Dermatology on American Indian and Alaska Native Reservations

American Indians (AI) and Alaska Natives (AN) experience some of the most severe healthcare disparities and worst health outcomes of any population in the developed world. American Indians and Alaska Natives from federally recognized tribes have a legal right to healthcare provided by the Indian Health Service (IHS). The IHS serves approximately 2.2 million AI/AN from 574 federally recognized tribes. Sixty-four percent of the population served by the IHS lives on reservations or in rural communities, mostly in the western US and Alaska. Although the IHS’s mission is to provide health services to all members of federally recognized tribes, the IHS is a severely underfunded federal health program. Because of funding shortfalls, the IHS focuses its efforts on primary and emergency care services, some specialty services, and limited prescription drug coverage. Despite the low rates of access to dermatologic care, AI/AN may suffer from a significant skin disease burden, and sometimes from more severe skin diseases, such as acne, skin cancers, photodermatoses, skin disorders related to rheumatologic and metabolic diseases, coccidioidomycoses, and environmentally related diseases. The health inequities that AN/AI face are not only due to the quality of health care available to this population, but also stem from many practical, infrastructural and socioeconomic factors. These social determinants of health include geographic hurdles; poverty; economic, employment and educational opportunities; safe communities and suitable housing; lack of basic community infrastructure; underrepresentation in the US physician workforce; and an inadequate health system to meet individual and tribal health needs. To optimally address these shortfalls in access to dermatology services, dermatologists must respect tribal sovereignty, understand the limitations of the IHS, and understand how to build and participate in sustainable practices for AI/AN.