by Kamet Larson

Dr. Larson is a Christian Century editor. This article appeared in the Christian Century January 26, 1977, p. 61. Copyright by the Christian Century Foundation and used by permission. Current articles and subscription information can be found at www.christiancentury.org. This material was prepared for Religion Online by Ted & Winnie Brock.

Ten little Injuns standing in a line,
One toddled home and then there were nine;
Nine little Injuns swingin’ on a gate,
One tumbled off and then there were eight.
Eight little Injuns gayest under heav’n,
One went to sleep and then there were seven;
Seven little Injuns cutting up their tricks,
One broke his neck and then there were six.
Six little Injuns kickin’ all alive,
One kick’d the bucket and then there were five;
Five little Injuns on a cellar door.
One tumbled in and then there were four.
Four little Injuns up on a spree,
One he got fuddled and then there were three;
Three little Injuns out on a canoe,
One tumbled overboard and then there were two.
Two little Injuns foolin’ with a gun,
One shot tother and then there was one.
One little Injun livin’ all alone,
He got married and then there were none

[“Ten Little Injuns Comic Song and Chorus,” by S. Winner, London, 1868].

“Put them under the Fish and Wildlife Service,” Senator James Abourezk proposed in a speech last summer, “and declare them an ‘endangered species’ along with the yellow scissor-tailed flycatcher.” Federal programs have long been notorious for endangering the psyche of the American Indian, and although the native American population is growing, recently charges of “genocide” on the reservations have sparked controversy -- over the use of that term and over the substantiation of the charges. When South Dakota’s Abourezk, chairman of the Senate subcommittee on Indian affairs, asked for an inquiry into reports that the Indian Health Service has been sterilizing Indians without their consent or knowledge, federal investigators uncovered some disturbing data which suggest a significant pattern of carelessness with Indians’ reproductive freedom. A Government Accounting Office report released in late November is likely to motivate long-silent Indian women who believe they have been involuntarily sterilized to begin filing a batch of lawsuits this year which could make clearer the lineaments of IHS negligence. Meanwhile, long overdue reforms in Indian health care are being pressed from several directions, and in coming months Indian advocates will want to monitor closely what progress the changes in the works may -- or may not -- bring.

I

Most of the 3,400-plus cases involved women who have been sterilized by Indian Health Service doctors (by specially hired physicians in one-third of the cases) -- whether voluntarily or for reasons of medical necessity is unclear, since IHS records blur that critical distinction. Going through three years of files in four of the 52 IHS service areas, federal investigators could find no conclusive proof that the sterilized patients had given their fully informed consent as HEW (which operates the IHS) defines it. For “voluntary, knowing assent” HEW requires a description of what the surgical procedure or experiment is, its discomforts, risks and benefits; a disclosure of appropriate alternatives; an offer to answer questions; and an assurance that the patient is free to withdraw consent at any time without losing benefits. Forms on file in Albuquerque, Aberdeen, Oklahoma City and Phoenix were found to be incomplete on these basic points, inconsistent, inadequate, and “generally not in compliance with the Indian Health Service regulations.” Among the stacks of material looked at were physician complaints that preparing the required summaries of conversations with patients was “too time-consuming.” Had the IHS been as careless with its patients as with its own record-keeping?

One person who thinks so is Constance Uri, a Los Angeles doctor and law student who has talked with Indian women deliberating whether to bring lawsuits this year for forced sterilization. In her many interviews with native American women, Dr. Uri has found that it is common for male doctors to recommend sterilization to female patients who are told it is time they “quit having babies.” The argument that Indian women are “seeking” tubal ligations is “simply not true,” Uri told us. When Indian women do agree to the surgery -- often fearing that federal aid will be cut off if they do not agree that doctor knows best -- misunderstandings frequently arise over what the sterilization means; and the consent forms used, Dr. Uri says, mystify rather than clarify. The GAO findings bear out these possibilities for “misinformed consent.”

Coercion is what Chief Tribal Judge Marie Sanchez calls it. Several lawsuits may come from her Northern Cheyenne reservation in Lame Deer, Montana, where the IHS runs a clinic for the 2800 residents, who must otherwise drive 45 miles to get to the nearest Indian hospital. Since the GAO report came out, Judge Sanchez has talked with 30 women, from 18 to 52 years of age, who admit to having been sterilized since 1970, and she is convinced that Cheyenne women at Lame Deer have “definitely” been coerced into sterilization. Sometimes under the false impression that later their tubes can be “untied,” women may also agree to the surgery after trying other methods of birth control in which their husbands, holding to tribal beliefs about physical being and life-giving powers, refuse to cooperate. Cheyenne standards of female modesty dictate that sexual matters be left undiscussed, and frequently sterilization surgery is kept secret from the family.

Judge Sanchez feels strongly about why IHS doctors seem unduly eager to perform this kind of surgery on Indian women. “The doctors that come to us are young, often fresh out of medical school,” she says, “and they want to practice on someone.” (Even the IHS admits that their average age is roughly 30-35: many stay only two years.) Is it also possible that the government is looking to sterilization as an efficient cure for “Indian problems” just as some doctors see it as a way out of the “welfare mess”? Sanchez thinks so; she also opposes any efforts, however well intentioned, that diminish the Indian population -- including the “snatching” of adoptive children off the reservations -- because she is convinced that her people must become strong enough to resist those who are after Indian land and natural resources -- an especially sharp threat in her area. Sanchez is pressing for a government investigation of the IHS in Montana, a state not included in the limited GAO inquiry.

Most startling of its discoveries was the fact that 35 women under 21 had been illegally sterilized in the three-year period, despite a court-ordered moratorium on the sterilization of minors. (The order came out of the notorious Relf v. Weinberger case, which is still on appeal, concerning the involuntary sterilization of some “retarded” poor black children in the south.) Five cases were chalked up to “administrative error.” The IHS had also failed to develop an official consent form or to revise its manual to reflect HEW rules adopted over two years before, and it passed the buck for quality control in cases where physician services were contracted out.

II

 “We’re in shock about the whole, thing,” says Eugene Crawford, a Sissiton Sioux who heads the National Indian Lutheran Board. In angry response to the GAO report, three religious agencies (including the National Council of Churches) issued a statement from New York calling the IHS’s sterilization practices “gross violations of human rights” and “a form of genocide.” Condemning all nonmedical sterilizations for Indians, they committed their support to responsible efforts for “a class-action suit against the US government on behalf of Indian patients who have been sterilized non-medically.”

One reason for caution in the use of the word “genocide” -- and also cause for more widespread alarm -- is that the danger of sterilization abuse is by no means confined to Indians. Moreover, some experts in the field consider HEW’s minimal protections, which are widely ignored, not stringent enough. In 1975, for example, the New York City Health and Hospitals Corporation adopted guidelines for female elective sterilization which require a 30-day waiting period (between consent and surgery) rather than the 72 hours HEW thinks adequate. The health advocacy groups, community boards, and women’s groups who helped to formulate New York’s municipal guidelines say that the 72-hour waiting period often occurs after a birth or an abortion when the woman, sometimes sedated, is still in the unfamiliar surroundings of the hospital without adequate privacy for consulting with family and friends. (In a 1974 lawsuit the USC -- Los Angeles County Medical Center was charged with eliciting women’s “consent” while they were still in labor.) Acknowledging that “consent obtained during these times will be presumed involuntary,” the New York law prohibits initial sterilization consent’s being sought from a hospital patient. The three-page consent form (written in plain English, Spanish, French, Chinese and Yiddish) must be completed by the patient in the presence of a witness (and an interpreter when necessary) and is signed again when the client returns for the actual surgery. (Obstetricians and gynecologists in New York have challenged the guidelines in court, maintaining that they interfere with the right to practice medicine, but the case is currently at a standstill. In two suits against HEW, women are suing to be sterilized.)

The contrast between New York’s consent procedures and the past practices of the IHS is striking. Especially given the vulnerable position of Indian-women who are dependent on government-issue care, maximum rather than minimal protections should be the sine qua non of the whole decision-making process about terminal birth control. This necessity is underlined by the fact that sterilization abuse is a particular menace to the poor and ill-educated -- and native Americans are the poorest minority group, with 40 per cent below the poverty line as compared with 13.7 per cent of all Americans (1973 Census Bureau statistics). In the Reif case the court found that the common fear of losing welfare benefits is not mere paranoia. Further research describing this menacing context shows that many physicians favor punitive action (compulsory sterilization, withholding of welfare support, or both) against poor women with children born out of wedlock, regardless of the psychological traumas that sterilization under duress is known to bring; and that some doctors are much more eager to recommend sterilization to their welfare clients than to paying patients.

III

Several reforms are now in the works to eliminate some of the institutional practices that allow racist and sexist attitudes to flourish. HEW will have to respond formally to the GAO report, but already the Indian Health Service has acted upon most of the GAO’s recommendations. Later this winter Congress will hear the report of Abourezk’s Indian Policy Review Commission, a joint congressional body with five Indian members, given a scant year to chart Indian policy for the next decade. Among its recommendations is the complete management overhaul of the Bureau of Indian Affairs, which could be taken out of the Department of the Interior (whose land and water policies conflicted with Indian interests) and made into a separate executive agency. That is apparently what the Carter transition team is seeking; pending action by an apathetic Congress, the president may create a new post of assistant secretary for Indian affairs at the Interior Department, where there is currently no Indian advocate at that administrative level, and he may put in new management at the BIA. Carter’s team also proposes a new Indian Career Service. Clearly, this is an auspicious moment for dramatic reorganization -- a signal to the Congress that regardless of the unpopularity of pro-Indian votes back home in certain states, it is time to show that care for native Americans is a higher priority than it has yet been.

The head of the commission’s task force on health, Everett Rhoades -- professor of medicine at the University of Oklahoma who has served on Kiowa tribal councils -- says that he has not been satisfied with IHS performance, but he blames Congress for not giving the agency the funds to do its job. (A few years ago a Senate committee was told that 29 of the 51 hospitals maintained for Indians by HEW were so bad that they could not meet certification standards. A doctor testified that on his reservation “we see people die from treatable, curable diseases. . . . These would not be tolerated anywhere else in the United States. Here it is a way of life.”) The policy review commission will also recommend that Congress fund a guaranteed package of Indian health benefits. That prospect seems brighter since the Indian Health Care Improvement Act came into being, with the help of pressure from the religious community, in September. This “landmark legislation” sets forth for the first time the federal government’s obligation to provide “the highest possible health status to Indians.” Originally drafted as a $1.6 billion seven-year plan (but opposed vigorously by the Ford Administration and HEW), the act calls for $475 million to be spent in the next three years for upgrading hospitals and clinics, improving sanitation, training Indian medical professionals (currently, about five Indian doctors out of 562 serve the IHS), and attracting other health personnel into Indian communities. This is good news for native Americans, an unhealthy group by national standards, though for some of them -- like the woman who was told her headaches were due to “female problems,” but whose brain tumor was not cured by the sterilization surgery she agreed to -- such health care benefits will be too little too late.

One source of information the GAO investigators avoided was the Indians themselves, who will now have to come bravely forward with their stories to the press and the courts. As many as eight lawsuits may be starting up soon; but the personal and financial risks are great for these women, and they are not optimistic. Doctors have taken care to obtain some kind of consent documents which can be produced in a courtroom; and even more discouraging than high legal bills is the risk of losing one’s place in the Indian community, where sterilization has particular religious resonance. Yet such landmark cases may be the most effective way to bring the truth about “genocide” into the open once and for all.

As Daniel Callahan has pointed out, the abortion debate is complicated by a growth in moral consciousness (on both sides) about what constitutes violence against and quality in human life. Likewise, in recent decades that extension of our moral awareness has also blurred the boundaries of the word “genocide,” used by many Indian advocates to describe any pattern of carelessness with the lives of native peoples, including their reproductive capacities. On the other hand, to the Indian Health Service the “genocide” label is unwarranted; officials also point out that the report does not prove forced sterilization, that the consent documents are on file, and that in the absence of reliable national statistics on sterilization rates, it is impossible to tell whether Indians are being sterilized at a higher rate than anybody else.

But no matter what the rates are, the continued stream of reports is disturbing, particularly in view of the fact that the US government is performing these irreversible surgeries upon what is in some critical ways a population at the mercy of the state. The destruction of a people or their weakening can happen through a series of administrative errors and laxities as surely as the “Ten Little Injuns” were knocked off, one by one, through an inexorable series of “accidents.” Agatha Christie used the theme for a classic murder mystery; whether this real-life one is actually murderous cannot yet be shown, for so few clues have been left behind. For the future, enlightened Indian policies will have to be very closely watched indeed, to ensure that 993,000 native Americans cease to be an “endangered species,” and that all they hold sacred -- including their generational powers -- be violated no more.