Invisibility of Native American Communities in Plastic and Reconstructive Surgery: The Role of Tribal Sovereignty and Self-governance to Improve Access

Out of sight, out of mind—this has largely been the state of American Indian/Alaska Native (AI/AN, Native) communities and issues in plastic and reconstructive surgery (PRS) spaces. There is being the “center of attention” or “on the periphery,” and there is “invisibility.” The latter is the state of AI/AN access to and representation within the PRS field. Native populations face significant disparities in subspecialty care access and outcomes, including plastic surgery.¹ Systemic healthcare challenges such as limited access to quality healthcare facilities and economic barriers are thought to contribute to these disparities.¹ Disparities are likely underestimated due to racial misclassification and shortfalls in data access and availability.¹ Lacking commitment within the field and disparities in Native plastic surgeons contribute to deficits in access to care.

Priorities are often driven by visibility and public awareness of issues. The invisibility of AI/ANs in Plastic and Reconstructive Surgery, the journal, was clearly elucidated in the Letter to the Editor response to “Diversity in Plastic Surgery: Trends in Minority Representation among Applicants and Residents” by Parmeshwar et al,² a piece aiming to highlight diversity representation in PRS training, all while failing to mention AI/ANs. These challenges underscore the importance of uplifting narratives and issues that have been neglected, while subsequently implementing solutions to the issues being brought to light. The understanding of tribal sovereignty and promoting tribal self-determination of healthcare is essential in this process.

The provision and delivery of healthcare to AI/ANs is unique, as it is a federal trust responsibility set forth through treaties between sovereign Tribal Nations and the United States government, which led to the development of the Indian Health Service (IHS).³ Inadequate funding and subpar implementation of services through IHS fail to meet treaty obligations and continue to influence stark differences in access and outcomes among AI/ANs. In 2017, per capita funding for the IHS was far below other healthcare spending in the United States at $4078, compared with Medicaid at $8109.⁴ Exacerbated by these notable deficits in funding are limitations of federal management of healthcare facilities within the IHS, often abated under tribal management. The Indian Self-Determination and Education Assistance Act of 1978 allowed for tribal management of healthcare facilities, acknowledging the benefit of tribal control.³ Tribes remain steadfast in self-determining their communities’ fate through management of healthcare and demanding accountability of the federal government to treaty obligations.

AI/AN populations confront significant obstacles in accessing subspecialty care, marked by systemic challenges across the medical education and healthcare delivery continuum. Recognizing the principals of tribal sovereignty and self-governance is crucial in addressing the disparities faced by AI/AN individuals in accessing plastic and reconstructive surgery. Recommendations to improve access through these principals are detailed in Figure 1. Collaborations with key stakeholders (Fig. 2) are essential for promoting policies and advocacy initiatives that respect and uphold tribal sovereignty, thereby fostering culturally sensitive healthcare solutions and ensuring equitable access to breast reconstruction and advancing health.

Fig. 1.

Recommendations and solutions through tribal collaboration and self-governance. This table provides a list of proposed recommendations with respect to advocacy, tribal collaboration and self-governance, and increased awareness, to help close the gap in reconstructive care access for Native people.

Fig. 2.

Key stakeholders. This is a nonexhaustive list of stakeholders; other stakeholders should be considered and included, especially regionally.

DISCLOSURES

Tamee Livermont is a member of the American Medical Association Medical Student Assembly Committee on American Indian Affairs, Policy Director of the Association of Native American Medical Students, and was a Udall Foundation Native American Graduate. As a tribal citizen, it is in the best interest of her community that this issue be brought to light to improve access to care and achieve greater health status. Lyndsay Kandi, MD, was a member of the American Medical Association Medical Student Assembly Committee on American Indian Affairs, and was an American Association of Plastic Surgeons Cannon Scholar, ACAPS 2022 Winter Meeting Scholarship Recipient, and the Arthur L. Garnes Society Scholarship Recipient. Tony Weaver DO is the president of the Alabama Osteopathic Medical Association, as well as on the membership committee of the Alabama chapter of the American College of Surgeons. The authors have no financial interest to declare in relation to the content of this article. Financial support for this article’s submission was provided through a grant funded by the UMN Medical School Surgery Departments Global Surgery & Disparities Program (UMGSD).