Notes on Native American Heritage Month
What We Are Learning Along The Way
For those joining us for the first time — welcome! To those who’ve joined us since day one, thank you for your commitment to diversifying our nursing narrative.
Attend the 7th Annual Native Nations Nurses Summit on Nov 19th , 2021.
The first attempts for honoring Native American heritage and culture can be traced back to the advocacy and efforts of Native Americans in the early 1900s. Early proponent and archeologist Dr. Arthur C. Parker, born in the Seneca Nation in 1881, successfully worked with the Boy Scouts to create an annual ‘First Americans’ day and sought to use museums as a medium of disseminating cultural pride. A Welch-Blackfoot tribesman named Red Fox James rode horseback from state to state in 1914 in order to obtain endorsements from 24 state governments to approve a day honoring Native Americans. And in 1915, the Congress of the American Indian Association declared the second Saturday of each May as ‘American Indian Day’ and also appealed for the U.S. government to grant Native Americans full U.S. citizenship. The first “American Indian” day is recorded as being celebrated in New York in May 1916, but it would take until 1924 for the Indian Citizenship Act to be passed granting U.S. citizenship to Native Americans, and until 1962 for the right to vote to be secured to Native citizens in every state.
As the decades passed since 1916 without an established federal holiday, recognition of Native American culture and contribution were mainly established at the state level on varying dates and months throughout the year. In the 1930s, during a time of high Italian discrimination in the U.S. and under Italian diplomatic tension, a one-time holiday honoring explorer Christopher Columbus was celebrated, which became a permanent holiday in 1934 and a federal holiday in 1971, during which Native Americans protested the designation:
Their leader, wearing a Chippewa tribe ceremonial headdress, called Columbus Day a day of mourning for Indians until “we are given the same opportunity to achieve the same social, economic and educational levels as the rest of those who call themselves Americans.” — Washington Post
In 1986 a designated week, from Nov 23rd — Nov 30th, was federally established as “American Indian Heritage Week to recognize Native Americans as the first inhabitants, explorers and settlers of the lands that would become the United States” and since 1990, proclamations have been issued by every administration to designate the month of November as National American Indian Heritage Month to honor the past, present and continuing contributions Native Americans have made to the country. National Native American Heritage Day has also been declared on the day after Thanksgiving. Starting in Berkley, California in the 1990s, the celebration of Columbus Day has begun to be replaced with celebrations of Indigenous Peoples’ Day by states, institutions, and local districts. While Columbus day remains a federally designated holiday, the administration proclaimed Columbus Day 2021 as a day of reflection.
Indigenous people originally inhabited — and continue to live— on their land that spans the entirety of the geographically diverse continent of the Americas, Pacific Islands, and the Caribbean. Globally, Indigenous people and tribes reside as far north as Greenland and as far south as New Zealand. Even with traditions so steeped for millennia in oral culture, theirs is a knowledge and history so vast it is uncontained in an entire library. This brief overview describes aspects or moments of Indigenous history as it relates specifically to U.S. professional nursing. It is designed to serve as a companion aid to share what we have learned thus far and address gaps found in present-day nursing curriculum. This overview is by no means definitive and, in truth, barely scratches the surface of a peoples’ history which pre-dates the founding of the U.S. by thousands of years. The goal of providing this overview is to more aptly frame the events that unfolded in the background and foreground of our subsequent nurses’ stories.
Some History You Should Know
The following sections describe:
- Native American Tribes and Population
- Health & Healing Practices
- From Boarding School to Nursing School
- Native American Nursing Workforce
Native American was primarily selected as a population identifier throughout this overview for consistency with Native American Heritage Month. Please note that numerous nursing texts, articles, and organizations also use American Indian and Alaska Native interchangeably to distinguish between Alaskan and American Indigenous tribes and for consistency with U.S. legal terminology. Updates or revisions are welcomed and will be added accordingly. This overview is intentionally a work in progress. Join the conversation by sending articles/edits to nursesyoushouldknow@gmail.com.
Trigger Warning: Please be advised that this overview mentions violence, forced separation of children from their families, un-consented sterilization, and other heinous acts committed by the U.S. government, as well as some unsettling public notices and graphic images.
Native Tribes & Population
Indigenous people have lived across the vast American continent for at least the last 15,000 years. In contrast, European settlers and Africans have been here for roughly 500 years. It is only in the these last five centuries that diseases such as small pox, measles, diphtheria, heart and cardiovascular diseases, obesity, diabetes, and alcoholism emerged to negatively impact the Native population. While exact figures are unknown, pre-European contact, the Native population has been estimated at tens of millions. Native Americans were not counted as part of the U.S. Census until 1860, eighty years after the Census began. Centuries post-European contact, the population was estimated to be as low as 90,000 from the U.S. Census of 1900, although undercounting remained documented for well over a century. As recently as 2010, the Census Bureau reported an under-counting of Native Americans by 4.9% (double other populations). Among other factors, Native Hawaiian or other Pacific Islanders were not counted until 1960 and Hispanic or Latino people were counted once in 1930 but not again until 1970, both of which account for Indigenous ancestry. This 2020 article from Indian Country Today provides an in-depth and fascinating history of the Census as it relates to the Native population.
Thousands of years ago, before the United States was even an idea, the first census took place. Indigenous peoples took count on rocks, buffalo hides, petroglyphs and more — Jourdan Bennett-Begaye
As of 2020, there are currently 574 federally recognized Native tribes in the U.S., over 200 of which are in Alaska alone. Federally recognized Native tribes can be found in 34 states. A total of 14 states recognize 66 tribes that have only state, but no federal, recognition. According to the 2020 U.S. Census, Native Americans now comprise 2.9% of the U.S. population, which is an increase of 86.5% from the 2010 census, the largest jump in modern history. The Navajo nation (aka Diné) has become the largest enrolled population among the tribes, with the largest contemporary contiguous land base that spans 16 million acres across three states — New Mexico, Arizona, and Utah — and is about the size of West Virginia.
Indian country describes the regions of self-governing designated Native American communities that encompass where Native Americans reside in the United States. Alaska (27.9%), Oklahoma (17.4%), New Mexico (14.5%), South Dakota (12%), and Montana (9.2%) are the U.S. states with the largest percentage of Native Americans. The map below represents Native tribes and locations without U.S. state boundaries imposed on the population.
Native Americans more broadly use a total of a dozen cultural territories that supersede U. S. state boundaries and are considered geographically or culturally adjacent areas, or both. The regions include:
- United South & Eastern
- Oklahoma Area
- Albuquerque Area Southwest
- Navajo
- Inter-Tribal Council of Arizona
- California
- Northwest
- Alaska
- Rocky Mountain
- Northern Plains
- Great Lakes
- Urban
Urban is used to describe the migration from the reservations to urban centers, which began as a U.S. policy in the 1950s, though more Native Americans increasingly choose to live off the reservation than on. Over centuries, these tragic maps also show the amount of total land annexed to the U.S. since settlers arrived on the continent (essentially the entire U.S. and most of the continent). The map below details the current footprint of self-governing Native American territory in the U.S. today, which comprises 2.6% the size of their historical land:
In The Indigenous Peoples’ History of the United States, author Dunbar-Ortiz describes the direct connection between the religious wars in Europe as a way to expand kingdoms to the genocidal tactics of Euro-American colonialism as a strategy to expand United States territory (page 39). The trajectory of Native American landholdings illustrates the impact of this strategy: Native Americans held 156 million acres of land in the 1880s, had decreased to 50 millions acres by the 1930s, and lost an additional 500,000 acres seized by the government during World War II. By 1955 their landholdings had shrunk to 2.3% of its original size as a result of U.S. Indian Termination Policy. As Dunbar-Ortiz explains:
“Everything in U.S. history is about the land- who oversaw and cultivated it, fished its waters, maintained its wildlife; who invaded and stole it; how it became a commodity (“real estate”) broken into pieces to be bought and sold on the market
…To say that the United States is a colonialist settler-state is not to make an accusation but rather to face historical reality. Settler colonialism…requires violence or the threat of violence to attain its goals…Euro-American colonialism, an aspect of the capitalist economic globalization, had from its beginnings a genocidal tendency…The peculiarity of settler colonialism is that the goal is elimination of Indigenous populations in order to make land available to settlers” (Dunbar-Ortiz, p. 7–10). During the Postbellum period after the Civil War, federal Reconstruction laws that required equal justice toward African Americans did not extend to Native Americans. As a result, when whites found gold on Indian land in Colorado and Dakota, they took it, leading to the final Plains Indian wars.
Centuries of efforts by the U.S. to impose, annihilate, appropriate, or assimilate Native Americans have included, but are not limited to, the seizure of land; enslavement; massacres; restriction of rights, citizenship, language, cultural, traditional healing, and religious expression; limitation of economic opportunities; forced relocation; forced sterilization; forced removal of Native children to Boarding Schools; the imposition of Christianity and alcohol; sexual violence; the intentional spread of contagious disease; destruction of food, water, and shelter; offering of Indigenous land for American settlements; and the breaking of hundreds of treaties. Vast and prolonged efforts to define, stereotype, and dehumanize the Native American population to obtain yet more access to Native land persists today. These tactics — and the generations of trauma, health impact, and vulnerability to climate change destruction resulting from them — are inextricably linked to Native American health and professional nursing issues.
The U.S. Constitution did not provide for the continued existence of Indian tribes (Moss, p. 22). As such, the impact of centuries of broken treaties and egregious tactics have led to the Native American population being America’s most regulated people — with dual U.S. and Native tribe citizenship. Navigating the complex intersection of federal, state, and tribal laws and programs is a shared lived experience among Native Americans with significant healthcare implications. Leading to the complexity of legal arrangements is that the definitions of tribes and Native Americans have been, and are, defined by the logic and interests of non-Native U.S. Congressional members.
To frame the contents of this overview, the following periods of federal government policy are useful to best contextualize healthcare implications, nursing education, and the time and place of our nurses’ stories:
Health & Healing Practices
Indigenous health and healing practices pre-date Western healthcare by several millennia. Much of the literal erasure of Native land across what are now the Americas corresponds with the real and threatened erasure of languages, ethnobotany practice, healing culture and knowledge, and the subsequent lack of awareness of Indigenous contributions in our mainstream media, culture, politics, healthcare, and education. This section will detail the innovative traditions of healing that are rarely recognized as originating from Indigenous culture(sourced from p. 39 and 179 American Indian Health and Nursing, page 42–43 of this 2004 article and this 2017, and 2019 article):
- Syringes / Hyperdermic Needles: Used from sharpened hollow bird bones attached to small bladders to inject medicine, irrigate wounds, clean ears, or for enemas.
- Baby Bottles: The Seneca tribe used washed, dried, and oiled bear intestines with a bird quill attached as a form of nipple which mothers could fill with a mixture of pounded nuts, meat, and water.
- Pharmaceuticals / Oral Contraception: Ethnobotany experts have documented how North American Indians have medicinal uses for over 2,000 plant species, hundreds of which are currently part of national formularies, U.S. Pharmacopeia, and best selling pharmaceuticals. Herbs to prevent pregnancy date back to the 1700s (centuries before biomedical options). As examples: The Shoshone used Lithospermum rudeale, while the Potawatomi used the herb dogbane.
- Antibiotics: Bacterial killing substances found in plants were used widely to prevent or treat infections.
- Anatomical Knowledge & Hemostats: Structure and function of the circulatory system was understood with the identification of which plants served as hemostats to slow or stop the flow of blood from incisions or wounds.
- Surgery & Asepsis: Sterile conditions during surgery, human hair used for sutures, and effective puncture practices to remove fluid between the chest and lungs or treat hydrocephalus were some of the native surgical advancements, as well as treating fractures, the use of prosthetics, and removing arrows and bullets. Wounds were also cleaned with sterile (boiled) water to prevent infection, which would not become widespread in western medicine until the 1900s.
- Anesthetics: Dating to 1000 B.C., Native healers used such as peyote, coca, and daturas pain relievers and for anesthesia during surgery.
- Sunscreen: Numerous tribes identified natural resources to prevent sunburn including western wallflower (Erysimum capitatum), petroleum jelly, fats from animals, and oil from fish or plants, as well as the use of aloe vera for treatment.
- Suppositories: To treat hemorrhoids, a small plug with medicinal properties was made from the dogwood tree (Cornus paniculata) that could be moistened, compressed and inserted for relief.
- Mouthwash / Toothbrushes / Dental Fillings: Numerous tribes used herbs in solution to soothe babies gums during teething and treat canker sores and sore throats. Teeth were polish were salt, charcoal, or the frayed end of a stick. Mayan dentists drilled and filled cavities and also inserted turquoise, gold, or jade inlays for fashion.
- Cataract Removal: Obsidian scalpels were used to remove cataracts as a tool sharper than metal.
- Public Health & Quarantine: Tribes practiced isolation for patients with contagious illnesses to prevent the spread of disease and employed street cleaners and other community-based approaches to public sanitation.
- Midwifery: Women across native cultures are viewed as life givers with pregnancy and birth perceived as sacred and ceremonial in nature. Native midwives were called to their role or apprenticed through family members. In Navajo culture, midwives were referred to as “baby medicine women” or “umbilical cord cutters.” Birth traditions vary across tribe and region. Prior to hospital-based births, labor and delivery may take place in designated “hogans” or on a bed of warm sand. Women from the tribe would be present for support and medicinal teas and herbs were used for relaxation, induction, or pain relief.
An underlying healing philosophy of health across tribes and regions is that of holism, which has been noted as complimentary with the metaparadigm of nursing (health, person, nursing, and environment). The Native Medicine Wheel represents the circle of life, the four directions, and includes inter-related aspects of internal and external forces that impact the health of an individual. A wheel can include Stages of life (birth, youth, adult (or elder), death), Seasons of the year (spring, summer, winter, fall), Aspects of life (spiritual, emotional, intellectual, physical), Elements of nature (fire (or sun), air, water, and earth), Animals (Eagle, Bear, Wolf, Buffalo and many others), and Ceremonial plants (tobacco, sweet grass, sage, cedar).
The aspects of the medicine wheel provide a spiritual foundation for Native prayers, songs, dance, and teachings, and inform traditional beliefs on thinking, planning, life essence, values, and faith. While medicine wheels are a widely depicted Native American imagery found throughout fashion and popular culture, its ubiquity underlies the revered and sacred status of medicine wheel sites which date back thousands of years, and hundreds of which remain in tact. Bighorn Medicine Wheel in northern Wyoming, for example, has been dedicated and protected for over fifty years as a site of Native and non-Native pilgrimage for pipe ceremonies, sweat lodges, and vision quests. More than 80 tribes pilgrimage annually to the “chapel in the wilderness” to pray for loved ones, for wisdom, for strength.
The medicine wheel is significant to the Earth, cosmos, our religion, and our way of life. The sacredness of the medicine wheel is the equivalent of the Vatican, of Mecca, or of other institutions’ places of worship — Manny Pino, Acoma Pueblo (page 40)
Despite preservation for some sites, many sites have been vandalized, destroyed by federal land managers, or targeted for logging, tourism, mining, ski resorts, or development. “The battle over sacred sites dates back more than a century, when the government forced Indians onto reservations and ordered them to abandon their religion for Christianity. After Congress passed the American Indian Religious Freedom Act in 1978, Native Americans returned to their religious sites — many on government-owned lands — to find some damaged by commercialism. [Despite lawsuits] courts ruled the religious freedom act did not prevent the government from doing as it pleased on its lands.” Land disputes continue through the present day.
From Boarding School to Nursing School
The educational model for Native American cultural annihilation emerged in the colonies when the Continental Congress passed a bill in 1775 to appropriate $500 to educate Native American youth. By the early 1800s the Fund for Civilizing Indians was created wherein missionaries were paid by the government to assist with the “civilization” mission. The Bureau of Indian Affairs was established in 1824 in part to allocate funding and oversight for what would become a system of hundreds of schools across 29 states. The Bureau of Indian Affairs was a division within the U.S. War Department until it was transferred to the Interior Department in 1847 (where it is still resides today). By the late 1800s, a total of 24,000 children had been enrolled with a funding of $2.6 million and by 1887 Congress passed Compulsory Indian Education Law with the Bureau of Indian Affairs sent to patrol reservations for children to send to boarding schools, often at gunpoint. The U.S. continued to support and fund Native boarding schools for over a century and a half (this also occurred to tribes across Canada).
The decades between 1890–1940 are generally considered the “nadir of American race relations”(coined by Historian Rayford Logan), a phrase that describes the period following Reconstruction when racism and white supremacy was the most pronounced it had been during any other period in the nation’s history. This period saw a fervent rise in the triple threat of nativism, eugenics, and imperialism. For formerly enslaved Black Americans this meant the enforcement of Jim Crow, the rise of the KKK, and the rescinding of citizenship and voting rights endowed to Black men from the 14th amendment; for immigrants it meant quotas, a preference for European immigrants, the U.S. takeover of Puerto Rico and the Philippines, and the Chinese Exclusion Act; and for Native Americans it meant being perceived as savage and unworthy to inhabit their own land — in other words, the beginning of what is known as the Allotment and Assimilation Period of U.S. federal policy (policy periods are listed in the Native Tribes & Population section above).
With the first Nightingale schools opening in New York, Boston, and New Haven in 1873, it is in this precise context of the “nadir” of American history that the profession of American nursing begins. The same year of the origin of professional nursing schools in the U.S., Field Nurses were introduced on Native reservations as a way for Native American women to be trained to promote a Western healthcare model and the use of early Indian Health Service hospitals over traditional Native healing methods. While the result was a hybrid nursing style that combined and accommodated both Native and Western healing, the strategy of deploying nurses and nursing schools as a more benevolent version of cultural imperialism had already been used in Britain across its empire and in the subsequent decades would be used systematically by the U.S. in Mexico, Cuba, Puerto Rico and as far away as the Philippines and India. By 1890, Field Matrons were established by the Bureau of Indian Affairs which employed white women (non-nurses) as “agents of civilization” with the goal of “civilizing” Native women with skills of domesticity who, in turn, could influence male tribe-members to accept Euro-American ways of life and gender norms. After thirty years white Matrons were replaced by white Field Nurses (non-licensed) or Public Health Nurses (those with a registered nursing license).
- Native Boarding Schools
Well before and persisting after the “nadir” of American racial history, the U.S. government and a multitude of states passed policies such as Indian Child Removal Act starting in the 1880s through 1950s to force Native children to attend boarding schools designed to accelerate assimilation to Anglo-Christian values, norms, and language. Presbyterian, Catholic, Christian Reformed, and Methodist missions were tasked with establishing and staffing the schools. Estimates suggest that by the 1920s nearly 83 percent of Native American school-age children attended such schools where their hair was cut, names were changed, corporal punishment was deployed, and their languages, religions, customs, and songs were prohibited.
The teaching prepared students to master English, religious and cultural assimilation, and take on jobs of common laborers on which to occupy the “lowest rungs of society” (Charbonneau-Dahlen & Crow, 2016). The schools adhered to Christian and Victorian-era gender norms. Male students were taught farming, carpentry, and metalwork. Female students were taught subservient domestic tasks such as cooking, sewing (in contrast to their culture of weaving), or the necessary preparation to enter nursing where they could then serve the Field Matrons when they returned to their reservations and serve in the Indian Health Service. Many children contracted contagious diseases and died while at the school (though exact numbers are still unknown — see footnote at end*), making it necessary for the school’s hospital to train high school students to assist and care for their ill peers in the hospitals or sick wards. Perversely, this served as pre-nursing training.
Between 1888–1895, a half a dozen Native American boarding school graduates became the first known nurses to graduate from Nightingale nurse diploma schools (some of which will be profiled in this project), but as with other non-white students, they were not broadly admitted to all nursing schools. In 1891, admissions of Native American nursing students were extended at Hampton Training School for Nurses, which opened in 1868 to educate previously enslaved Black Americans following the Civil War. Native American nurses would go on to serve in World War I , World War II, in the Red Cross, as well as in the Indian Health Service.
Spurred by the 1969 U.S. Senate Report titled Indian Education — A National Tragedy, A National Challenge, national recognition of the harm of the schools resulted in systematic closures over the subsequent decades. The ultimate closure of boarding schools left behind physical infrastructure that would sometimes be converted for health purposes. For example, a 1898 boarding school in western Rapid City, South Dakota was converted to a Native American tuberculous hospital and in the 1960s became one of the first hospitals run by the Indian Health Service. However, while boarding schools ultimately all closed by the 1980s, a subsequent wave of child separation began from the 1950s — 1970s through the Indian Adoption Project which was funded by Bureau of Indian Affairs and the Child Welfare League of America to support the needless removal of Indian children from their homes, often based solely on poverty, and placed Native American children with white families to encourage assimilation to mainstream culture. In Minnesota alone from 1971–1972, 13% of all Indian Children (25% of Indian Children under age 1) were in adoptive homes and 90% of placements were in non-Native homes. In 1978 Congress (H.R. Rep. 95–13896) enacted the Indian Child Welfare Act (ICWA), stating:
the wholesale separation of Indian children from their families is perhaps the most tragic and destructive aspect of American Indian life today
While the Act declared tribal courts as the best decision makers regarding the interests of Indian children with maximum effort to keep children in the same tribe, twenty years after the Act was passed, the need for legal centers to ensure it is upheld still exist. The issue of missing Native Americans has become a higher national priority after a 2019 task force established the disproportionate rates of missing and murdered Indigenous people, and led to the designation of May 5th as Missing and Murdered Indigenous Persons Awareness Day in 2021.
- First Native Nursing School
The region now known as Ganado, Arizona had been inhabited for generations by Indigenous people who defended their land against Spanish, Mexican, and American forces until their forced deportation in 1864 during the U.S. policy period of Removal and Relocation. Known as The Long Walk, the Navajo (aka Diné) were forced to walk from Arizona to Eastern New Mexico and were not legally able to return until 1868. By 1869 the Ganado area was fully occupied by the U.S. government. As occurred on many occupied Native territories, funding and land were instead given to Christian missionaries to enforce “civilizing” missions and cultural assimilation. This occurred in Ganado when land was given to a Presbyterian mission starting 1901. In the first years, they worked with the Navajo to construct a meeting house, day school, dining hall, farm, and church. The first hospital at the mission was established in 1911.
The early decades at the turn of the 20th century coincided with major flu, typhoid, and diphtheria epidemics, which necessitated a need for trained nurses across the country. The co-dependent model at this time made hospitals dependent on the students of Nightingale training schools to provide free labor in service to patients and physicians, and the nursing schools dependent on hospitals for funding. Clarence and Cora Salsbury, a Canadian physician and nurse-trained wife with over a decade of experience serving as medical missions in China, were recruited to establish a three-year accredited nursing program at Ganado Mission in 1927. The physician’s first impression was finding deplorable conditions in a hospital operated by the Bureau of Indian Affairs that was more than past capacity with inadequate housing for nurses and:
“a couple of nurses were doing all the work at the little hospital. I didn’t know a thing about Ganado or about Indians, either” (Trennert, 2003, p. 354)
Yet together they led the first reservation-based Native American nursing program for the next 23 years. Much written on the nursing school is gathered from oral histories, archives, and letters written by the Salsburys. Much of the correspondence is from Clarence, as nurse training and curriculum were generally dictated by physicians until the 1960s. While Cora is described as “shrewd with a practical intellect,” less is known about her nursing perspective and her specific view or experience of the school. Within three years of their arrival, they were able to fund what became the most advanced medical facility on the reservation and the first reservation hospital in the country to be accredited by the American College of Surgeons. Sage Memorial Hospital, opened in 1930, was a 75-bed hospital with a surgical unit, laboratory, and x-ray department (the first in 26,000 square miles) in which the nursing students could apprentice. Unless otherwise linked, most information for this section is credited to the recently published Medicine Women: The Story of the First Native American Nursing School by Jim Kristofic.
With a new hospital came the meeting between a community accustomed to Navajo healing culture with the norms of western medicine. Beds were not traditionally used in the home and it was perceived as lazy to lie down during daytime, odder still to have one’s movement restricted. The questions peppered by physicians were seen as a weakness that they could not intuit the underlying issue as they were accustomed with shamans, stargazers, or tribal medicine men. The intimacy of care provided in their home was replaced by clinical interactions with strangers. Prescribed treatments could become lost in translation. Perhaps most importantly, superstitions around proximity to death kept patients from seeking care in a place where known deaths had occurred and was akin to voluntarily going to a haunted house. A nurse writing about the experience in 1938 wrote the “colossal egotism and know-it-all attitude” of Americans presumed Navajos should discard their ideas in five minutes. “But instead…we must try to give them knowledge in the place of signs and beliefs” (p. 119). Gradual acceptance by influential Native healers of certain illnesses or surgeries best fit for the hospital helped to gain community acceptance of when western medicine could be integrated without spiritual or cultural compromise.
A year after the hospital was built, a more home-like student dorm was constructed for the nursing students to live. A year after that, the school was granted full accreditation by the Arizona Board of Nurse Examiners, which meant its graduates were eligible to sit for the registered nursing license in Phoenix — both students passed the exam “with flying colors” on their first try. By 1939, the hospital had grown to 150-beds admitting over 1500 patients a year and a new dormitory named Florence Nightingale Lodge was furnished with Navajo rugs and decor to accommodate the growing nursing school. In 1944 Mary Kobara, an American-born Japanese women who had been held at an internment camp near Tucson during World War II, graduated from the school as part of the U.S. program to train young, single Nisei women as nurses. The year she entered the school, she joined a class of Native American, Spanish American, Cuban American, and Mexican American nursing students. She was nominated by her class and hospital staff to be gifted with a full luggage set and instrument kit for her future travels following graduation and went on to became the only nursing student to achieve a perfect licensing exam score in the state.
The Ganado Mission High School, a Presbyterian and English based institution taught by missionaries, was just graduating its first class when the nursing school had opened. While this ultimately created a feeder to the school (its first two nursing students had graduated from there), there was no other Native American nursing school and the initial programs established by the Bureau of Indian Affairs — nine-month courses to become licensed practical nurses — limited their employment to only government hospitals. Word spread about the program in the coming decade and students from over fifty Native American tribes, Black Americans, and bilingual students from Spain, Mexico, Cuba, China, Japan, and the Philippines, attended without facing the prejudice of other nursing schools at the time. The mission also became known to physicians from the clinical conferences it held and were known to attract doctors from across the country and became a place where Catholic, Jewish, Chinese, and Christian doctors could freely learn from one another.
To be accepted to the school, students needed to be between 18–30 years old, with 4 to 5 letters of recommendation, and a year of chemistry and algebra. As a mission-based school, nurses were seen as essential, in equal measure, to both caring for patients and delivering the word of God to them. As customary of Nightingale schools at the time, students were strictly supervised from 6 am through 10 pm in isolation from both family and potential suitors and made their own uniforms. The curriculum was a mix of courses and devotion to Christian prayer and medicine with a six-month probationary period before students attained their nursing caps.
The requirements included 105 hours of anatomy and physiology, 75 hours of chemistry, 45 hours of microbiology, 15 hours of professional adjustment, 200 hours of nursing arts (wound care, massage, personal hygiene), 36 hours of psychology, 60 hours each of obstetrics and pediatrics, 60 hours of nutrition, foods, and cookery, gym, and courses in communicable diseases; ethics, drugs, and solutions; treatments of illness; and the history of nursing. The curriculum omitted the practice and philosophy of Native healthcare and replaced its legitimacy with western medicine. By their third month they spent time supervised on the hospitals wards. As in boarding schools of the time, students provided manual labor to run the hospital, especially on the night shift, without wages or allowance.
The mission was self-sufficient, growing and cooking all of its own food, with farming part of the unpaid work of the Mission’s day and high school. The low rates of malignancy, diabetes, and low blood pressure on the Navajo reservation at the time motivated Dr. Salsbury to conduct preliminary studies to see if the vegetable, fruit, and whole animal diet was correlated with improved health. Collecting data on 25,000 admissions, he found the rate of cancer was three times lower on the reservation than published data from Philadelphia at the time. Though he presented his findings to physicians at UCLA, subsequent publication is unknown. While he advanced Anglo-Christian views and leaned on the popular tropes of primitivism from his time, over the decades he and Navajo medicine man Red Point worked closely together at Ganado, with Red Point attending the nursing school graduations. An empathy and advocacy became apparent throughout his letters, with the acknowledgement that Navajo omens and taboos made as much sense as anyone else’s superstitions and that Native Americans had an equal capacity to work as nurses. According to Medicine Women: The Story of the First Native American Nursing School, he wrote it was:
disheartening to see how misunderstood the Navajo people were. Hardly anybody took the trouble to study them with an open mind…many things in the Navajo culture are admirable and should be preserved. Their religious beliefs are firmly entrenched and have been for thousands of years, and while you or I can never accept or adopt it, it has been their mainstay for ages. So while we cannot accept it, neither should we ridicule it…without seminaries, they were ministers. Without medical school, they were physicians. Without Freud, they were psychiatrists…It was only a short time ago that our medicine was almost as primitive” (page 99–100)
By creating mobile vaccination clinics to tour the reservation in a station wagon and visit residents in their homes, nurses gained further integration with the community and the community needs, in turn, informed their practice. Before the school closed, over twenty years and over 150 nursing graduates later, Ganado Mission had transformed from a desert outpost into a nationally recognized institution, attracting visitors such as Dr. W. Mayo of Mayo Clinic Foundation fame. Graduate nurses took work at Sage Memorial or at Presbyterian hospitals across the country; took roles in the Army, Navy, or the Red Cross; returned to their reservations, or to Cuba, to work as public health nurses; or became nurse missionaries. When the Salsburys retired, the school was converted in the early 1950s from a three-year registered nurse program to a licensed practical nurse program by the Bureau of Indian Affairs.
Sage Memorial Hospital still exists today as a 25-bed, community-owned, non-profit that serves thousands of Hopi and Navajo patients. It is the first Native-managed private comprehensive health care system in the country and the only Native American hospital to hold both a license from the Arizona Department of Health Services and Accreditation from The Joint Commission. It has been managed since 1978 by an independent, entirely Navajo Board of Directors.
Native American Nursing Workforce
Although the first nursing schools opened in the Northeastern U.S. in 1973, Native Americans did not gain citizenship until 1924. During these decades nursing schools did not yet exist on reservations, but interested students were ineligible to attend other nursing schools without full citizenship status. Even after citizenship was granted, the Bureau of Indian Affairs mainly hired white nurses and physicians to staff reservation hospitals (today hiring preference is given to Native American staff and clinicians).
The first nurse-training program course funded by the Bureau of Indian Affairs in the 1930s was at the Kiowa Indian Hospital in Oklahoma. At the time it was nine months, lacked accreditation, and students graduated with a practical nurse license. The Ganado Mission nursing program opened during the same time. All graduates passed their registered nursing exam to be licensed registered nurses and 40% of its graduates served in the military during World War II. That it closed and was converted to a licensed practical school in the 1950s wherein graduating nurses would not be eligible to become registered nurses speaks to the expectations and capacity of the Bureau of Indian Affairs during the mid-twentieth century. The differing ideology between a missionary-led, religious based education or a Bureau-led, secular nursing education during the early decades of professional nursing are detailed here.
During the same time period, the U.S. was able to build and fund the corollary predominately white, female American nursing workforce in to order to support the Spanish-American War, World War I, World War II, and the national expansion of the U.S. hospital system following the Hill-Burton Act. Paradoxically, some nursing institutions, in Appalachia Tennessee, for instance, barred Black Americans from being eligible for admission, but accepted select Cherokee nurses as early as the 1930s. While in states like Virginia, which passed the Racial Integrity Act, Native Americans’ status in a binary “white or colored” categorization based on the one drop rule, arbitrarily designated them as “colored,” thus obliging them to the same nursing school admissions discrimination until the passage of the Civil Rights Act. Thus, both de jure and de facto segregation across the country functionally limited the gained professional status of nursing to white female nurses between the 1870s and the 1960s.
By mid-century, nurse leaders in mainstream white America would establish the community-college based Associates Degree in Nursing to replace diploma schools (of which Ganado Mission essentially functioned in practice decades earlier), advance the idea of nursing as a Baccalaureate degree, and shortly after develop the first Master’s prepared nurse practitioner programs. These nationwide educational progressions belied the discrimination that initially existed, even at the community college level, for non-white students until the post-Civil Rights era. Meanwhile, during the same time period, reservation education stagnated and regressed its nursing educational offerings. In comparing the access to nursing education for mainstream white Americans, the historical evidence is plain that the U.S. concurrently delayed and made insignificant investment to build and support the Native American nursing workforce during the early and mid twentieth century.
In reviewing the periods of U.S. Native American policy it can be argued that the multiple centuries devoted to assimilation, removal, and termination of Native Americans made the provision and funding of health services overall — and investment in nursing education specifically — an inherently counter-logical effort during these eras. As was the case with midwifery practice across the country in the early to mid-20th century, a 1942 law required indigenous women from reservations to travel to hospitals for delivery because their traditional methods of delivery were outlawed (Medicine men and healing practices had already been subject to bans and imprisonment for fifty years prior, including outlawing of herbal remedies). When Congress transferred total responsibility for Native American health from the Department of the Interior to the Public Health Service in 1955, the newly established Indian Health Services (IHS) became responsible for supporting facilities and providing healthcare services during what is now know as the Termination Period. A first step was, in fact, to close down hospitals.
The IHS began providing family planning services for Native Americans in the facilities that remained in 1965, under the authority of the Public Health Service and funded by Medicaid and the Indian Health Services. However this resulted in uninformed sterilization procedures during the sixties and seventies, estimated to have affected approximately 25% of Native American women or more between the age of 15–45, some of whom included Native nurses. Historians report that forced sterilization emerged from the Eugenics movement as far back as the 1930s, but became more systematic after 1965. Women of All Red Nations (W.A.R.N), founded in 1974 and others, organized to put pressure on Congress to enact new regulations to protect Native women. In 1976 the U.S. General Accounting Office admitted that during a three year period in the 1970s. 3,406 Native American women underwent coerced sterilization procedures, of which 36 women were under the age of 21.
History shows that nursing education typically expands or contracts in relation to healthcare crises, surplus, and shortages, but Native American healthcare during this time was perceived less as a tool for improving health requiring a skilled workforce, than as an agent of surveillance and reproductive control. In fact, nurses who were able to obtain their license were frequently assigned to different reservations by the Bureau so as to reduce their cohesion with their tribe and reduce the presence of potential whistle blowers. This was contrary to the needs of the Native community who preferred access to nurses from their tribe which served to aide in self-determination of their health services.
When I began researching the history of pregnancy and childbirth on Indian reservations, Native American nurses were not on my radar. Years later, I have concluded that these women were key historical figures in the evolution of Native women’s reproductive experiences over the course of the twentieth century. Through their presence and their labor, Native nurses helped shape patients’ experiences of government hospitals. They served as cultural mediators and often as patient advocates and watchdogs. At key moments in Native American history, their status as “insiders” within the federal medical apparatus spurred Native nurses to activism - Brianna Theobald
Indeed, despite the barriers to education, there were enough Native American nurses by the early 1970s to form their first professional organization, the American Indian Nurses Association (AINA), which sought to mitigate health disparities, maleficent treatment, and expand the Native American nursing workforce.
Ironically, during the time of IHS’ criminal behavior, the white mainstream nursing profession sought to address care gaps in underserved populations. After starting the first nurse practitioner program in 1965, more than 200 nurse practitioner programs would be available with more than 15,000 nurse practitioners serving the nation by the early 1980s. However, the first Baccalaureate nursing program on a reservation was not established until 1996 in Northern Arizona (near Ganado Mission), with no current nurse reservation-based practitioner programs. This is a limiting factor for reservation students outside of Arizona to access a Baccalaureate qualification, which in turn, limits eligibility for nurse practitioner programs. By comparison, mainstream Americans have had access to just under 1,000 Baccalaureate nursing programs, but cost, commute, and other barriers exist for Native American enrollment.
Scholarships at mainstream nursing schools alone were not sufficient to narrow the Native American educational opportunity gap. The University of North Dakota, for example, graduated a total of 19 Native American students with a Baccalaureate by 1990. With a critical nursing shortage in the Indian Health Service, concerted effort and funding of recruitment and retention of Native American nurses began at dozens of nursing schools in the 1990s which continues through today. The University of North Dakota, for example, was able to increase their graduate Baccalaureate-prepared Native American over 14 years — from 19 to 174 graduates — as well as graduate 50 Master’s-prepared nurses through a program of mentorship, educational support, and connection with family and cultural identity. South Dakota State established the Native American Nursing Education Center. The University of Montana launched the Caring for Our Own Program; the University of Wisconsin School of Nursing, in collaboration with the Native American Center for Health Professions, launched facilitator-led monthly talking circles to reduce cultural isolation for Native American students; and the University of Alaska has helped hundreds of Native American students navigate — and graduate — nursing school. The Campaign for Action also launched a video in 2020 with the benefits of entering nursing as well as a Native American student toolkit for nursing faculty.
Chronic lack of access to Baccalaureate programs over the last century not only impedes professional development to enter the nurse practitioner workforce, and other advanced practice roles critical for addressing primary care gaps in rural and reservation areas, but limits research, funding, knowledge generation, and national leadership without doctorate prepared Native American nurses able to compete with nursing’s educational standards for deans, tenured faculty, and researchers. Albeit slowly, change is coming: In 2013, N Nurse aggregated the published research of doctoral Native nurses spanning research across a dozen disciplines. By 2015, there were about two dozen doctorate-prepared Native American nurses. and the first-ever PhD in Indigenous Health was launched by University of North Dakota in 2020.
The founding of NANAINA in 1993 (the precursor organizations had disbanded with approximately two thousand members in 1984), followed by NCEMNA in 1998 has led to increased visibility in the 21st century. The 2010s has been a decade with multiple new resources and publications — including organizations like N-Nurse in 2013 and the first ever American Indian Health and Nursing text just published in 2016 (plus many others listed below in the ‘Build Your Library’ section). Native American enrollment and graduation rates across all educational levels have increased since 2010 — though room to grow remains. In this era of Native American self-determination, renewed attention exists to merge traditional Native healthcare practice, support Native American-led health organizations, and improve health equity. To fully realize the potential of Native American nurses, what is also needed is a full understanding and integration of Native American nurses’ contributions incorporated into our nursing narrative and curricula. It is our hope that this overview, and the companion resources listed below, can serve as a step towards that goal.
Build Your Library
As trained nurses, not historians, we are indebted to the noted nurses, scholars, journalists, and authors who have helped contextualize the historical and socio-political background of Native American professional nursing. Many of the resources shared here were merely hiding in plain sight. The intention of this overview is to deepen our readers’ curiosity to continue to learn more about the intersection of Indigenous nurses and nursing’s professional origins.
Books
- Moss, M. (2016). American Indian Health and Nursing. Springer Publishing.
- Pollitt, P. (2016). African American and Cherokee Nurses in Appalachia: A History, 1900–1965. McFarland, Incorporated, Publishers.
- Kristofic, J. (2019). Medicine Women: The Story of the First Native American Nursing School. University of New Mexico Press.
- Theobald, B. (2019). Reproduction on the Reservation: Pregnancy, Childbirth, and Colonialism in the Twentieth Century University of North Carolina Press.
- Trafzer, C. (2019). Fighting Invisible Enemies: Health and Medical Transitions among Southern California Indians. University of Oklahoma Press
Articles
- Csordas, T. (2000). The Navajo Healing Project. Medical Anthropology Quarterly, 14 4, 463–75 .
- Trennert, R. A. (2003). Sage Memorial Hospital and the Nation’s First All-Indian School of Nursing. The Journal of Arizona History, 44(4), 353–374.
- Charbonneau-Dahlen, B., & Crow, K. (2016). A Brief Overview of the History of American Indian Nurses. Journal of Cultural Diversity, 23(3), 79–90.
Podcasts
- The Modern West’s Shall Furnish Medicine three-part series on COVID-19 and the struggle for tribal control over healthcare. Produced by PRX.
- Interview with John Lowe, PhD, RN, FAAN
- Interview with Rachel Radyck, LPN
- Interview with Beverly Warne, RN, MSN
- Interview with Evelina Achee BSN, RN, PHN IV
References
- Dunbar-Ortiz, R. (2014). An Indigenous Peoples’ History of the United States. Beacon Press.
- Nebraska Public Media’s Native American Citizenship and the U.S. Indian Policy Timeline
- University of Oregon’s Mapping History
- National Museum of the American Indian’s Native Knowledge 360
Resources
- Native Land Digital
- Navajo Traditional Medicine Program
- Center for Indigenous Midwifery
- Navajo Epidemiology Center
Webinars
Films
Media Outlets
Research Sources
Books We Didn’t Reference, But Found Along the Way
- The Medicine Wheel: Earth Astrology
- Native: Identity, Belonging, and Rediscovering God
- Healing Ways: Navajo Healthcare in the Twentieth Century
- The Role Of Dance in a Navajo Healing Ceremony
Additional overviews in our series that connect nursing history with accompanying heritage months include Hispanic Heritage Month and Asian American Pacific Islander Month (Black History Month will be forthcoming in February 2022).
*Footnote from section on Boarding Schools: The U.S. Secretary of the Interior Deb Haaland, historically appointed in 2021, is the granddaughter of children forced to attend boarding schools and now serves as the first Native American to head the department that once ran them. In her role, she has ordered the government to search the ground for unmarked graves.
Should you know of books, articles, resources, relevant historical context — or even corrections — that should be added here, always feel free to contact us and we will update accordingly: email is nursesyoushouldknow@gmail.com.
