Behavioral Objectives
After reading this chapter, the nurse will be able to:
- 1.
Outline verbal and nonverbal communication barriers that may affect health care for the Yup’ik and Inupiat.
- 2.
Describe values related to space that may be found among the Yup’ik and Inupiat.
- 3.
Discuss the value and role of elders for the Yup’ik and Inupiat.
- 4.
Explain how traditional time orientation may affect compliance with a health regimen of individuals of Yup’ik and Inupiat descent.
- 5.
Discuss attitudes and beliefs of the Yup’ik and Inupiat that relate to health and illness.
- 6.
Identify the impact of the adoption of a Western diet and lifestyle on health and illness patterns apparent in persons of Eskimo descent.
* Special appreciation is extended to Dr. Nancy Sanders for her contributions to this chapter.
Overview of Alaska
The Land
Alaska is often described in superlatives. One fifth the size of the continental United States, Alaska has more coastline than the other 49 states combined and is by far the largest state in the continental United States. With a land area of 570,641 square miles, it is more than twice the size of Texas. Everything in Alaska appears to be on a grand scale. It is the home of the largest mountain in North America, Mount McKinley (also known as Denali, an Athabascan word meaning “The High One”), which rises to a height of 20,320 feet ( ) and is joined by six other peaks that are over 14,500 feet high. Alaska is also the home of the Bering Glacier, which, together with the Bagley Oil Field, covers 2000 square miles, an area larger than the state of Delaware ( ). There are more than 100,000 other glaciers in Alaska, only a few of which are named. Across Alaska, large mammals, including bear, moose, and caribou, roam largely undisturbed, providing for the subsistence needs of the Alaska Native population.
The chief influences on the climate in Alaska are its northern latitude, its large landmass, and its coastal waters. In the southern part of Alaska, the warm marine currents cause the climate to be temperate and damp, resulting in spruce rain forests on Kodiak Island and in the southern panhandle of the state. On the Aleutian Islands, where the climate is also temperate, grasses and shrubs predominate.
The interior of Alaska is bordered on the north by the Brooks Range, on the south by the Alaska Range, and on the west by the Arctic environment of the coast. The boreal forests of the interior consist of “relatively small specimens of white and black spruce, alder, birch and aspen [which] cover most of the rolling hills” ( , pp. 6–7). The river drainages are marshy and flat and attract many species of waterfowl important to the Athabaskan Indians who live in this area. The temperature in interior Alaska varies dramatically from lows of −50° F in the winter to more than 90° F in the summer.
A 200-mile-wide band extending along the western coast of Alaska from Bristol Bay to the border of Alaska and Canada is the Arctic region ( ). This area is drained by the Yukon and Kuskokwim rivers and their tributaries. It is in this area that Eskimos live. The Inupiat Eskimos live in the northern section from the Seward Peninsula north to the Canadian border. Yup’ik Eskimos live south of the Seward Peninsula to Bristol Bay in southwestern Alaska, both along the coast and inland along the Yukon and Kuskokwim Rivers. Winters in this area are long, and summers are short and cool.
An unusual feature of Alaska’s terrain is permafrost, or permanently frozen ground. In the Arctic region, continuous permafrost underlies surface dirt in depths of about 2000 feet. Some buildings and highways have been erected on permafrost; when the permafrost thaws, those structures sink. More recently, climate change has accelerated permafrost thawing, impacting the stability of infrastructure and ecosystems. Loss of sea ice has negatively impacted several animal species on which Inupiat peoples depend for subsistence, and coastal erosion has forced some villages to relocate for safety reasons ( ).
Over most of the arctic, annual snowfall is quite light, as little as 4 to 6 inches. While actual snowstorms are rare, ground blizzards, which whip up dry snow already on the ground, may persist for days ( ). At cold temperatures, wind speeds the rate of heat loss from the skin, thus increasing the risk of freezing injury ( ).
Alaska has 33,000 miles of coastline ( ; ). Migratory marine mammals (walrus, seals, and whales), fish (particularly salmon), and birds return to birthing grounds in Alaska during the summer. The Bering Sea, the Yukon and Kuskokwim Rivers and their tributaries, and the migratory bird nesting areas make the hunting and fishing resources an important source of subsistence food for the Alaskan Native population, including the Yup’ik and the Inupiat Eskimos ( ). Limited income-generating opportunities in rural villages make subsistence activities crucial for survival.
For many years the Eskimos claimed that certain lands belonged to them without effect. However, when oil was discovered in the state, the U.S. government recognized the right of Eskimos to their traditional lifestyle. The 1971 Alaska Native Claims Settlement Act (ANCSA) created 12 regional Native corporations and provided for the allocation of lab and monies to those corporations and to 200 Native villages. While any Alaska Native who lived in the geographic region of the corporation could become a shareholder, the shareholders of four of the corporations are primarily of Yup’ik or Inupiat ethnic origin; a fifth describes its shareholders as being of Yup’ik, Alutiiq, Aleut, or Athabascan origin.
Eskimos, individually and through their regional corporations, have varied in their responses to resource development proposals. In 2002, when the Bush Administration proposed drilling in the Arctic National Wildlife Refuge (ANWR), where the Inupiat Eskimos hold title to 92,000 acres, the Natives sided with the state and labor unions in favor of drilling. Environmentalists have argued that, while other Alaskan oil projects had not harmed the region’s polar bears and caribou, ANWR drilling could threaten those species ( ). To date, drilling in ANWR has not occurred. However, the polar bear population in the Beaufort Sea has dropped by nearly 40%, presumably due to reductions in polar sea ice ( ).
In contrast to their response to ANWR drilling proposals, Native groups have been largely united in their opposition to the proposed Pebble Mine, which they have argued would negatively impact important salmon streams in the Bristol Bay region ( ). There continues to be tension as various groups struggle to achieve a balance between income-generating resource development and culturally relevant subsistence activities ( ).
In the former Soviet Union, Eskimo communities near the Bering Strait were moved inland to limit contact with the communities in Alaska. As relationships improved between the United States and the Soviet Union, visits by friends and relatives across the Bering Sea were resumed between 1988 and 1999. However, after a father and son drowned while returning home from Alaska, Russia restricted such trips until 2014, when a group of 12 men traveled in two aluminum skiffs from Provideniya, Russia, to Gambel, Alaska, to visit U.S. relatives for several days ( ). Still, visits between relatives living in Russia and Alaska are infrequent.
Overview of the People
Archeologists believe that the ancestors of the Eskimos came across the Bering Strait from Asia about 30,000 years ago ( ). The results of a genetic study of five populations of Eskimos suggested that at least four separate migrant groups crossed the Bering Strait at various times ( ). For centuries, the native people of Alaska lived in isolated regions and were undisturbed by outside cultures. Archeologists have estimated that 48,000 Eskimos lived along the Arctic region of North America from 1750 to 1800 a . d ., with the majority (26,000) living in the area now known as Alaska. Approximately two fifths of these early Alaskans spoke Yup’ik and lived in southwestern Alaska, with the Yukon River as the natural dividing line between this group and the Inupiat, who occupied the more northern coastal areas ( ; ).
Significant population change occurred with the U.S. purchase of Alaska from Russia in 1867. Beginning in 1883, missionaries began to convert the Alaska Native population to Christianity and introduced limited health services ( ). In the early 1900s, “outsiders” discovered the wealth of Alaska’s natural resources, and the long-undisturbed culture of the natives residing in rural areas came face to face with elements of the Western culture brought by Alaska’s new occupants. Outsiders also brought infectious diseases, including smallpox, influenza, hepatitis, and measles, to which the native people had no immunity ( ; ). Epidemics killed thousands of the native people.
The gold rushes in the early 1900s brought miners and their families. In the 1940s and 1950s, military personnel came to Alaska because of its strategic geographical location. Between 1941 and 1945 over $1 billion was pumped into Alaska by the federal government to develop transportation systems including railroads, highways, airfields, docks, and breakwaters. The most recent influx of westerners arrived after 1968, when a large oil and gas reservoir, estimated to be twice as large as any other oil field in North America, was found on Alaska’s north slope. The 800-mile Trans-Alaskan pipeline was completed in 1977 at a cost of $7.7 billion ( ; ).
Today, Alaska has a diverse population. In 2013, Alaska’s population was estimated to be 735,132 (U.S. Department of Commerce, Bureau of the Census, 2011, Census Briefs, 2015). Of those, 67.3% were White, 3.9% were Black, 14.7% were Alaska Native or American Indian, 5.8% were Asian or Pacific Islander, and 6.6% were Hispanic ( ).
Members of the indigenous population are often referred to collectively as Alaska Natives , and when such things as employment rates, educational levels, and disease incidence rates are discussed, the numbers and percentages generally refer to all Native groups (i.e., Indians and Eskimos); thus the poverty rate is known for Alaska Natives in general but not for the Yup’ik and Inupiat subgroups. In fact, the Native population is divided culturally and linguistically into five major groupings: Interior Indians (Athabaskans), Aleuts, Southeast Coastal Indians (Tlingit, Haida, and Tsimshian peoples, which have disparate languages), Northern Eskimos (Inupiat), and Southern Eskimos (Yup’ik) ( ). In 2010, Eskimos composed 56.8% of the Alaska Native population, with those of Yup’ik descent predominating slightly (30,868 compared to 25,687 of Inupiat descent). The median age for all Alaska Natives in 2010 was just 26.7 years, compared to 33.8 years for the state’s entire population. This may be partly attributable to a fertility rate of 3 among Alaska Natives compared to a rate of less than 2.5 for non-Natives in Alaska ( ). Although Alaska Natives are a young population, in 2010 their life expectancy at birth was only 70.7 years, compared with 78.1 years for all Alaskans and 78.7 years for all U.S. people ( ).
The seasonally adjusted unemployment rate in Alaska in September 2014 was 6.8% and ranked forty-first in the nation ( ), while the national rate for the same month was 5.9% ( ). Unemployment among Alaska Natives during the first half of 2013 was 11.7%, compared with a rate of 5.5% among white Alaskans ( ). From 2007 through 2013, when the U.S. poverty rate was 14.3%, the rate among Alaska Natives living in Alaska was 21% ( ).
Culture and Heritage of the Eskimos
The word Eskimo is from the French esquimau(x) . The term refers to peoples living in arctic and subarctic regions from Greenland, through Canada and Alaska, to extreme northeast Siberia. The term is sometimes considered derogatory because it was erroneously thought to mean “eaters of raw meat” ( ). As controversies about the naming of various sports teams have emerged in recent years and possibly because some Eskimos believe that the “eaters of raw flesh” attribution puts them in a poor light with modern audiences ( ), exhibits at the Alaska Native Heritage Center ( www.alaskanative.net ) and the Smithsonian Arctic Studies Center at the Anchorage Museum ( www.anchoragemuseum.org/exhibits-events/permanent-exhibits/alaska-native-culture/ ) are simply identified as being of either Yup’ik/Cup’ik or Inupiat origin. In Canada, the term Inuit has largely replaced the use of the word Eskimo ( ).
Although some customs, traditions, and heritages are shared among Alaska Native groups, the groups have traditionally been enemies. Disputes over territorial rights to land or game resulted in the development of an animosity that has been carried on through the generations. These animosities are kept alive through the retelling of tales, and when things were missing from an Eskimo village, “the Indians” were blamed ( ; ; ).
The Eskimo people have managed to preserve artifacts and many unique and interesting customs. Artifacts of Eskimo and other Alaska Native groups can be found at the Smithsonian Arctic Studies Center, which opened at the Anchorage Museum in Spring 2010. Yup’ik and Inupiat elders have provided commentary on many of the artifacts included in the Center exhibits. Additionally, a full list of Alaska museums, many of which contain artifacts of Alaska Native peoples, can be found at www.museumsalaska.org . However, the traditional way of life is changing for the Eskimo as they have assimilated into the dominant culture, taken on mechanical trades and professional roles, and moved away from reliance on the land. Many young Eskimos are leaving rural villages to go away to school and are returning with new knowledge of the outside world. Some do not return ( ).
The Eskimo people have lived in the harsh and frigid regions of northern and southwestern Alaska. Until recently, parkas and footgear ( mukluks ) made of animal skins were worn to survive the temperature, wind, and blizzards ( ). To survive in this frozen, non–crop-producing region, the Eskimos have hunted, fished, trapped, and gathered food on the tundra. Thus the dietary mainstay of the people traditionally consisted mainly of wild meat, such as caribou, and seafood, including seal, fish, and whale. A century ago the government brought reindeer to Alaska from Russia and Scandinavia in an effort to improve the meat supply. Under the terms of the Reindeer Act of 1937, which is still in effect today, only Alaska Natives were permitted to own reindeer ( ). However, commercial ranching has remained small; herders participate in the Kawerak Reindeer Herders Association ( www.kawerak.org/reindeer.html ), which provides administrative, logistical, advocacy, and field support toward the development of a self-sustaining reindeer industry.
Traditionally, dog teams were used for traveling, but this is no longer common. When dog teams were used, they had to be chained for the safety of villagers and to reduce the risk of dogs catching rabies from Arctic foxes. One tradition that remains from dogsled days is the annual Iditarod Trail sled dog race across Alaska from Seward to Nome. However, dogsled racing has been almost entirely taken over by non-Natives who can afford to pay the high cost of competition, estimated to be at least $30,000. Although animal rights activists annually oppose the race, it is a special event for many Alaskans and is promoted around the world as a tourist attraction ( ). Instead, many rurally residing Eskimos use snow machines and all-terrain vehicles (ATVs) for transportation. The reliance on mechanized transportation carries risks. Between 2000 and 2007, Alaska had an ATV mortality rate of 2.67/100,000, more than twice that of the next nearest state ( ). The impact on Alaska Natives is disproportionately high ( ).
Traditionally, kayaking served as water transportation, and whaling was an important component of the economy for Eskimos who lived near the ocean ( ; ); walrus and bearded seals were also important in the Inupiat diet. Today, tightly regulated whaling still occurs along the northern coastlines. When a whale is landed, the entire village participates in butchering the animal and the meat is shared. Salmon, other fish, seal, and migratory birds and their eggs were and are important components of the traditional diet of Eskimos who lived away from the ocean ( ). Reliance on foods obtained from water sources (i.e., oceans and rivers) is, however, a two-edged sword. Between 1996 and 1998, Alaska’s drowning rate was three times higher than the national average. Within the state, the drowning rate for Alaska Natives was almost three times that of non-Native Alaskans (43 vs. 15/100,000 population). From 2000 through 2006, when Alaska Natives made up only 17% of the state’s population, they accounted for 44% of drowning deaths in the state. Examination of individual drowning deaths indicated that the use of personal flotation devices (i.e., life vests) was substantially lower among Alaska Natives compared with non-Native Alaskans ( ). Further, because Alaskan waters are so cold, the primary benefit of a life vest is largely that it aids efforts to find the body later.
Eskimos, as well as members of other Alaska Native groups, have traditionally shared a common set of values and beliefs that guide their behavior and that sometimes conflict with Western beliefs and values. These have included honesty, prioritizing communal and family needs over individual considerations, valuing sharing over accumulating, and respecting spirituality and interconnectedness with the natural world ( ; ). In the northwest United States, the potlatch, a festive gathering of friends and neighbors among coastal Indians, would involve sharing not only food but also blankets and other useful items ( ).
It is a misconception that Eskimos live in dome-shaped ice-block shelters called igloos. In fact, such shelters were used primarily as emergency bivouacs by the Canadian Eskimos. The early Alaskan Eskimos lived in dwellings that were partially underground and covered with sod. Both the ice igloo and the sod huts had long, dipped tunnels as entrances so that the cold air, which is heavier, was caught in a natural trap, thus permitting the interior of the hut to be heated more easily. However, with the passage of the ANCSA in 1971, rapid and continuing change has occurred in many Alaskan Native villages ( ). Today, wood frame houses, heated with wood or fuel oil, predominate in small villages that are scattered widely along the coast and major river systems.
Originally, “honey buckets” were used for sewage disposal. Later, honey buckets became black polyethylene bags that, when full, were tied and placed outside the door to be collected and transported to a dump outside the village ( ). Also houses may have water storage tanks that allow running water as well as sewage storage tanks; both require regular servicing, with water tanks being filled and sewage tanks being emptied at regular intervals.
Today, because of government projects, many of the larger villages have a sewage treatment plant that includes a piping system where central water tanks supply water to houses via insulated plastic pipe, and raw sewage is piped out to sewage holding and treatment areas. However, winter temperatures play havoc with such systems, causing frozen lines and a need to temporarily revert to the old honey bucket system.
Permanent villages range in population from 20 to 1000 persons, with an average of 400 persons. Most of these villages share community water supplies, electricity, churches, stores, and irregular mail service by airplane.
Rapid changes have impacted Eskimos in recent years and caused social disorganization and cultural conflict. Those issues, in combination with the subsistence lifestyles, severe climate, and harsh terrain characteristic of remote areas, contributed to increased health risks for all ages of Eskimos ( ). From 1999 through 2009, the four leading causes of death among Alaska Natives (all groups) were malignancies, unintentional injuries, heart disease, and suicide; for all of those causes, the death rate was considerably higher when Alaska Natives were compared with White Alaskans ( ). Using a slightly narrower time frame, from 2004 through 2007, the Alaska Native Epidemiology Center reported cancer to be the leading cause of Alaska Native deaths, accounting for 20.7% of deaths. Heart disease was reported as the second leading (14.2%) cause of death, followed by unintentional injury (13.1%, third) and suicide (6.8%, fourth). Among U.S. Whites, unintentional injuries ranked fifth and tenth, respectively, as the cause of death. Neither chronic liver disease nor homicide was among the top ten causes of death among U.S. Whites; among Alaska Natives, they ranked seventh and tenth ( ). Indeed, death rates for a wide range of causes differ significantly for Alaska Natives compared with White Alaskans, as examination of Table 12-1 makes clear.
| Mortality Cause | Alaska Native Rate | Non-native Rate | Difference/Significance |
|---|---|---|---|
| Unintentional Injury (1990–2009) a | 122.59 | 44.84 | 2.73 * |
| Motor Vehicle Accidents | 17.42 | 19.11 | 1.72 * |
| Poisoning | 33.76 | 12.11 | 2.79 * |
| Falls | 6.60 | 5.54 | 1.19 |
| Suffocation | 5.77 | 2.46 | 2.34 * |
| Drowning | 12.60 | 2.05 | 6.14 * |
| Fire/burns | 4.85 | 1.56 | 3.11 * |
| Infectious Disease (1999–2009) | |||
| 0–19 years | 9.40 | 2.00 | 4.67 * |
| 20–49 years | 21.0 | 5.30 | 3.98 * |
| ≥50 years | 255.20 | 104.10 | 2.45 * |
| Cancer (1999–2009) c | |||
| Males | 298.70 | 207.20 | 1.44 * |
| Females | 232.60 | 155.50 | 1.50 * |
| Stroke (1999–2009) d | |||
| All | 144.30 | 95.60 | 1.51 * |
| Males | 150.30 | 95.60 | 1.57 * |
| Females | 138.00 | 94.60 | 1.46 * |
| Heart Disease (1990–2009) e | |||
| All | 413.50 | 325.0 | 1.27 * |
| Males | 519.50 | 406.20 | 1.28 * |
| Females | 329.50 | 249.10 | 1.32 * |
| Chronic Liver Disease (1999–2009) f | |||
| All | 39.10 | 16.90 | 2.30 * |
| Males | 32.30 | 21.70 | 1.50 * |
| Females | 45.60 | 11.80 | 3.90 * |
* Significant at P < 0.05; all rates are per 100,000 population. a ; b ; c White et al., 2014; d ; e ; f .
noted that American Indians and Alaska Natives have the highest rate of reported disability of any racial or ethnic group in the United States. In the mid-1990s, 63% of American Indians and Alaska Natives over age 64 acknowledged having a disability; 52% reported their disability as severe. In the general population only 52.5% and 33.4% reported having any or severe disability, respectively ( ). Jackson concluded that Alaska Native elders constitute a major risk group for poor health, chronic disease, high medical expenditures, and institutionalization.
Death by violence is a significant concern among Alaska Natives, whose rate of suicide from 2004 through 2007 was 43.1 per 100,000, more than twice the rate for all Alaskan Whites (17.3 per 100,000) and considerably higher than that for U.S. Whites (12 per 100,000). During the same period, the homicide rate for Alaska Natives was 10.9, compared with 4.3 for Alaskan Whites and 3.8 for U.S. Whites; however, the homicide death rate among Alaska Natives has decreased by 70% since 1980 ( ).
Great strides have been made in reducing both infant and postneonatal mortality among the Alaska Native population. From 2004 to 2007, the adjusted infant mortality rate among Alaska Natives was 9 per 1000 live births; between 1980 and 1983, the rate was 17.2/1000. Despite substantial improvement over the past 25 years, the Alaska Native infant mortality rate compared unfavorably to the rates for Alaska Whites (4/1000) and for U.S. Whites (5.8/1000) ( ). Among the leading causes of infant mortality for both U.S. Whites and Alaska Natives from 1999 through 2009 were congenital anomalies (first leading cause, 243.6/100,000 population) and sudden infant death syndrome (SIDS) (second for Alaska Natives and third for U.S. Whites). However, the rate of congenital malformations among Alaska Native children was more than twice that of U.S. Whites (213.7 vs. 134.9/100,000), and the Alaska Native rate of SIDS was nearly four times the rate among U.S. Whites (240 vs. 54.3/100,000). Among Alaska Native children, unintentional injuries were the fourth leading cause of death (192.3/100,000); among U.S. Whites, the rate was only 23.4/100,000 ( ; ).
Over the years, the Indian Health Service (IHS) has targeted specific health problems, such as the high rate of maternal and child health problems, with specific programs. For example, in 1984, Alaska was one of 10 states to receive a Child and Adolescent Service System Program to improve state services for troubled youth ( ).
Until recently, medical care was provided to Yup’iks and Inupiats by the U.S. IHS as a treaty right. Doctors assigned to the IHS hospitals in Bethel, Nome, Kotzebue, and Barrow, and to the Alaska Native Medical Center (ANMC) in Anchorage provided inpatient and outpatient care. The physicians also traveled at least one time per year to the villages, where most Yup’ik and Inupiat people live, to provide medical care. In addition, the State of Alaska provides preventive health services using public health nurses who travel to each village at least once a year and as needed.
Over time, a system of health care, using indigenous residents located in each village, was instituted by the IHS. These “health aides” work in conjunction with the IHS and regional corporation doctors through the regional hospitals by using standing orders and consulting with the doctors via telephone. The level of care provided by the village health aides has increased substantially in recent years, partly as a result of the successful use of telemedicine technology in the areas occupied by Yup’iks and Inupiats. All of these approaches in providing health care fall within the Western biomedical paradigm, although some facilities also rely on indigenous providers, or “tribal doctors,” to collaborate in caregiving.
After the ANCSA passed in 1971, a number of regional for-profit Native corporations established nonprofit health corporations programs to work on many health concerns ( ; ). In 1999, the health care of Alaska Natives came under the control of the regional native health corporations as a result of the adoption of the Alaska Tribal Health Compact, a self-governance agreement with the IHS. In the rural areas, the regional hospitals and clinics came under the management of the regional health corporations. In Anchorage, the Alaska Native Tribal Health Consortium (ANTHC), a body of tribal organization representatives, manages the ANMC, which opened a new state-of-the-art comprehensive medical facility in the late 1990s. In this way, decisions about how to allocate funds are made by the Alaska Native recipients of care, which allows direct input into the prioritization of health concerns to be addressed. In 2014, seven tribally managed hospitals, 44 tribal health centers, and 160 tribal community health aide clinics provided services to meet the health care needs of Alaska Natives, some of whom also take advantage of other health care options available in the state ( ).
Communication
Language
Although some authorities have related the language of persons native to the Arctic to the Athabaskan or Algonquian language groups ( ), others have asserted that they are related only to the Aleut language. There are two branches of the Eskimo language: Inupiaq and Yup’ik. While Inupiaq is a single language with different dialects, there are actually three distinct Yup’ik languages in Alaska, including Central Yup’ik, Alutiiq, and Siberian Yupic. Until recently, children were discouraged from speaking any Eskimo language ( ). In recent years, several schools serving Yup’ik or Inupiat Eskimo students have initiated various form of bilingual and/or Eskimo language immersion study options. Also, students enrolled at campuses of the University of Alaska Fairbanks (UAF) are able to complete a bachelor of arts degree in either Inupiat or Yup’ik.
Originally the Eskimo language did not exist in written form; thus the recounting of events in story form and in dance provided the only record of Eskimo life. Indeed, both the Inupiat and Yup’ik peoples had a rich tradition of storytelling with myths, stories, histories and songs being passed across generations ( ; ). Today a phonetically written form of the Eskimo language, initially developed by missionaries, exists and is under continued study at the Alaska Native Language Center on the UAF campus.
In the oral language spoken by Eskimos, pronouns have no gender distinctions; the same word is used to convey that he, she, or it is eating. Further, intonation rather than words are used to convey questions. Thus English phrasing of an individual whose primary language is Eskimo may sound somewhat unusual. The word “let” may be used to express causation, permission, or obligation; for example, my mother let me bring in wood rather than my mother made me bring in some wood . Articles may be missing from spoken phrases: He went to party instead of He went to a party ( ; ). Verb phrasing may differ from that typical of primary English speakers; for example, it is not uncommon to hear an Eskimo saying I will eat my pills rather than I will take my pills . Unlike children learning English, who generally begin to effectively use the passive structure of the language around the age of 4 years, children learning Inuktitut (one dialect of the Eskimo language) learn a simple and complex form of passive vocabulary as early as the age of 2 years ( ).
In the past, each person in the Eskimo culture had a defined role in the group; therefore, the anticipation of each person’s action required little verbal communication. Also, individuals who learned English as a second language seldom understood common English idioms ( ; ; ). However, with English as a primary language of the young people and with the exposure to the world via satellite television, the Internet, and schools, idioms and abstract ideas have begun to have meaning. Still, the nurse who cares for Eskimo clients from the “bush” (i.e., remote areas) should avoid the extensive use of idioms, such as “a bull in a china shop,” “out in left field,” or “robbing Peter to pay Paul,” which may lack meaning, especially for elders.
The language of the Eskimo people reflects their dominant concerns and interests. Certain words take on a more significant meaning than do other words. Because Alaska is seasonally a land of snow and ice, those words take on a more significant meaning. For example, there are three different Eskimo words for snow for which there are no single-word equivalents in the English language; different words are used for falling snow, soft snow on the ground, and drifting snow. Another important word for the Eskimo is ice. Different words describe freshwater ice, saltwater ice, and icebergs because ice also serves different and important purposes in those cultures ( ).
For the older generation, English is the second language. When one is speaking to an older person, comprehension can be facilitated by speaking slowly and in literal terms. Children who know only English may have trouble communicating with their grandparents who know only Eskimo ( ). Translators may be helpful, but it is important to remember that the Eskimo language has no translation for the future or for abstract ideas. When providing care to an Eskimo client, the nurse should provide an explanation about specific therapeutic interventions in English and, if a translator is available, in Eskimo. The need for a trained medical translator fluent in the appropriate dialect of the Eskimo language cannot be overemphasized, especially when working with elders; translation services are an integral part of services provided by most of the regional Native hospitals.
Use of Silence
Eskimos tolerate periods of silence more easily than do people in Western society ( ). In fact, it is considered rude to fill silences with chatter because it prevents one from having the space to express viewpoints. The perceived Western intolerance of silence serves to increase the Eskimo’s feelings of being dominated and inferior ( ; ). Traditionally in Eskimo culture, each adult is given the opportunity to express a viewpoint without a time limit. For example, an Eskimo may go to see a White person for some reason and just sit in silence for many minutes before saying why he or she has come. However, individuals in Western society may be insensitive to this mode of communication and interpret silence as nonparticipation or passive acceptance ( ). Generally, Eskimos are a polite people who are unlikely to criticize other people’s opinions and actions unless such actions cause a threat to the social group. There appears to be a proscription against verbal expression of negative effect ( ; ). In dealing with people in Western society, the younger generation of Eskimos has, for the most part, adopted Western ways, which includes becoming more verbal.
Touch
There is a wide range of acceptable open demonstration of affection displayed in public among various subgroups in the Eskimo culture. However, the handshake is considered universally acceptable and a mandatory politeness. Hugging is an acceptable greeting between family members and between women friends. Eskimo men are more reserved in their expressions of affection, using a handshake with only one movement, not up and down, as a common way to greet friends and family.
Elders asked about traditional healing practices reported that massage was commonly employed as a technique to treat both pain and constipation ( ). The late Eskimo healer Della healed many people through the use of massage, manipulation, herbal medicines, and love ( ; DeLapp, personal communication, 1979; ). According to Keats, she inherited the skill of her hands and learned the use of herbs for healing from her mother and other Eskimo elders. Through love, touch, and a combination of old and new medicines, Keats reportedly healed her people (DeLapp, personal communication, 1979).
Traditional Eskimos are very modest about exposing the body, and it is often difficult to persuade older Eskimo people to undergo complete physical examinations, particularly for diagnostic purposes. The nurse who cares for Eskimo clients needs to establish a trust relationship before diagnostic examinations are initiated. In the presence of pain and illness, however, there is less resistance to physical examination ( ).
Kinesics
Eskimos use nonverbal communication extensively through body posture and facial expression ( ). Years of watching animal behavior for survival needs have made the Eskimo people experts in the interpretation of nonverbal language. The nurse who understands the Eskimo culture will look for nonverbal clues, such as watching the face for raised eyebrows or blinking (indicating “yes”) or a wrinkled nose (indicating “no”). Older Eskimos seldom disagree publicly with others. Although smiles and head nods in the Western culture may indicate agreement, for Eskimos, they may simply acknowledge the other person’s words. Among Eskimos, actual agreement is determined by action. Insincerity and deceptiveness are quickly perceived through body talk and lead to distrust and eventually to social ostracism. Thus, others are evaluated by body language, and this evaluation is nonverbally communicated back by inclusion or exclusion of the person in future activities. The nurse who lives and works among the Eskimo people will eventually understand the nonverbal language of Eskimos and its significance.
Implications for Nursing Care
For effective communication to occur, the nurse must develop a trust relationship with the client that in time will give rise to acceptance of the nurse. When the nurse works in an Alaskan village, the villagers may appraise the nurse not on skills but on the nurse’s endorsement of the community. Some villagers may perceive acceptance in terms of the nurse’s willingness to visit in homes, to take time to have a cup of coffee, and to participate in village activities. It is important for the nurse to recognize that some Eskimos have a need to know they are accepted as individuals and as a community. Thus, insincerity may be inferred by a discrepancy between nonverbal and verbal language and will cause mistrust and block communication. When dealing with Eskimo clients, whether in villages or in an integrated mainland U.S. society, the nurse should be assertive but not aggressive and use a suggestive rather than a directive approach ( ). Time should be provided for a slower pace of communication with Eskimo clients. The nurse should be aware that Eskimos are sensitive to comments that indicate lack of respect and that Eskimos report feelings of racism and lack of respect by health care workers ( ).
Some Eskimos respect the right of personal choice and self-determination as long as these actions do not affect the welfare of the family or community. The culturally sensitive nurse will avoid issuing direct orders, which may be viewed as being “bossy.” When working with Eskimo clients, it is may be most effective to approach nonemergency situations in a roundabout way. For example, a public health nurse making a home visit may notice a baby’s bottle rolling around on a dirty floor. Later the nurse may see the toddler pick the bottle up, take a few sips, and throw it back on the floor. If the nurse corrects the mother about failure to protect the child from the dangers of unrefrigerated milk and bottle-mouth syndrome, that mother may not come to the clinic or allow the nurse in the house again. However, the advice may be more readily accepted if the nurse waits until the mother brings the child in for health care, where teaching can be implemented and emphasis placed on the importance of refrigerated milk and dental hygiene to prevent bottle-mouth syndrome.
Eskimos are very sensitive to the power of the dominant culture ( ) and may withdraw when they sense judgment by health care providers. Thus, it is of little value to lecture about alcohol use, chewing tobacco, or dipping or pinching snuff, which some Yup’ik women may “chew” several times daily. The development of trust and acceptance is the best form of demonstrating support for the community. This approach will allow the village community to educate itself and seek to change unhealthy lifestyles of community members. Health care providers should not fall into the trap of thinking that they alone can effect change; rather, change results from collaborative interaction, support, and nonjudgment between providers and the community.
When providing health teaching for a client who lacks English-language skills, the nurse should use educational material that can be understood. Many educational materials available for children in English do not address the specific kinds of injuries encountered in Alaska. The Emergency Medical Services program at the Yukon-Kuskokwim Health Corporation has developed four educational curricula with a specific focus on safety and first-aid issues appropriate for the Alaskan Eskimos. Two sets of books were created, one written in English and the other in Yup’ik, to ensure that culturally and linguistically appropriate materials were available ( ).
It is also important for the nurse to be aware that some Eskimos have been found to have chronic otitis media, which has impaired their ability to hear self-care instructions delivered verbally. Audiological services, including access to hearing aides, are available through the regional health corporations.
Space
In the Eskimo culture, individual space is often shared with family members ( ; ). What is perceived as crowded living conditions by individuals in Western society may be viewed by the Eskimo as living in the warmth and security of the family group. The Western cultural need to be territorial by owning private space was not a traditional value of the Eskimo people. Instead, the Eskimo people valued sharing and perceived it as a preferable norm ( ). Acculturation has weakened this particular value system, but family rights still take precedence over individual rights. For example, if a family member desires the privacy of a room for a few hours, this request may be accepted as a personal need. However, if this same individual demands such privacy continuously in a two-room house with five members, ridicule and accusations of selfishness may result. As the need for individual space arises, individual family members may go on hunting, fishing, or camping trips to meet privacy needs as well as to return to nature.
A handshake distance between two people is considered the acceptable space for socialization on a daily basis. Closer approaches without permission are perceived as threatening, while greater distances are perceived as rude. An outsider who desires input from the Eskimos in a public meeting must recognize the decision-making process of the people and the effect that spatial requirements have on the decision-making process. The public zone for communication incorporates an intimate physical space where people sit in a circle, without a leader dominating the group. Some Eskimos view Westerners as masters of the savior attitude, which can serve to block communication with an impenetrable wall ( ).
Implications for Nursing Care
The nurse who cares for Eskimo clients should remember that certain requirements for spatial distances must be observed. Requirements for space must take into account that the client may have unique beliefs about space and may be disturbed when a nurse ventures into personal space to do such routine procedures as give a bed bath or provide oral care, especially if a trust relationship has not been established. The nurse must determine how much self-care can be implemented by the client and how much must be implemented by the nurse. When self-care is threatened, clients who are protective of space may become withdrawn, overly aggressive, or overly passive. The nurse must be careful to allow the client to make decisions about care, and thorough explanations should be given when the nurse must venture into the intimate or personal zone without blocking communication.
Social Organization
Family
The family unit, with its kinship ties, was paramount to survival in the harsh Arctic environment. The survival of the group traditionally was considered more important than the survival of the individual members. Several family units would band together in a migrating social group. These social groups were not permanent because families could disband and join other groups during a lifetime. However, the roles for individuals and for families within a social group were clearly delineated, so that the groups were not weakened by the shifting of members ( ). In fact, this shifting may have strengthened the culture by extending kinships. Extended families consisted of parents, their children (from a current or previous marriage or from adoption), grandparents, and single blood relatives. The husband was the head of the family, but the responsibility of bonding the family into a strong unit belonged to the mother. Thus, if the family was unsuccessful, the blame was placed on the woman. The woman’s role for family bonding has continued into the modern cultural adaptation. However, in recent years, some male members of the Eskimo society find themselves at a loss with the diminution of the role of hunter and subsistence gatherer. Inactivity and lack of jobs for men have led to alcoholism and family dysfunction.
The role of Eskimo elders in the family had been one of respect, honor, and inclusion in the family unit. noted that when Eskimo elders are relocated to nursing or assisted living homes, considerable stress on both the family and the elder occurs. They described a Marrulet Eniit (Yup’ik for “Grandmother’s house”), which opened in Dillingham, Alaska, in February 2000; the facility has provided a model for other Native-serving assisted living facilities in Alaska.
Kinships were vital social relationships when Eskimos lived in isolated areas. Kinship boundaries extended beyond blood relations through such practices as wife sharing, hunting partnerships, and the adoption of children. The code of behavior between kin was as binding as that between blood relatives ( ). These extensive kinship relationships were partially responsible for the cultural similarities in Eskimos that spread across the vast Arctic regions. History has recorded incidents of lost Eskimo hunters who crossed paths with another Eskimo band and were killed if the lost person could not prove kinship to a member of the new group ( ).
In Eskimo culture today, the extended family plays a very important role ( ). Survival no longer depends on kinships, but these relationships are far from dead. There still is a linking of families, which is evidenced by the sharing of Native foods or the formation of business partnerships. Eskimo villages have multigenerational families living in the same household or in a household in close approximation. Conflict has begun to occur because of the impact of members of the younger generation adopting dominant culture views toward elders instead of maintaining the strong influence of the views of elders in guiding family functioning.
The extended family involves the informal adoption of babies between families. If someone finds it impossible to care for a baby, adoption is an accepted practice. In the past, adoptions were frequently carried out with little or no litigation. Over the past decades, the informal process has been replaced with a more formal process. In addition, the Indian Child Welfare Act strictly limits adoption of Alaska Native babies by non-Natives ( ). An adopted child is fully incorporated into the extended family. Because of close family ties, the child is often related to the adoptive parents.
The rapid entry of the Eskimo into the American cash economy and value system has led to the restructuring of the Eskimo social and economic system. The nurse who interacts with persons from these cultures should recognize that partially accepted Western values may be superimposed over Eskimo values that are still practiced. The new elite class in Eskimo society is based on the ability to earn money without regard for old, established kinships and extended families, and a disregard for and severance of family and kinship ties underlie conflicts that may be found in villages today ( ).
Individual Freedom Exists within the Family or Group.
Eskimo cultures maintain respect for individual thought and personal freedom for behavior and decisions. At times, this individual freedom appears extreme because others in the society take on a noninterference attitude. For example, a husband may beat his wife without anyone lifting a finger to stop the beating, or a person may drink to oblivion day after day, and no one will take the bottle away ( ). The value of individual choice of behavior is honored as long as the integrity of the group is not in jeopardy. However, the Eskimos have decided as a group that alcoholism is destroying the fabric of their culture. A sobriety movement that urges Natives to become and stay sober has emerged within the group and become widespread across the region. The importance of the community as part of the pathway to sobriety has been operationalized by implementation of a local community option regarding the legality of possessing and purchasing alcoholic beverages by the State of Alaska. Of the 475 communities listed in the State of Alaska Community database, 20.6% ( n = 98) have opted to impose limiting conditions on the sale and/or importation of alcohol. Of those 98 communities, 78 (80%) are described by the state as being traditional Yup’ik or Inupiat communities. Of the 78 Eskimo communities, 75 (96%) have chosen one of three limitations, including banning (1) sale ( n = 9; 12%), (2) sale and importation ( n = 39; 52%), and (3) sale and importation and possession ( n = 27; 36%) of alcohol ( ). Further, efforts to understand pathways to sobriety among Alaska Natives have led to the recognition that prevention and treatment efforts should include attention to the importance of family and community in promoting sobriety ( ; ; ).
Social Status within the Family Structure.
Formerly, social status was attained by successful hunters who could provide food and skins not only for their own families but also for others. Successful hunters soon were recognized as leaders in the social group by the members. The opinions of successful hunters were given precedence over the opinions of others. A woman’s status was secondary to her husband’s and was gained through her own skills in keeping her family well fed and clothed. Each family member had an expected role to play. Grandparents were the primary educators of the children and imparted knowledge and skills required for survival. Children learned skills through play activities that also contributed to family needs, such as finding birds’ nests for the eggs or challenging a playmate in picking the most berries.
Some Eskimo parents do not punish or even correct their small children because tradition says that the spirits of a deceased relative guide each youngster. In the Eskimo cultures the spirit of the deceased relative was considered so paramount to the survival of the young child that while a woman was in labor an old woman was brought to the bedside to recite the names of the child’s dead relatives. The name that was uttered at the time the child became visible was regarded as the appropriate name, and thereafter that deceased ancestor was believed to become the guardian spirit of the child ( ; ). Many Eskimos still believe that the essence of a dead relative is found in children born around the time of the death of a relative. For this reason many new babies may have the same name of a recently deceased family member.
For the Eskimo child, praise from parents and grandparents provides a positive learning experience and a strong self-concept ( ). In Eskimo culture undesirable behavior traditionally was ignored, and if the behavior continued, the child was shamed through teasing and ridicule. Social controls within the community followed a similar pattern. There were no rigid rules. If a social standard was broken, it was assumed that the individual had a valid reason for the breach of conduct. Behavior was kept in control through teasing, gossip, and ridicule. If the behavior threatened group survival, the person was ostracized. To be isolated from the group meant certain death because an individual could not survive alone for long in the Arctic. The traditional Eskimo society is an example of a society that bases status on sharing and contributing to the well-being of the group that employs a positive feedback system to control its members ( ; ).
Traditional Eskimos did not have any formal recognition of puberty ( ). This was in contrast to other primitive societies where formal rituals frequently marked the coming of age. Boys are recognized by a feast at the first kill, which is shared with the family. In traditional Yup’ik Eskimo culture, girls were recognized when they danced with the older women for the first time.
For the nurse to give culturally appropriate nursing care to the client whose cultural makeup encompasses traditional values regarding social status, it is necessary for the nurse to appreciate traditional family roles. In most cases, it is also necessary to involve both nuclear and extended family members in the planning, implementation, and evaluation of nursing care.
Political Structure
The political development of Eskimos has evolved into the development of councils, native corporations, and health care corporations. The Alaska Native Land Claims Act of 1971 spurred a political development pattern loosely similar to the political system in other states. Where once each community had an informal social structure that revolved around family and kin, now most villages have a decision-making council headed by an elected spokesperson.
Implications for Nursing Care
Extended family ties can be used to encourage noncompliant clients into following recommended therapy. These ties can also be used to find reasons for noncompliance because the client may not feel free to contradict the nurse. In Eskimo culture it is considered impolite to openly disagree with others. Cooperation, patience, and nonaggression are important values. Attempts to persuade or counsel another person, even to keep that person from doing something dangerous or foolish, are considered rude and are not tolerated. Attempts by health care staff to “help” through advising and counseling may be seen as meddling, which may be resisted by the client ( ). The nurse may need to resolve a difficult situation by asking other family members for guidance. With the increased educational levels of the younger people and with the help of the nurse as an advocate, some Eskimos are beginning to assume autonomy in questioning medical therapy and social programs. It is essential that the nurse encourage the Eskimo client to take personal responsibility for health or illness in consultation with the appropriate family members. As appropriate, the nurse should directly involve the client in planning health care and in activities that pursue solutions to health needs.
Childrearing Practices
Eskimo parents have been observed to be highly sensitive to their children’s behavior cues and appropriately responsive to those cues. At the same time, development was more likely to be promoted through child-initiated rather than parent-structured learning activities and positive reinforcement was the norm ( ). Children are considered individuals as soon as they learn to express themselves. What this means for the nurse is that a child is given the right to refuse or accept health-related care. Some parents will not force a child to do something that the child refuses to do. For example, a parent may make a statement such as, “I tell Sam to brush his teeth, but he won’t do it” or “JoJo won’t let me put drops in her ear.” The parent may tease, shame, or ridicule the child in an attempt to persuade the child, but the parent will seldom demand the appropriate behavior. This is consistent with the findings of a study that used predominantly Eskimo focus groups in the Yukon-Kuskokwim delta to ascertain attitudes to ward tobacco use. The authors concluded that, for Eskimos, it was culturally inappropriate to tell others, including their own children, what to do ( ).
Implications for Nursing Care
Nurses working with Eskimo families should recognize the “unusual strength of their sensitivity to the child and the gentle nature of discipline” ( , p. 455) and to reinforce those strengths as an abuse prevention. At the same time, the nurse needs to emphasize that certain health care behaviors, such as brushing teeth or appropriately using medications, are important in preventing more serious problems, such as dental caries and otitis media. However, the implementation of these health-related practices may be difficult in view of culturally based childrearing practices.
In fact, dental caries is a significant problem among rural-residing Alaska Native children, where incidence rates as high as 87% among 4- and 5-year-old children and 91% among 12- to 15-year-old adolescents have been reported, with incidence being higher in villages without fluoridated community water systems ( ). The high prevalence of dental caries imposes high intervention costs ( ). In response, the ANTHC initiated a Dental Health Aide Therapist Program in 2004; graduates, who practice only in rural communities, provide both preventive and treatment services, including education, and sealing, fluoridating, cleaning, filling, and extracting teeth as needed ( ).
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