time, space and energy coupled with a political ethic driven by scale utilitarilmism can be against Q Native American metaphysics of p/oce and power con-elated with an emphasis on ecological spirituDl balance integration (Deloria 2001:31). Sciencejrom archaeological analysis to string theory has moved from mechanistic reductionist to more compler, non-linear holistic investigation recently

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solidifyingfor Native intellectuals corifirmation in the wisdom of Native American cosmology (Alfred Fixico 2002). In many ways biomedicine's epistemology the paradigms it informs continues to cling to modes of thought that the cutting edge of western science discarded over thirty years ago (Kleinman Boer 2000, Rhoades 2002). "A singular premise (historical) western science and (contemporary) clinical practice is its commitment to a fundamental opposition between spirit matter, mind and (Scheper-Hughes and Lock 1997:209). In the culture of biomedicine epistemologies are often organized around central metaphors whereas body as a machine is manifest through practices like artificial orthopedic hip replacement surgery (Fox It should be clear why Native Americans who hold a divergent epistemology issues in biomedical arenas. Native American cultures do not hold the same distinctions between medicine religion so familiar to peoples. An example comes from ethnography of the Kiowa Apache where "formants relayed that in their belief structure body mind are not .parate and strictly biological or medical approaches to treating disease among their people no meaning (Bittle /960:142). Biomedical trainingfollowing the philosophy of Descartes "preserved the soul as the domain of theology legitimated the body as domain of science" (Scheper-Hughes Lock 1997:210). Writing in reference to both cosmological differences in time/space metaphysics 1'elated to health a Native American elde1' remarked 1960s "How do we protect strengthen our children as we live in crowds, walk on concrete, in a strange language far from old ones. from the mountains.from the turtle bear?" (Flxico 2000:48). The questions of this traditionalist elder still puzzle confound many of the collaborators of paper whose tribal perceptions inform them that time is a continuum the past is present and the future. as today don't have clear cut answe1'S for why spirit of the urban American Indian as it manifest itself through healthcare indicators still to be broken by the weight of colonialism. The. epistemological differences on a very practical meaning within the context of health healing. The critical profound differences between Indian and Western medicine obviously derive from underlying cultural precepts of each. A generally accepted Indian concept of health is that it is a tangible reality. not simply a state beingfree disease. '/his health or wellness is often described as the ability to erist in a harmonious relaJionship with all other living things. but with a number of spirits, including a great all-powerjul spirit. The emphosis on the spirit W01'Id, supematural f01'ces religion stond in to the secular emphasis on disturbed physiology the purely physical explanations of common Within Western Medicine (Rhoades 2002:04).

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Drawing directly from the Native Americans authors whose tm I read more significantly the who collaborated on this text I hove learned about an epistemology that challenges my conceptions of facts and things forcing me to attempt to understand that facts are not separated from values, physical manifestations are connected to social contexts social relations interweave material events, contrary to my biomedical understanding of health. Social interactions can reinforce clashing cultures' power dynamics in ertremely subtle ways. Social forces affect medical encounters by causing the conditions of sickness patients bring to a clinic or healthcare environment (Waitzkin "The sick person is a depentknt anxious person, malleable in of the doctor health system open to their manipulation andmoralism" (/'aussig 1980:4). In urban medical facilities like in Denver social character of medical encounter, where consultation and healing occur in privatized and individualistic settings underwritten with natural science, cultural rites, rituals customs, it is difficult for Native peoples because the system's design is devoid of the moral metaphysical connections Native Americans consider important in healing Fixico 2002). Biomedicine not attempted to create space in its contemporary practical dialectic to address the sources of many Native American Health issues including urban racism historical trauma (Singer 1998). A collaborator addresses ideas on Native American cosmology among Denver's Indians it affects healthca1'e Western cultural health behaviors passed down among descendents inform its practitioners on art oj bullet pointing sickness and illness into quantified symptoms. This is a practice maximized efficiency accepted on the of medical providers patients. Historically this

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practice and its place in discourse of health can be traced to the anatomy philosophical beliefs of Newton and Descartes and their tkductive epistemologies of the bcxJy. These understandings are often token lor granted, because these values are not universally experienced shared many Native American urban resident communication problems often In the discourse thatlollows between me a collaborator who works at this distinction is revealed The Native patient who does not share with the American a common acceptance of linear time, time efficiency chronological logic is underserved by a medical format that relies on these concepts for evaluation, progress completion of the medical event between clinician and patient. According to one health care practitioner some Native Americans tend to struggle more the transition to urban health care from their past experiences knowledges of reservation based healthcare.

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A collaborator shares a poignant example of Native cosmology operating in a biomedical environment. As read the other testimonies offered throughout the rest of this etJmography please keep in mind the overlooked differences between the Native American collaborators examples of issues with healtheare the ways cosmological epistemological differences between cultural groups contribute to issues that are faced in the Denver area by indigenous peoples.

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As an introduction to this chapter it is important to provide some historical contextual iTf/ormation on nature of urban Citizenship for Native Americans. American Indians have been urban citizens since before colonia/ism (Fixico 2000). Commenting on this history one Native American scholar remembered, "the once great Caholcia stands quietly eroding to the east oj St. Louis. Almost unnoticed and Without a sound, the ancient, massive urban of mound building Indians reminded me that this was perhaps the greatest Indian City north the Rio Grande. I reflected on the fact that the urban Indian experience is very old and not a 2'" century phenomenon" (Fixico 2000:ix). history of urban livingfor Native peoples precedes the history Native peoples living as minority populations in dominated cities which is considerably more recent (Fixico 2000:3). Native identity is challenged in urban areas as is elucidated below several collaborators. Native peoples, whether first generation urban residents in the twenty first century or second or third generation, experience conflict between their social constnJcts those the dominant Euro-American society (Sorkin 1978, Bartl Tribal peoples in urban areas are expected to transitionfrom communalism to western individualism (Firico 2000:3). "Urban Indians/elt the pressures assimilation considerably more his or her reservation counterpart" (Fixico 2000:6). Pan-Indian social structures like the Denver Indian Center, the Denver Family Resource Center and the Denver Indian Health, and Family Services Center been established to help Native peoples regain political solidarity, power and identity within the metropolitan community. More than afew Native Americans in the DelIVer area were moved to this location through the federal government's Bureau of Indian Affairs relocation offices in the late 1940s and 1950s (Fixico 2000:4). By late 6,200 Indians oj an estimated reservation population 0/245,000 hod settled in large cities (Firico 2000: relocation program was instrumental in removing Indians throughout the twentieth century, more than 100,000 total before the program ended, so that today the majority the over million Native Americans live in cities (Firico 2000:4). Many Native peoples who were relocated did not comprehend political nature of the federal programs interest in integrating them

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into mainstream American urban life. Eliminating population bases of reservations cut the numbers of treaties the federal government had to honor and the funds neetkd to be redistributed to the reservations in compensation for natural resource ertraction, grazing fees, water rights and timber harvesting on a per capita basis (Finco 2000:6). Many Nattve American scholars and activists today claim that the historical agenda to Native peoples into urban areas was conceived in order to eliminate the population base for claims sovereign nation status, relief from the federal government's fiduciary and treaty obligations, and to free up natural resources for private corporate ertractionfrom Indian (Sorkin Deloria Fixico 2000, Trer 2001, Prins 2003). The Bureau of Indian Affairs offers a much more benevolent perspective. "The prime directive according to program of relocation services memo twenty eighth October nineteen fifty seven was to assist American Indians who wanted independence from the Federal Government and who were eager to their place in free enterprise system" (Finco 2000: Many Native peoples, however, throughout the 1950s and 1960s called relocation an ertermination program and said that the federal government officials believed "the Indians would be integrated by all youngsters the reservation, the old would die off, the young would be integrated and the would become free for public domain so all the other white people could grab it" (Finco 2000:20). In urban areas it has been noted that mutual tribal concerns interactions dissolved 1IUlIIY barriers between tribal groups that hod no history offriendly association interaction (Finco 2000:25). In as in most other urban areas, the numbers of any one specific group of Native peoples im't big enough to recreate tribal structures (Sorkin A look at the Board Directors of the Denver Indian Center c01ifirms its place as a pan-Indian institution. Over fifteen different tribal nations throughout the Rocky Mountains plDins states are represented. Native peoples in the Denver area, whether are seeking health treatments through the Denver Indian Health Family Services Center or returning to a reservation for services through an I.R.S. facility or from a traditional healer need to connections with their tribal governments communities in order to maintain recognized tribal affiliation typically required to maintain eligibility for biomedical 2002). On a purely psychological level, "Indians attempt to avoid dismembering themselves from their Native community since they are frequently alone in city. They consider themselves as a of the people even though may live ofmilesawayfrom their traditional homeland" (Fixico 2000:37). A significant number of American Indians undergone urbanization, yet they retained a large degree oftraditionol tribal values (Sorkin 1978. Fixico 2000, Clark Mendoza 2001). This persistence occurs through the continued practice

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traditional tribal culture, like sweating or Native American Church ceremonies, that remain mostly invisibk to the larger society (Ortner Indian socializations, through pow-wows among other venues provide opportunities for the retention traditional social structures in urban areas. These events their perceptions of traditional culture are itifluenced by the reservation (Clark and Mendoza 2oo1). Socialization with other Native Americans from different tribes, which can be thought as the hallmark of the urban Indian experience, has been the savior of urban Indians (Fmco l000:57). Urban Native peoples often are considered the lost or forgotten peopk of American. "To the Bureau of Indian affairs, to the Indian Health Service all to frequently to hislher triba/leadershlp, he/she no longer exists" {Bailey Fixico 1000: A collaborator expresses their on being an urban Native American:

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In order to better understand the state of healthcare for Native Americans living in the Denver metropolitan area it is necessary to gaze into the community as a whole. The best way to this I believe is to community members, who as collaborators of this text, speak about their experiences impressions as members of this community. Despite fact that the Front Range Colorado historically the home of the Arapahoe and Cheyenne tribes during at least colonial times most of these Natives were forcibly resettled during the late IV" century to Oklahoma reservations. According to one Health Care clinician who works exclusively with the Denver area Native community, many adults living in Denver are first generation urban dwellers. Withheld), Other collaborators besides these two confirmed for me that believe the majority Native American Denver residents are first generation urban citizens. Another collaborator comments here regarding the ill-equipped stature of first generation Native people seeking healthcare in Denver. Their negative outcomes in dealing with the biomedical system in Denver is due to the fact that they have an overall dearth of knowledge on how to communicate in a style that is necessary for successful outcomes. It is also to the simple fact that lack of experience in dealing with a medical system that even, in opposition to the LH.S.

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hospitals on the reservation, does not recognize anyone without the proper paperwork, identification cards appropriate credit. Many Native people land in Denver without tribal identification, let alone birth certificates and driver's licenses that are standard material for for public assistance healthcare hospitals. It is difficult to form the permanent social structures needed in an urban area like Denver that can maintain a political voice representing a unified community when a lot the population considers itself temporary transient both culturally geographically. Many urban Native people simultaneously attempting to negotiate dual identities (Anderson 1991, AppandJJrai one identity remains with the reservation economy whereas another is navigating the urban political economy. In cases this represents a dichotomy between personal ownership vs. communal ownership in other words, the rural communal socialism that can be witnessed on most Indian reservations vs. the urban individllalistic, capitalism in the United States. A collaborator here discusses the differences between being a second generation urban Native person with connections in contrast to the faced by many other Native people newer to the Denver area without these same relationships.

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While agreeing that Denver's Native community is transient in some regards one collaborator who represents the Denver Indian Family Resource Center in Lakewood believes that politics not transient populations is the biggest impediment to improving economic and health for the area's Native peoples. Native People living in Denver today who were bom raised primarily in metropolitan area also developed dual identities. For some, it was simply their city reservation identities. For others it was their Indian versus Indian identities. Whether as defense mechanisms as minorities as access gaining points to different social circumstances, transitional trans cultural identity constructions are utilized often employed by adolescents coming to grips with public school texts depicting their culture as only ertsting historically in America. when 'Indian culture was presented to many Native peoples as youths in Denver it often the stereotyped romanticized plains Indians who bore standard many could relate to in their own families adBlts many Native learn to develop separate identities the reservation, for their urban Indian environment, andfor their urban Euro-American environments. One collaborator explains their experience. ss

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Some Native youth transition so frequently between the Denver area the reservation that they struggle to connect with either community as their Many urban Indian families also live from supplemental income traveling to pow-wows which keeps from tkdicated sole-source education healtheare. The construction of identity politics under these circumstances leads to unique psychological. physical social health issues

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The simplest way to begin to explain the complaity of Native American identity construction is to investigate the differences between Indian Western intellectualism. One Native American scholar explained Indian intellectualism in the contert of itkntity construction in the follOWing manner. 'The question of telling Indian stories is still at the heart of what America believes to be its narrative of self. distinguishes Native American intellectualism from western scholarship is its interest in tribal indigenousness and this makes the ego-centered biography or the non-tribal story seem unrecognizable or even important, non-conummal unconnected' (Cook-Lynn Across the board review of recent Native American literature has confirmed a common dichotomy the individualism ofwestem culture versus a pan-Indian itkology centered on a foundational spirit of collective communalism (Cook-Lynn 1998, Alfred Deloria 2002, Finco 2002). This is an important distinction to keep in mind as one seeks to 1I11Ikrstand improve state of for urban Native Americans who, unlike their reservation counterparts, are minorities not within the country, but within their community. They are not just minorities as an ethnic group, but also from a cosmological perspective. Native Americans bi-culturalltves in comparison to the mono culture of Euro-Americans, who, tkspite having many different ethnic backgrounds, embraced were motivated to see themselves in tkmocratic equality unification in opposition to their native European history of royalty class based society. American Indians are still the sum individual tribes within individual tribal autonomy cultural distinctiveness without a centralized or unified organizational superstructure (Clark and Mendoza 2001). Identity construction politics are an issue for Native people today that aist at the juncture of history, the present, and the future. It involves colonia/ism, manifest tkstiny, the reservation system, the dominant Anglo society's rules of genetics, biology It is manifested in personal, intertribal, federal government decrees on skin color, tribal enrollment records and blood quantum levels. It is by far one of the most glaring emmp1es of the present day fMthodological continuance of colonialism's dualist goa1s of assimilation or death for the indigenous population. There are many scholars including, Vine Deloria Donald Firico, Tataiake Alfred Elizabeth Cook-Lynn, who continue arguing this point Euro-Americans created many institutional structures like the B.I.A. which still erists today. Historically they were created to erase indigenous population's ability to compete for control of resources, and cultvral autonomy here in the United States. What is surprising is the degree to which most tribes, while claiming sovereignty, continue to formally embrace their

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imperialist colonizers' definitions of they are what they can be. According to many collaborators this construction is even more and negatively applied off the reservation in urban areas and destabilizes and has deleterious effects on urban community building.

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Identity construction impacts Denver Natives that transition between Denver and a reservation those that maintain a more committed relationship to the area. The adaptation colonialist definitions coupled with political polarizations of splintered urban Native factions emergtngfrom in-fighting over ever dwindling resources has deleterious effects on health and community. A collaborator told me about a Native friend who has ancestry from tribes from his two parents. This coauthor erp/ained that hisfriendts predicament the perfect example of how occasionally no tribe will recognize you as a member even though you derive all ancestry from Indian blood. His friend has no single identity that sufficiently strong in the eyes oj the tribal governments of his parents because he does not meet the blood qualifications one specific tribe. It is a perfect representation on an level that illustrates contemporary Native people continue to SI!fIer from artificial Western culturally constructed definitions oj itkntity. This collaborator states that not enough Native people Ulll:krstand the way colonialist dfinitions identity to impact and eliminate Indians. This elimination is not literal as in death by firing squod. but legally socially Indians over generations are birthing non-Indians even when two 'legal 'Indians have offspring in a pan-Indian multi-tribal environment.

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A coauthor here illustrates this type of internalized racism impacts the Denver Indian community's ability to organize around health issues. They dl!veloped a conscious denial colonial ethnocentric definitions of Indian identity.

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The blood quantum issue bleeds over into affecting health care opportunities for many Native peoples living in the Denver area. One collaborator who works in the health care field explains their frustrations with D.I.H.F.S. when community members who aren't enrolled members of their tribes trouble getting healthcare services. This collaborator sheds some light on another issue. It is difficult for non-enrolled Native people to get enrolled ex-post facto because many tribes infused with economic ironically, do not want to extend the monetary benefits that enrollment entails from a dwindling pot of resources income. This collaborator continuI!s to illustrate how identity politics combines with power dynamics and history in the Denver area. It foments a strong argument on why it remains difficult to organize a core group of Native people operating as eqrmls reservations when so opinions between and within tribes about who is im't Native.

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A collaborator here offers their perspective on why Denver's Native American resource centers are geographically separated from each other seem to occupy and operate in the bortkrlands (Ortner within metropolitan Denver. Contemporary metropolitan Denver has a complex urban society as do most urban areas in North America of its size. The Native community's internal stroggles with identity and power juxtaposed on top of the fragmentation that urban geography allows for has preclutkd a widespread dominantly continuous structural formulation kind of uniform let alone heterogeneous multi-tribal itkntity. This heterogeneous /andscape can be considered a bortkrland for indigenous peoples. Borderlands are a concept that emerged within the anthropological literature on ethnic minority studies and draws attention to the construction of complex, hybridized itkntities for those who live within, yet are exclutkd from, the dominant cultural order (Ortner Within anthropology the itka of a bortkr/and has been used as a strategy to get away from bounded timeless cultures and to attend instead to encounters between people and images across cultvral political spaces (Appodurai Clifford This narrative has revealed with the interplay of self, itkntity and healing among urban Native Americans in the context of living within a pluralistic, but Euro-American dominated Denver metropolitan area a strong illustration of the bortkr/and cultural Not only does this phenomenon propagate territoriality and isolation between agencies but it also maintains minimal visibility for non Indians un informed Indians alike their eristence and purpose. The urban Native Americans are aware of these groups who advocate offer vital and important services

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struggle with transportation to and between these different agencies which are not close to their neighborhoods or places of employment. Another important observation presented by a collaborator below illustrates a core issue for the jragmenJation DertVer's Native community. Denver's Indian community often becomes splintered over rifts between generations of families where individuals who were not directly involved in the primary conflicts continue to face personal discrimination from other Native people based on relative's historically perceived transgressiOns. This manifests itself most poignantly within upper realms of DertVer's urban Native community agency administrative levels. According to several collaborators it is far from an organic or holistically cohesive picture. Using a corporate metaphor it would be like a corporation trying to come together on a common goal while having each department not only located in physically separate places, but not overcoming this issue with structured, organized, open communication integration channels let alone interoffice mail or meetings. This fosters distrust between agencies their agendas fimctionally prevents, on formal structural or symbolic level, true collaboration.

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Despite having many different resources available to them throughout the outskirts. of Denver some suburbs one collaborator believes the lack of a meeting place in central Dmver for the core Native peoples, many of them homeless, is an urgent issue needing addressing. As will illustrated the collaborator of the health issues pressing the Native community are as much about poverty as about being Native American. What;s unique ;s how disproportionately the majority of this group's population lives in poverty compared to other minorities as well as how weak their lobby, their political weight or voice, in the community continues to be. This community seems caught, circling in the borderland of the dominant cultural order both culturally economically.

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lOU

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The boarding school experience gave many urban Native individuals living in Denver a colonizers' perspective of what it means to be Native. These issues continue to play out in contemporary Denver's Native American community although many members are overcoming the internalized racism prevalent in this education. effects of Manifest Destiny's reprogramming of Indian in the boarding school hod a lasting impact on the Denver Indian communities' affliction with negative self-esteem, depression, identity crisis, and related alcohol and drug problems. One collaborator also relates how these issues affect Indians in their experience throughout the Americas.

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As will be discussed more by other collaborators a social structural problem restricts Denver's pan-/ndian community from overcoming the divide and conquer mentality of the Euro-American mainstream society that has positioned individual Indian agencies against each other for dwindling resources and kept the community the bottom socio-economic nmg. There is a need to demonstrate community agreement consensus when dealing with powerful insensitive supra-local agencies that control needed resources that Denver's pan-tribal representation has not been able to generate. failure of consensus and political irifighting during the "10 Year Plan" project is one example. New pan-tribal cooperation integration will to occur first before positive outcomes will seen. A new collective response with new leaders responding is necessary to overcome the funding crisis facing this community. Only a constructive community consortium approach that bridges the different Native agencies together can focus unite this community. This organization perhaps modeled after a similar group that emerged in the late 1980s in Los Angeles will wield the political weight arouse the spirit or common interest of such a diverse Indian population (Weibel-Orlando One collaborator believes that in addition the structural issues, a pan Indian cultural trait that is erpressed individually prevents many Native people in Denver from developing the assertiveness required to acquire the services necessary both economically and medically in an urban area like Denver

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According to one collaborator, an ajJliction many Denver Native Americans face is a poverty mentality that contributes to passive unaccountability that impact many aspects of their being, including seeking and participating in their own healthcare. It starts with experiences they have as and is underwritten by many eiders' boarding school memories impacting today 's future Native generations.

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It is often easy to forget that Native peoples not lived in Euro-American cities from time immemorial. Native peoples were often barred from cities by Federal State law the city of Boston, MA just passed legislation in 2005 ma/cing it legal once again for Native Americans to visit or live within the city limits (New York Times 2004). Likewise, pan-Indian cultural phenomena have a contemporary history of less than 200 years (Brito Pan-Indian activities are viewed by many to be cultural defense mechanisms to the genocidal principles of Manifest Destiny colonialism that continue to haunt Native peoples from all tribes (Finco 2002). Pan-Indianism takes many forms; pow-wows, Native American literary SOCieties, inter-tribal financial institutions, the Native American Church and the Denver Indian Health Family Services clinic here in Denver among others. Pan-Indian movements cultural resistance have a history of addressing health issues. The Handsome Religion of the Iroquois, the Ghost Dance movement of several western plains tribes and the pan-Indian Native American church all arose during the nineteenth century, bo"owing from intertribal customs, beliefs practices to develop responses to health issues among Native peoples (Fixico 2000:96). Native peoples on the brink of extinction in the nineteenth century reunified and strengthened their resolve by developing new socio-cultural interfaces among previously isolated or antagonistic tribes in

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order to respond with common interest to the dominant Euro-American discourses of assimilation and annihilation pressed upon them (Radin Csordas 1997). Pan-Indianness is an intertribal response to colonialism that was enabled by the mass movement dislocation of Native peoples historically and the incorporation of Native peoples contemporarily in the social and geographic enviromnents that are inseparable from the colonial project itself. It is evident that the creators of Manifest Destiny understood that Native American power was directly related to geographical position (Sorkin One of the ways Euro Americans sought to disenfranchise Natives' power was through the passing of the General Allotment Act of also as the Dawes Act (Sorkin This instrument of federal Indian policy that for thirty years pressured Indian peoples to discard their traditional cultures through assimilation permitted the breaking of tribal and reservation lands into individual allotments at the discretion of the President of the United States (Sorkin "By mil/ion acres, two thirds of the Indian land base had passed into non-Indian While the wars against Native peoples by the Federal Government had encouraged previous pan Indian movements, this land steal through legislation wherein the end even the Department of the Interior concluded that the resource levels of the Native peoples were no longer capable of sustaining their populations, fostered permanent Indian organizations responses" (Sorkin 1978). American Indians have been subjected to colonial domination by European nations their tkscendents for over five centuries, resulting in a radical destabilization of their socio-cultural and economic systems, a general deterioration of mental physical health and rapid depopulation that has only recently been reversed (Hassin 2001:251). This domination tkstruction of American Indians their cultures began with the genocidal actions of the European invaders continues today through a tkpressed socioeconomic structure and over arching unemployment (Hassin 2001:252). The large scalefederal Indian relocation program that began during World War II andwas officially implemented nationwide in in order to "remove the surplus labor from the reservation areas" (Sorkin played a large role inforcing Natives to develop Indianism as individual nations realized the futility of petitioning the federal govenunent only as an individual tribe. "Forgotten or more likely deemed unattractive as ethnographic subjects the acculturated Indians surviving in demoralized disintegrated communities in urban ghettos or depressed rural pockets faced alarming rates of alcoholism, disease, accitknts and su;citk. Repressed by white society and increasingly estranged from their traditions, American Indians faced the choice between assimilation and cultural revitalization" (Prins 2003:50). Pan-Indian cultural affiliations organizations are attempts at cultural revitalization.

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Phenomena like the Native American Church, which has the malleability to allow different traditional Native American cosmologies to be tribally applied and reconstituted in practice (Stewart are just one example of this of inter cultural response. "Pan-Indian cultural representations provide an abstract enough template upon which Native Americans can graft their specific tribal cosmologies" (Quintero Pan-Indian devices are not homogenous in that individual tribal nations develop syncretic elements in line with traditional epistemologies contertualizing historical Native pathways within a modern globalized intertribal set of connectiom (Quintero Many anthropologists and Native American scholars have written that pan-Indian organizations function as defensive strategies against transculturation (Aberle 1983, Stewart Snake Fixico 2000, Quintero 2001). Transculturation been defined as "the process whereby individuals under a variety of circumstances are temporarily or permanently detached from a group, enter a web of social relations that constitute another society come out under the influences of its customs, ideas and values to a greater or lesser degree" (Hallowell 1963:523). Native Americans have reaffirmed Indian cultural significance while resisting complete assimilation by adapting the cultural pluralism of pan-Indianism (Fixico 2000:58). Pan-Indianism is of the decolonization process of Indigenous peoples in North America (Glenn Morris, personal communication 3/3/03). Sun Dance, the Ghost the Native American Church are a few examples of indigenous, multi-tribal movements that attempt to counteract the assertive and individualistic hostility confusion Native peoples face when confronted with non-Native social relations (Fixico 2000: spirit of pan-Indian pow-wows in urban centers, like Denver, revitalizes Indianism rather than tribalism since members of different tribes attend (Fixico 2000). The unification of Indians at these events manifests what pan-Indianism means as a revitalizing reaction against their placement within the Euro-American social spectrum as just another ethnic minority group. The pan-Indian sub-culture is based on traditional, but flexible dynamic tribal social structures which Native peoples alter and adapt to fit urban settings (Fixico 2000:57). One of this study 's collaborators erplains what pan-Indianness means to them. j

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follows here is a great narrative on attempts at pan-Indian, locally community socio-cultural healing. Some collaborators believe that this is a strong model for improving urban Indian health in Denver. This narrative also magnifies the difficulty of getting consensus in such a diverse community. A central theme that is revealed this collaborator is the difference in acceptance between 'ififormal' or generally uncontested urban pan-Indian cultural events like the pow the politically charged lack of participation when it comes to attempts at creating 'formal' traditionally iriformed urban based pan-Indian ceremonies. Pow-wows are not the only iriformal events that spark easy pan-Indian cooperation organization. The protests against the Columbus Day celebrations in Denver bring many Native people from many different nations together as well. One of the top administrators at the Denver Health and Family Services Center called me late in 2004 to let me know that Donald Finco a prominent Native American academic historian at the University of Arizona was speaking at the University of Colorado in nearby Boulder sponsored by the University of Colorado Native American Student Council. While this administrator lives in Denver it is a great illustration of the networking among metropolitan Native peoples that takes place to promote area Native based events. When I attended this talk by Finco on The American Indian Mind in a Linear World I asked Finco, who is an expert on urban Native American issues, why it is so hardfor Native people to recreate formal ceremonies traditions in urban areas. While hod no definitive answer he believed the individualized orientation de-emphasis on the traditional Native value system which is traditionally rooted in a strong connection with the and the history of the community were issues still not being addressed by urban Native peoples. Many urban Native peoples he believes struggle to implement their Indian thinking against the baclu:Jrop of the American mainstream consciousness of consumerism and individualist conditioning. A collaborator explains their perspective here on experiences in Denver where urban living drives Natives to develop westernized 'egos'that tend to prevent solidarity and divide people with common goals. In

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particular this collaborator illuminates the difficulty of recreating pan-Indian formal ceremonies. The point being that different Indian nations still struggle in urban environments to give up their tribal allegiance. sovereignty and authority to locally based inter-tribal agencies and officials. In addition this collaborator discusses the differences between the cultural homogeneity of reservation areas that make ceremonies easier to control. implement and access because of a comfort among individuals regarding their identity within the reservations boundaries. In opposition this collaborator believes the urban pressures metaphorically represented by the focus on the ego combines with inter-tribal political pressures spacing out and disconnecting pan-Indian social structures making urban ceremonies very difficult to sustain

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There is a great deal of difficulty practiCing ethnically sensitive healtheme for Native Americans in Denver. Although the community is united under the common historical relationship of all being Native Americans, they are at least as diverse as the many ethnic groups that can be uncovered among all the European nation/states. The diversity of tribes and their cultural beliefs specific pan-Indian oriented approaches very difficult to pinpoint since there are few universals to use as a blueprint for success. The pan-Indian movement should be untkrstood as a movement of political connections and not one that has changed the dynamic cultural differences of tribes or their urban representatives.

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One collaborator shares some of their experiences on the Denver Indian community. Having lived in several other metropolitan areas with large Native populations they found that Denver's community is very similar to the Native urban community elsewhere. Internal racism, including the notion of who is Indian who is not, permeates many urban Indian comnnmities, but this collaborator believes it is an impediment that can be overcome. One important observation by this collaborator others is that many Native groups in Denver are individual issue groups, narrowly focused to integrate with other groups to focus on macro-level social concerns.

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Another collaborator comments on the unity issue.

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diversity of tribes cultural values making up the Native population living in the Denver metropolitan area makes community consensus and successful organizational implementation an arduous journey. This process is often even more difficult when the leadership of community based groups contain more non Native representatives than indigenous peoples or especially when it appears to the Native people themselves that the ultimate control still resides in the hands of the traditional power base.

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Denver's Native community often can appear to an outsider to be a continuously shifting community without boundaries; transient, decentralized and difficult to wrap arms around outside the highly visible subculture of the pow-wows. At the core of this dynamic andfluid place lies a common issue for many minority indigenous peoples, a disconnect from primary source economic avenues limiting structural change when internal discord within the community distances community leaders from each other and opportunities for new developments. In this environment many projects stop because they lack the semi-permanent institutional structures that allow initiatives to transcend generations so many Native people become conditioned to accepting a lack of power and progress. Consequently, Native people still feel the daily sting underwritten by a history of patriarchy and paternalism informing the dialectic of Euro-American and Native American relations. The history often divides Native people over whether in the long run it is benefiCial to partner with Euro-American driven attempts at providing improvements in the heaIthcare. The power and position the Native person has acquired can be usurped, challenged, distilled or threatened often as the price one pays for compliance and cooperation. One collaborator prOVides insight here regarding this phenomenon from data takenfrom the "10 Year Report".

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Below a collaborator illustrates how of the healthcare issues faced by the Native community here in Denver are common to all people who are in the lowest socio-economic position. Being poor effects both the population and the agencies that try to serve them equally. Although these heahhcare problems are systemic for all poor people in the United States the Native community bears an increasing burden as they attempt to not only overcome economic disadvantages which effect them at higher rates than other minority groups, but also the cultural differences that communication and navigation overtly difficult as well. In reflection, I find it incredibly troubling that the federal government Indian money in the possession of the Department of the Interior that could be distributed to build and full fledged l.HS. facilities, in urban areas like Denver, where the majority of Native people reside, but is failing to release those funds back in Indian hands for these worthwhile projects. n-A

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In order for coalition community strengthening improvements to occur that could advance advocacy for the Denver Native community several issues must be addressed The itifighting and jealousy issues between semi-competing Native American agency personalities must overcome, racism and its impact on identity politics must be addressed with a more serious reckoning by the non-Native populations and the biomedical community devote more time resources, not window dressing P.R in listening to and embracing its Native population's concerns.

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What follows is a listing of the general themes I developed in my journal of field notes that summarizes concerns the collaborators told me were the most pressing issues facing the health of Denver's Native American community. General Themes Lack of resourcesEconomic, Education, Organizational 2. Lack consensus amongst community 3. Geographically Variable and migrant populations 4. Intimidating Culturally Foreign Bureaucratic Institutions 5. Historical Trauma Internalized Racism Healthcare Themes Substance Abuse 2. Depression Diet 3. Diabetes 4. Hypertension Women's Care, Specialty Care Dentistry There is no way to discuss healthcare for Native Americans living in Denver without first introducing the primary community health center which is directed, staffed utilized by Denver's multi-tribal Native American community. The Denver Indian Health Family Services center was started in is directed by Sherry Albertson, a Fort Peek AssiniboinelSioux tribal member originally from Poplar, Montana. The center located at King St provides re/e"ais, direct clinic services, MedicarelMedicaid outreach specialists an indigent care program to Denver area Native Americans to even some indigenous peoples from as far away as Aspen and Pueblo, Colorado. center estimates it serves a Denver Indian population of approrimately twenty.five to thirty thousand people. It attempts to fill the gap in services that Native peoples need. Despite the fact that Colorado is in the heart 1ndian Country' the closest full

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service f.H.S. facilities are near Albuquerque, NM and Sioux City, SD. While D.f.HF.S only has the staffing funding to care for a small percentage of the metropolitan area 's indigenous Native American population it has national visibility through its director. She has testified before the Senate the Department of Interior's B.f.A. on Indian Health. D.f.H.F.S. 's position as the primary political representative of the Denver area's Native peoples' vision for improving their community's health access and catapults this group into the nerus or spotlight for understanding the opporhmities and struggles this community faces. D.f.H.F.S. is a primary care clinic whose services include basic non emergency sick care, diabetes care and prevention, mental health, youth crime prevention, victim services community health assistance including dental, optical, prescriptions, health aid program coordination refe"al assistance with inpatient outpatient substance abuse programs. After first learning about D.I.H.F.S. I approached one of the Native American managers at the clinic to solicit their support in helping me complete this research through the follOWing dialogue. I began by attempting to summarize why I was in their office. My conversation led to the development of this individual being one several collaborators from the Native American community who partnered with me to produce this document. In order to provide local historical background contextual understanding on the applied attempts of those before me in improving healthcare for Denver's Native American community this collaborator directed me to a semi-private historical document. In a series of dialogues was initiated between Denver Health. the City County of Denver 's public hospital and the Native American community to address issues of Native American health and access to healthcore services in Denver. Together with members of the Native American Community, Denver Health created a comprehensive strategic plan, the ten year vision for Native American Health Care in Denver. In the Rose Community Foundation awarded Denver Health a Native American Community Health Improvement Project grant to support the redefinition and implementation of the plan. Native American community members were hired as project staff including the project coordinator a community health advisor. Whereas the metropolitan area's Native population was widely disseminated, three city neighborhoods with high concentrations of indigenous peoples including Westwood, Mar Lee Capitol Hill were recognized Alongside representatives from Denver Health on this commission were representatives of D.f.H.F.S., the grant and some other community advisors.

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A Denver Health administrator who was deeply involved with the bureaucracy management of the coalition of Native Americans and Denver Health offiCials provides some first backgrmmd on their experiences with the facilitated meetings and their outcomes. Several issues are raised from this dialogue including documentation of the lack of insurance of of the Native patients tracked by Denver Health over a year's time period. Another issue raised that needs addressing is the fact that indigent Native patients are directed to Denver Health from throughout the county metropolitan area only to find out that they cannot receive healtheare services without a Denver address. More significant is the subtle suggestion that many Native people struggle with healthcare because of a more generalized lack of assimilation to the urban culture's bureaucracy. From communication difficulties to a general lack of understanding on how to navigate layers of administrative barriers, many Native people need more training and education to better understand healthcare access in Denver. n-So

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As will be pointed out several tinres throughout this ethnography the number of Native peoples the Euro-American community acknowledges live in the Denver area community is about one-half the number that the Native collaborators and other Native American representatives claim. I believe that there is a strong political Clm'ent underwriting this difference in numbers as it reflects the larger debate between the federal govermnent and tribes attempting to gain legitimization recognition throughout the United States.

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Some positive change occurred because of this project. Many obstacles were uncovered through the hard work of all of the participants. A theme generated from among the participants emphasized the role that history played in development of the situation. A general consensus stated that American society hod not traditionally placed a lot of value on Native Health. An example some Native people gave me was a quote attributed to Andrew Jackson, the former president of the country, who is credited with once declaring "the only good Indian was a dead Indian". reservation system's ultimate goal, according to several collaborators, was obviOUSly to eliminate Indians from the American landscape. all the issues identified, one the most poignant could be most of the health issues experienced by Native peoples on the reservations also occur in metropolitan Denver's Native population. The difference being there are simply fewer resources available less focus paid to these issues despite the fact that a majority of the Native population today lives in cities in a Denver and not on reservations.

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Despite many positive ideas developed during the offiCial sessions between Denver Health representatives of the Denver American Indian community, political discord malcontent developed between the hospital and some Native officials, most notably the director of the Denver Indian Health and Family Services Center. It is belief that for improvements in healthcare to occur the future for the Derrver area's Native population dialogues of cooperation and commitment will be necessary between these two institutions. Below, a Native collaborator who was a former Denver Health administrator and who was also a part of the ten year planning committee explains where the tension arose.

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Another non-Native administrator discusses the ten project that they worked on the cultural educational issues that were revealed grappled with by this individual during that process. 1 begin by challenging this on what

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the hospital is doing to help improve culturally appropriate care for its Native patients. n

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The distance between the Denver Indian community and Denver Health in its position as a representative of biomedical standards in America might never have been further in the few years than when conflict erupted over one Native family who could have benefitedfrom local Native leadership and community assistance. were not assisted in that effort in a way that many Native American people living in Denver believe they should have been. While the biomedical institution positions itself as upholding patient confidentiality the Native population according to several collaborators sees a continuation of colonial mentalities of paternalism. Here is the opinion of a director of patient services at Denver Health beginning with a reference to a highly publicized case where one Native mother andfather had their baby temporarily taken almost immediately after it had been born by state social services after employees at Denver Health decided according to various accounts that the parents were unfit. Only after pressure on the mayor and governor by Indian activists did the state relinquish the child back to the parents. Critics pointed to the corifidentiality western medical constructs which prevented other Native community members from assisting the family onsite at the hospital. Many believe a /ack of cultural sensitivity led to a senseless and disrespectful spectacle. jj-As

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A Native American collaborator provicks some of their experiences related to working on the health improvement project.

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Below another collaborator who still works at Denver Health prOvides their experiences with ten year vision planning committee. Together these two collaborators echoed the sentiments of almost all of the Native people I spoke with regarding the 10 Year Plan. believed that although Native input was sought out during the planning implementation meetings the purse strings the power to orchestrate the changes they suggested always remained outside their community's control. I troly believe Denver's Indian community hod access to the money being held in trust for them the department of the interior they could have taken the work put into the 10 Year Plan and have implemented it in a culturally appropriate way. Instead the temporary nature of the grant money and the ultimate economic controls held non-Native bureaucracies led to what people now feel in a cynical way was simply a waste of time no improvements for Native healthcare. n

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Another collaborator presents their insights into why the coalition between Denver Health and D.l.HF.S. fell apart after so much work was devoted to the 10 year vision project.

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withheld)

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Additional insight is revealed through other collaborator's interpretations of the history context involving the relationship between Denver Health and D.I.H.F.S. This collaborators narrative is widely shared by other collaborators I interviewed The attempts made at improving health care for Denver's Native population was both noble meritous

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As an introduction to this section I wanted to share some written responses I received on a one page questionnaire I distributed to four friendly looking Native Americans I met sitting a pow-wow in Lyons, CO. attempting to get an interview with a prospective col/aborator that never panned out despite having set up the interview waiting for over three hours without the person showing up. The reason there are only four is because I only hod questionnaire copies with me I wanted to keep a clean copy for taking notes with my prospective interviewee. I never replicated this process again during my fieldwork, but the answers these Native participants gave taught me a lot. After introducing myself, explaining the nature of my research validating that the individuals were Denver area residents I asked these four people they wouldn't mind filling out my questionnaire in return for a soda a free pen. What follows is a collection of their written answers directly from the questionnaires that I have retyped together under each question These are the same questions off the same questionnaire that I used as the building block of interviews with co-authors. Without me asking the questions and entering into a dialog the answers were shorter more precise than those received during conversations from other collaborators. 1. What are some of the healthcare practices or services you utilize? 2. How are these practices or strategies helpful?

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3. What are some of your strategies for preventing sickness? 4. What are some of your practices for healing once you become ill? 5. are some of challenges or obstacles you face as a Native American living in Denver in attaining healthcare services? 6. do YOU feel Native Americans living in Denver could teach biomedical institutions about healthcare healing? 7. How do historically traditional or modem Native American medical practices ofgy a role in your life in an urban non-reservation setting like the Denver area?

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8. What are the biggest Native people with sickness disease in Denver? Native American medicine biomedicine represent two different cultural traditions of solving the same types of problems. In 2005, Native peoples often synthesize strengths from both systems in attempting to handle illnesses. Native American medicine is a misnomer. This medicine is not one holistic system, but a meta-narrative of hundreds of mini systems as diverse and unique as fish in sea. The medicine takes the form of indigenous pharmaceuticals, surgeries, psychiatric approaches and others worthy of study in their awn right. Just as pan-Indian activity allows Native peoples to focus on their common cultural traits, Native American medical systems from different tribes have many things in common. Native American medicine been described as metopyschiatric (Rhoades 2002:404). An example of the epistemology that informs this type ofmedicine is illustrated in the lollowing comment from Black Elk speaking to ethnographer John Neihardt, "Whether it happened so or not I do not know, but you think about it, will see it is true "(Deloria and Wildcat 2001:6). This type olnon-linear and non-sequential thinking dominates Native American metaphysics. This metaphysics is able to connections between things that no sequential relationships (De/oria 2002). Understandings are not necessarily conceived from

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the principles of cause effect that dominate biomedicine, but are often based on "when a certain sequence of things begins certain other elements or events would occur" (Deloria Wildcat 2001:26). In diagnosing illness, for example, biomedicine often searches for the cause of sickness utilizing reductionist questioning on a variety of correlated erperiences and comparing these responses to diagnostic tests with statistically measurable outcomes. Biomedicine is searchingfor the linkages that experience teaches it existed in specific types of situations. A lot of Native American health healing comes from the psychological metaphysically positive relationships of community that can overcome the frustration depression that often leads to sickness (Firico 2000: 108). Native American medicine a greater societal, rather than biological basis and plays a greater role in the maintenance of community integrity than does biomedicine (Rhodes 2000: 404). Commenting on Native American medicine as manifested through practice in the Native American Church one member said "Our holy medicine within it four powers love, hope, charity faith That's what medicine ;s about. It helps us to interpret life. It helps our minds to open become tolerant of even our weakness" (Snake 1996:41). Native Americans benefitjrom indigenous medicine because it often puts them in contact with a community they feel they are not connected to within biomedical environments (Firico 2000). Commenting generally on why indigenous practitioners successfully heal, Arthur Kleinman, a medical anthropologist, believes it is because of its focus on treating primarily three types of disorders. First, indigenous medicine, like biomediCine, treats acute, self-limited naturally remitting diseases. Secondly, indigenous medicine treats "non life threatening, chronic diseases in which the management of illness, psychological cultural problems, is a larger component of clinical management than biomedical treatment of disease" (Kleinman and Sung 1979:24). Third, indigenous medicine treats secondary somatic manifestations somatization of minor psychological disorders and interpersonal problems. 'The treatment of disease plays a small role in the care of these disorders. Therapeutic efficacy for these problems is principally a function of the treatment the psychosocial and cultural aspects of the illness (Kleinman and Sung The benefit of retaining a strong, indigenous medical tradition for urban Native Americans is that it can provide them with a second system for understanding on how to remain healthy vibrant. this is difficult to out in Denver or other urban areas is reinforced by several collaborators later in the tert. A collaborator comments on the value of Native medical traditions.

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Many urban Native peoples actively blend biomedical traditional health care practices spirituality. For many of these people according to one health care practitioner better health is seen among them as compared to other Native urban residents who embrace neither system with any commitment. Two important Native American healing traditions that collaborators I worked with participate in, sweating participating in the Native American Church, were both at one time illegal under federal thanks in to the complicity of biomedical political representatives of the American Medical Association who testified before congress as to dangers these practices represented to the Native peoples' health (Aberle /957). Native American medical knowledge their systems of application often exhibit counter-hegemonic elements that resist in subtle ways the elitist and bureaucratic patterns of biomedicine (Baer 2000). As several collaborators discuss the knowledge base and traditions of indigenous medicine have been strained and are shrinking since colonial time due to many factors. As the collaborator's testimony illustrates not much is being done today in Denver within the biomedical community to include Native healing traditions or Native healers in the process of healthcare for urban Native peoples. This is despite a call to all biomedical institutions that the strongest strategy for increasing Indian participation acceptance with biomedical care is to promote a collaboration between western and American Indian medicine as Native healers are the important missing participants in improving urban community health (Rhoades 2002:82). Today, many urban

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Native people attempt to blend whatever knowledge has been preserved by their tribes and other tribes with biomedical approaches to health and healing. A Native American collaborator who works at D.l.H.F.S. explains. urban Native people freely combine or synthesize both what become pan-Indian traditions originatingfrom specific tribes' cultural history with western healthcare practices such as diet and erercise regulation to achieve improved well ness. More often than not these Native people have received western education at the least in the undergraduate level that exposed them to these bridges. It is

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alluded to one collaborator that in urban settings these types of practices, sweating, and attending Sun Dance or Native American Church ceremonies outside the immediate metro area, are often the benefit of economic mobility that accompanies higher levels of educational attainment in American society, but difficult for the majority the Native population time for or afford

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n

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A collaborator here discusses their experience with the personal intersection of colonization, western medicine, and non-urban reservation-based Native healthcare initiatives traditions. believe these Native, predominately reservationbased, traditions represent an underutilized and under-explored opportlmity for improving Denver's Native American community's health. Reconnecting with discarded or difficult to maintain traditions in an urban area requires Willful and highly focused efforts to place importance on these traditions against momentum of forces the larger and omnipresent western culture of contemporary America which devalues marginalizes these traditions through the idea that Indian culture is only alive in museums and the historicalization of Indian people in general. This collaborator speoJcs about reference to Native American Church. A Roadman is someone who has gone through an apprenticeship to learn ceremony structure, songs and methods.for utilizing the peyote medicine. This person is usually schooled in traditions associated with particular

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tribal cultural practices, but often leads ceremonies for persons from many different tribal groups.

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A collaborator explained to me that in their experience being erposed to other systems of advancing wellness besides traditional biomedicine resulted in Native patients becoming more comfortable with western clinical environments.

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health importance of sweatingfor many urban Native peoples is c01Ulected to their cultural sense of self.

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Many Native urban residents will return to the reservation for both community family-based healing traditions and LH.S. care that cannot be replicated in Denver. Havingfamily members on reservation can make this simply an inconvenience of time and money, but with without family on the reservation eligibility for LH.S. services is more complex than one might think. Dating back to the Snyder Act and now regulated Title of the Code of Federal Regulations: Public Health 1952, Native Americans must prove Indian descent, tribal membership, ownership of property, participation in tribal affairs and residence on tax-exempt in order to technically qualify for LH.S. services among other criteria (Rhoades 2002:86). More importantly for residents of the Denver area is that "an individual must reside within a specific contact health services area (CHSDA) of counties on near reservation areas. Indians who move lose eligibility must reestablish residence for 180 days" (Rhoades 2002:86) before regaining eligibility. Several collaborators told me that the letter of law is stricter than the spirit and that care is rarely denied based on leaving the reservation in their erperience. A collaborator comments witnessing the trials a patient moving between Denver and their reservation for healthcore needs experiences.

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Another collaborator comments on this issue.

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A collaborator elucidates how in their experience many urban dwelling Natives /eave Denver for both economic and cultural reasons when seeking healthcare. For some, it is because there is no trust in the urban system, for others it is the appeal syncretism: opportunity to actively control with more subjective sovereignty the blending indigenous healing traditions grounded in reservation's peoples with the biomedicine at the LH.S. facility. Anthropology has analyzed this type of phenomena within other cultural areas as transculturation (Hallowell 1963). These opportunities are not available for all Native peoples living in Denver though Having the economic resources of transportation and vacation time as well as relatiomhips with extended family on reservations are important preconditions.

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According to one colklborator many Native people living in Denver have healthcare practices use both indigenous and biomedical solutions. Frequently, Western diagnosis of healthcaTe problems fall for Native patients because these diagnoses no roots in their cultural knowledge and do not reflect their cosmological beliefs or experiences. Urban healthcare settings are transient, syncluonic and disconnected in comparison to even the LH.S. experiences of several collaborators. The time, stability and relationships needed for Native people to feel comfortable are hard to locate. This is the personal side healthcare for Native people: trust, cultural knowledge and shared experiences. Couple these issues with biomedical clinicians who often may not respect and openly mock Native healing traditions and it becomes easier to understand why a Denver area Native drives three hundred to six miles/or Native-based cosmological healthcare experiences uniquely rooted in the metaphysical nature wellness positioning the in the circular universe.

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Many families face a strain on their resources, both health and economic, as they try to live in two places at once, city and the reservation. Right now, although there are exceptions, Denver area Native peoples generally leave the metropolitan area to go back to a reservation to incorporate more traditional indigenous types of medicine in their lives. Unfortunately, there are many Native peoples simply don't have economic resources to make this According to some indigenous collaborators traditional medicine been de-emphasized and downp/ayed in importance on some reservations like the Navajo reservation to point that it is barely being sustained on the reservation let alone

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being transported culturally to an urban area like Denver. I have come to understand Navajo medicine as being most similar to biomedical psychiatry, but more spiritual in construction in opposition to the antibiotics or clinical surgery side of biomedicine which I have come to understand from a Native viewpoint as being closer in relation to the western cultural construction of indigenous healers who are often referred to as "shamans This distinction, although a generic stereotype that does not fully itiform one of the diversity within these tribal groups, illustrates no one single blueprint can be put forward to handle Native American Health. A collaborator example is offered This one person erperienced related to me in general, Pueblo people tend to utilize traditional tribal medicine more frequently without biomedicine. Whereas many Navajo people practice traditional types of medicine to handle mental issues readily access biomedicine more for physical ailments in conjunction with traditional medicine. A collaborator here explains how there are only a few token indigenous medicinal leaders in the Denver area. While there are over.fifty different Native nations with members living in the Denver area only a handful of these tribes members who understand Native traditions in spirituality healing. Simultaneously it has been pointed that many Native healing traditions are based on years of relationships between the healer and the patient through family interaction. People often struggle trying to substitute those relationships between individuals without connections let alone between different tribal traditions languages often resulting in superfiCial exchanges. Native medicine cannot be exchanged between Indian nations as can be seeing an internist in an urban hospital in New York or California for a Euro-American moving between states. Although Native peoples today share and bon'ow among each other this has not translated into a thriving pan-Indian healing leadership or resource center for Denver's Native community. It simply not coincidence that urban hospitals not created cultural spaces for the healing traditions of Native healers. Biomedicine is rooted in an exclusive claim healthcare superiority unquestioned authority in America throughout western culture. Its claims authority rest heavily on power of objectivity, unquestioned authority prominence through autonomy secular rituaiization (Katz A collaborator explains their experience with these relationships.

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This collaborator. through their experience. believes that primory reason traditional indigenous medicine is a jlickeringjlame the breakdown of its reemergent system on reservation. There are no schools. no money and little interest amongst a population fluttering the bottom of our nation's socio economic ladder for promoting its benevolence and knowledge base. The urbanization of the Native American population World War II has removed people from the traditional and community fusions traditions that ground and itiform most Native American tribal medicine discourses. &eluding the sweat traditions of1lltD1J' Plains tribes. it remains difficultjor other Native peoples to continue traditions in Denver lost their vitality on reservations. Furthermore. of the conditions experienced by Native peoples are Westernized diseases illness for which there are no traditional ceremonies that can be used to CUTe.

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Numerous collaborators suggested creating a council regional elders who could help Native community negotiate and navigate difficult healthcare experiences in Denver metropolitan area as a resource organized network oj advocacy

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leadership. Here collaborator reacts to these other collaborator's ideas upon hearing them from me for the first time. Another collaborator here comments on how Natives in Denver utilize many non official or unrecognized resources eristing outside mainstream health institutions for illness treatment. They believe it would be difficult organize structurally institutionalize these people even though that might benefit more of area's Native population

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D.l.H.F.S. employs a youth prevention counselor who attempts to help Native being raised in Denver negotiate the difficulties operating in an urban environment as a Native American.

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The Native youth program offers important self-esteem training models that will allow today 's Native Americans living in Denver better preparation for acculturation ",ban landscape than past generations which should provitk a better foundationfor improved health as adults both physically psychologically.

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Although collaborators recognize the benefits of such pan-Indian phenomena like Native American Church opportunities to blend western biomedical care with Native driven healthcare traditions it does not represent a solution for everyone. Here a collaborator erp/ains how this cmif/ict exists on both reservations in urban areas. What is unique is this issue underwrites larger contertuai Native American issues such a navigating two cultures in America, identity health.

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Health issues for Native Americans in urban areas can be more complicated than for Indians in reservation settings (C/ork Mendoza 2001). For exmnple, Indian alcoholism in the urban setting is complicated by cultural alienation from the urban mainstream culture (Finco 2000: 104). Biomedicine has not a strong history in urban areas of being very receptive to urban Indians who are not of that heaJthcare system's economically oriented community structure. '1n Chicago, the Uptown hospital away Indian patients because they had no money to pay services. This was not an isolated situation since each city hod deal with a fundamental problem involving urban Indians in that the federal government had no designated services for Indians in cities the federal government expected urban Indians to seek health care like mainstream urban Americans" (Finco 2000: 112). '/his flies in the face of Native American oriented research which has concluded, "because of cultural values mainstream stereotyping, Indian find access to mainstream health care either difficult or impossible" (Keliiaa Fixico 2000:119).

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Many urban Native peoples are medically indigent and do not use the urban health facilities that other Americans granted as intentkdfor the general population (Sorkin The urban Indian populationfaces across the country significantly lower of health than that the prevailing non-Indian urban population (Rhoades 2000). Health care facilities in urban areas, both city, state county not with federal health service agencies to assume general cooperation in provision of services particularly in identifying meeting urban Indian health needs (Sorkin Fix/co 2000). A collaborator here provides a perspective on healtheare for Native Americans living in Denver during our interview. Native Americans encounter several impediments when seeking healthcare in the Denver Metropoliton area. .As discussed in more detail elsewhere in this paper communication misunderstanding between them biomedical practitioners, a of erperience the hospitaVinsurancelweljare bureaucracy all contribute to these phenomena. a more micro-level scale some Native simply move urban areas with a lock of basic indigenous or biomedical

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healthcare knowledge also are ignorant of the services that can be accessed at the Denver Indian Health Family Services Center. One practitioner comments here on economics of health for Natives.

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A collaborator who has lived in both Phoenix and Denver revealed that a problem for many Native Americans is assumption 1.H.S. insurance coverage and or facilities wililollow them to Denver One collaborator shares their history experiences in Denver as individual who has benefitedfrom single drug alcohol treatment center lor Native Americans in Denver who today, from experience following this individuDl, works ertremely organizing health lairs, creating educational programs at schools and providing some outreach to Native families in need 01 heaJthcare education. This job is, in mind, often overlooked, underappreciated incredibly undI!r-funded Still, seeing this Native person on responsibilities ofwhat should normally be organized

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implemented by a team of individuals i1lspired efforts to document provide a voice to these issues. This collaborator describes how their experience politics allowed the drug alcohol treatment center in Denver to be open only to Native peoples living on several southwest em reservations not to metropolitan Native citizens, many o/whom need these same health services.

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A second collaborator who has been employed by Denver Health as a clinician and has a strong background in bio-sc"nce illustrates despite this knowledge they still experienced some difficulties interacting with other biomedical representatives treoting their family members

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One problem many Native people experience as a patient in an urban biomedical facility tMir is importont to tM;r heolth they aTe always to themselves to people in the health care system. Generally more they to attempt to re-edacate on their iI2as less time allocated to each session and more opportunities for communication breakdown become available. A Native American hea/thcare worker at D.LH.F.S. explains.

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The problem for Native patients in biomedical clinical environments revolves around conflicting cultural systems that emphasize different values. Urban biomedical institutions emphasize speed, efficiency standardization while Native pan-Jndian cultures tend to regard patience, deliberation and well chosen discourse as the key to problem solving health issues. Even D.I.H.F.S. where culturally sensitive care is stressed their one non-Native clinician remarked that many urban Native patients do not share their traditional health and spiritual practices as fully with them as might with another Native person. I find most interesting is that this clinician not immediately see connection between !heir patient participating in the Native American Church their role in evaluating this patient's healthcare healing

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A collaborator here gives an example some experiences with biomedical physicians here in the Denver area.

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Prevention in the biomedical sense is not a well understood concept for many urban Native people. combined with an common tradition among many tribes to tolerate not in a western sense, but in a uniquely Native way leads issues with urban Indian health. A Native collaborator shares their experience on this concept.

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Learning ownership of health a difficult adjustment for Native Americans living in metro Denver. It is I believe healthcare institutional proctices fail to sense to the Native patient. It involves transitioning between the dichotomies of urban western healtheare, which is extremely individuDlistic versus reservation and indigenous originated and driven health systems which are communal in construction. You can inclUlk biomedical heaJthcore as represented by I.H.S. facilities which is to a lesser ertent still culturally more and inclusive of Native in 2005 than urban environments. collaborator shares their opinion on this topic.

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Many issues been identified concerning this topic. These issues include transportation around the city from places a/employment housing to the geographically disconnected medical social service facilities in the metropolitan area. Also, there are issues for Native people getting back andforth between the city reservation as well as navigating understanding how to use social services without having the benefit of prior experience in this enterprise in any conterl. A Native American health clinician at D.LH.F.S. illuminates these ideas below.

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A large proportion of Denver's Native American community finds itself at the lowest rung of the ladder according to several collaborators. This presents challenges to American seeking healthcare. Economic conditions underscored by a deep fear of falling into insurmountable debt from emergency room bills as so many their relatives friends from the reservation have done, prevent Native peoples from accessing appropriate biomedical care. One collaborator here explains the situation faced by many of their friends in their community. Financial illiteracy remains an important topic for Denver's Native community related accessing biomedicine. A collaborator educates me on this topic.

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A collaborator explains their impression of healthcare diJliculties that witnessed as a Native American living in Denver for In particular a regression of Native American urban health resources been experienced over this time period.

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In some Native American Denver resilknt's minds there remains an urgent need to implement cultural training/or biomedical clinicians that relates to the diversity II1Jiqueness 0/ the Native American patient

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In order for future biomedical educational training to effectively improve care Native American patients. communication skills, identity issues, the metaphysics of Indion cosmology must be fDMn into account. A collaborator odvised me here that communication issues between Native patients non-Native clinicians alongside institutional racIsm leveled towards Natives by non-Natives remain contemporary issues in Denver Healthcare.

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(subtle), A second collaborator comments on these same

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One collaborator states that based on their experiences living in Denver and worldng in the healtheare field they developed an idea that several other collaborators presented to me independently for improving health in their community. Although not unique to Native American comnnmity in Denver from a cultural perspective systemic issues uncovered by this group of collaborators are illustrative general malaise facing healthcare in urban environments. The refe"a1 process its related bureaucracy need to streamlined red

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must be eliminated between the Denver Indian Health Family Services clinic and local areas hospitab. The frustration duplication of the cu"ent situation is spelled out here by one D.LH.F.S. clinician who believes that the cun-ent system limits access for Native patients time related needs. D.I.H.F.S. clinicians realize their facility's own limitations need more comprehensive accessible cooperation community hospitalsfor their patients. ldeasfor solving these types of issues pressing on the community including designated D.LH.F.S clinic days in conjunction Denver Health and hiring a permanent medical liaison to coordinate healtheare activities were first presented in under the facilitated meetings between representatives of the Denver American Indian Community Denver Health. Unfortunately, much of the progress and vision these plans hos lost its direction focus since political disagreements led to the disintegration of participant group sponsoring the 10 Vision for American Indian Health Care in Denver. A theme emerged from several clinician patient dialogues is that a permanent andfully funded liaison position working independently in full complicity with D.I.H.F.S. and Exempla Lutheran. St. Anthony's, Denver Health University Hospitals to coordinate admissions, referrals clinician/patient education could bring about a large improvemenJ to the Denver area's Native American people.

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A Native American collaborator describes what they see as a void in communication between the hospital, patient community for urban Native peoples. There is an example given here on impact one person has mot:Ii! in volunteering to attempt to coordinate these resources to provide more culturally appropriate care. this example illustrates, I believe, is dire needfor more macro-level coordination of these social structures institutions in order to improve health care jor Native peoples living in the Denver area.

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Another collaborator shares some additional ideas here for improving healthcare for Denver's Native peoples.

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(Indian)

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Another collaborator here explains their model for improving Native American Health in Denver includes a discussion on identity and the need for spirituality in public health discourse for Native peoples. They also address the difficulty injecting Native spirituality into the urban health curriculum. The cherished liberal American principal of separating church state becomes an impediment for Native people are receiving or federal funding/or health programs not allowing them to religious or spiritual references in programs projects. This tenet also supports more fully funding increasing the I.H.S. reservation hospital level of core at D.I.H.F.S. in Denver in my opinion.

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The Denver Indian Health Family Services clinic does not only treat indigent Native American patients without health care coverage, but also Native patients with insurance seek culturally appropriate care. Currently D.I.H.F.S. ;s limited in its ability to grow and aggressively more Native patients due to several factors. First. D.lH.F.S. gets only 1 to of I.H.S. while the rest is earmarked for on reservation clinics. This is a historical reltztionship that needs remedy as majority of Native population taday lives off the reservation in urban areas like lJe1Iver. Secondly, current D.l.H.F.S. stqff is consumed economically and time-wise with their current patients. This /eaves the staf!without the appropriate time to complete documentation and research in order dnnonstrate a needjor federal let alone develop a

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marketing public relations campaign advertising their services. As tried to learn more about Denver area Native Americans I ojtenfelt it was a community without center. A people who overlooked by larger metropolitan area, despite this being the Cheyenne Arapahoe Indians traditional kInds, today's Native American community is not highly visible or celebrated in opinion by Euro-American Hispanic American communities that now dominate region. Denver Indian Health Family Services Center is one of a handful of community centers where contemporary urban Native peoples SllTTounded by a predominantly non-Native metropolitan community find the remain grounded indigenous expressions of individual cultural traditions. Some patients in waiting there this to say regarding my question of why they were at the clinic seeking healthcare. Patient #1 Patient Patient Patient Patient

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Shortly after speaJcing with these patients waiting to seen I with one of the clinicians D.LH.F.S. asked them what they thought could help improve the level of health care for coming to their clinic.

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Coordinating patient care between Denver Indian Health and Family Services D.IH.F.S. Denver Health is a thorny topic as evident by many collaborators. Repairing and strengthening this relationship will, according to several individual colloborators, represent an Immediate opportunity for positively impacting the healthcare of many Native peoples. Overcoming access issues for patients are not residents of the city county of Denver perhaps by setting up a formal partnership on Native American community health between Denver Health University HospitIJis for those metropolitan patients are cu"ently falling between the cracks of the system appears to the potential to be ertremely beneficial.

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Some Native peoples had positive erperiences with health care at Denver Health. One collaborator has sIDled that as a Denver Health employee a great deal of difficulty coordinating care for D.IH.F.S. patients the past because so of them lived in the city and county Denver. Despite the recent setbacks on the ten year plan/or American Indian Healthcare in Denver due to politics, economics lock of long term funding stability, this collaborator believes that creating a permanently funded metropolitan Native liaison position/or the community's Indian population would be a great idea/or improving healthcare access.

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D.I.H.F.S. follow of the rules Imposed through the federal bureaucracy triba/laws on lH.S. reservation facilities regarding who can and cannot receive care. It causes Native peoples a great deal of dJ.fficu/ty in getting culturally appropriate care in the Denver area. One collaborator provides some background on this current situation.

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