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Breast Cancer Research and Treatment (2018) 168:771–772 https://doi.org/10.1007/s10549-017-4647-0

L E T T E R TO T H E E D I TO R

Consideration of population and cultural factors in American Indian/ Alaskan Native (AIAN) research

Susanna N. Basappa1

Received: 7 December 2017 / Accepted: 26 December 2017 / Published online: 13 January 2018 © Springer Science+Business Media, LLC, part of Springer Nature 2018

To the Editor,

I have reviewed your paper “Adherence to screening in mam- mography among American Indian women of the northern plains,” published in 2013, and intend to address concerns that arose when considering your publication.

First, there is a need to address the population studied. While North Dakota, South Dakota, Nebraska, and Iowa are known to have a high density of Native Americans, this study did not include the populations of northern Minne- sota, Wisconsin, and Michigan, states with higher densities Northern Plains Natives (NPN) [1]. Specifically, in 2010, in MN, 100,000 individuals identified as AIAN, as well as 86,000 in WI and 139,000 in MI. In contrast, in SD there were 82,000, in ND 42,000, in IA 24,000, and in NE 30,000 [1]. Consequently, limiting the study population to these four states reduces the relevance to the larger NPN population.

Today, there are 1.4 million individuals who identify as AIAN in addition to white, nearly a quarter of the total Native population [1]. Furthermore, consistent intermar- riage has resulted in issues involving blood quantum laws, such that only those individuals with specific percentages of Native blood (tribe-specific) may be receive tribal enroll- ment benefits. A child of a Native person might grow up on a reservation but may have no access to IHS-provided healthcare as an adult [2]. Intermarriage also affects health outcomes; for example, among NPNs, cancer rates surpass those of non-Hispanic whites and are often only matched by black populations. This is in sharp contrast to Southwestern Natives, who remain largely genetically isolated, and the majority of whom identify as AIAN alone—a group which has significantly lower rates of cancers such as breast cancer [3]. These concerns must be taken into consideration when- ever research is performed with NPN subjects.

However, despite these reflections, I would like to thank the authors for their interest in and contribution to research with Native peoples. As acknowledged, there is limited trust between Native peoples and historically abusive and neglect- ful health institutions, and ethical research that contributes to the body of knowledge that benefits our health is greatly appreciated. Regardless, there is a distinct need and call for Native peoples to engage in research on ourselves for our- selves to allow for greater consideration of cultural concerns and values in health care.

To that end, I propose that, more than just recruiting and providing the service of an IHS Mobile Women’s Health Unit, greater interest and adherence to health care provi- sion and screening may be induced if there is an effort to educate those who are willing to engage health care provid- ers. The goal of such an initiative would be to have these Native persons who are willing to work with providers and staff to then go on to propagate their teachings among other Native peoples who might be less inclined to trust institu- tions which have wronged them in the past. In the context of the research published by the authors of this particular paper, this goal might be furthered by not only involvement of Native persons in the running and implementation of the MWHU, but also the preparation of education resources that may be distributed by the Native persons involved to and among members of the community who are hesitant, or who do not understand the need for mammography.

While the authors did comment on the self-selective nature of their methods, they did not follow this acknowl- edgement to its logical conclusion. That is, this self-selec- tion bias identifies a gap in care that not even mobile low cost telemammography can address on its own. Therefore, to reiterate, to work with Native peoples in an equitable manner with minimal care gaps necessarily requires Native involve- ment on the planning and implementation level. Nothing can be done to fix the atrocities committed against Native peoples in the past, not even repatriation or reparations. What can be done, however, is to engage communities in our

* Susanna N. Basappa [email protected]

1 Mayo Clinic, Rochester, MN, USA

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own care, to treat us with respect and consideration for our many and varied cultures and how they affect our choices in healthcare, and to provide education for us so that we can educate ourselves. The authors of this paper comment on tribal differences and state that there is no single solution that might be proposed to bridge the gap of Native peoples who do not receive mammographic screening despite our increased need. To that, I say that there is indeed a potential solution in order to meet this identified gap, and that solution is prospective community engagement and empowerment research.

Funding No funding was received for this study.

Compliance with ethical standards

Conflict of interest Susanna Basappa declares that she has no conflict of interest.

Ethical approval This article does not contain any studies with human participants or animals performed by any of the authors.

Informed consent Informed consent was not required for this study.

References

1. Norris T, Vines PL, Hoeffel EM (2012) The American Indian and Alaskan Native Population: 2010. 2010 Census Briefs. http s:// www.cens us.gov/prod /cen2 010/brie fs/c201 0br-10.pdf

2. Schmidt R (2011) American Indian identity and blood quantum in the 21st century: a critical review. J Anthropol 2011:1–9. http s://doi.org/10.1155 /2011 /5495 21

3. Data Source: Centers for Disease Control and Prevention. National Vital Statistics System. Accessed via CDC WONDER 2010-2014. Source geography: County

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