[摘　　要]：

Disparities in health status between American Indians and other groups in the United States have persisted throughout the 500 years since Europeans arrived in the Americas. Colonists， traders， missionaries， soldiers， physicians， and government officials have struggled to explain these disparities， invoking a wide range of possible causes. American Indians joined these debates， often suggesting different explanations. Europeans and Americans also struggled to respond to the disparities， sometimes working to relieve them， somet......更多

Disparities in health status between American Indians and other groups in the United States have persisted throughout the 500 years since Europeans arrived in the Americas. Colonists， traders， missionaries， soldiers， physicians， and government officials have struggled to explain these disparities， invoking a wide range of possible causes. American Indians joined these debates， often suggesting different explanations. Europeans and Americans also struggled to respond to the disparities， sometimes working to relieve them， sometimes taking advantage of the ill health of American Indians. Economic and political interests have always affected both explanations of health disparities and responses to them， influencing which explanations were emphasized and which interventions were pursued. Tensions also appear in ongoing debates about the contributions of genetic and socioeconomic forces to the pervasive health disparities. Understanding how these economic and political forces have operated historically can explain both the persistence of the health disparities and the controversies that surround them. THE INDIAN HEALTH SERVICE (IHS) faced a daunting challenge when it was established in 1955. Indian populations living in rural poverty suffered terribly from disease. Tuberculosis continued to thrive， and infant mortality reached 4 times the national average. During the past 50 years， the IHS has improved health conditions dramatically， but disparities persist—American Indians continue to experience some of the worst health conditions in the United States. Although this persistence is striking， it is even more striking that the disparities have existed not for 50 years but for 500 years. From the earliest years of colonization， American Indians have suffered more severely whether the prevailing diseases were smallpox， tuberculosis， alcoholism， or other chronic afflictions of modern society. The history of these disparities provides perspective on many vexing problems of contemporary American Indian health policy. European and American observers have offered a diverse range of causes to explain Indian susceptibility， from the providential theories of Puritan colonists to emphasis on environment， behavior， genetics， or socioeconomic status. How did American Indians and their observers evaluate these long lists of potential causes and determine which were most important or meaningful? Observers have offered a similarly diverse range of responses， from attempts that relieved disparities through health care to efforts that ignored or even exacerbated them. How did political and economic interests shape their choices? The history also raises questions about the actual causes of the disparities. Health disparities have persisted， even as the underlying disease environment has changed. Do American Indians have intrinsic susceptibilities to every disease for which disparities have existed? Or does the history of disparity after disparity suggest that social and economic conditions have played a more powerful role in generating Indian vulnerability to disease? Understanding the histories of health disparities may explain the complex reactions they provoke and why efforts with the best intentions have fallen short.关闭