Response to Nguyen et al: "A plea for involving American Indian researchers and allies in research and manuscript reviews"

This Letter to the Editor was written in response to a previously published version of Nguyen et al that used the term “tribal homelands” in place of “tribal areas.” The terminology and discussion in the manuscript has since been revised by the authors on in May 2023 after our letter was published online on April 28, 2023. To the Editor: Nguyen and Bray’s1Nguyen B. Bray F.N. Access to dermatologic care in Indigenous American communities.J Am Acad Dermatol. 2022; 87: 904-906https://doi.org/10.1016/j.jaad.2022.04.026Abstract Full Text Full Text PDF Scopus (0) Google Scholar “Access to dermatology care in Indigenous American communities” brings attention to a worthy issue as follows: a paucity of dermatologic care in Indian Country. However, their discussion is insufficient and fails to address the numerous barriers that hamper the ability of American Indians and Alaskan Natives (AIAN) to access dermatology services. The study reports the density of dermatology providers in AIAN “homelands”—a term with which we take issue. “Homelands” is not an accepted or legally significant term by which to refer to tribal lands in the continental US, nor do the authors define this novel terminology. The Biden administration uses “tribal homelands” in their Tribal Homelands Initiative to improve the stewardship of public lands, waters, and wildlife, but it does not refer to specific geographic areas. We are left to assume that “homelands” refer to the federally recognized Indian reservations and 2020 Census Tribal Designated Statistical Areas listed in Table 1.1Nguyen B. Bray F.N. Access to dermatologic care in Indigenous American communities.J Am Acad Dermatol. 2022; 87: 904-906https://doi.org/10.1016/j.jaad.2022.04.026Abstract Full Text Full Text PDF Scopus (0) Google Scholar More specific and accepted terminology, such as “American Indian reservations and state-designated tribal statistical areas,” should have been used instead of “homelands.” Furthermore, the authors’ approach to dermatology access issues for American Indians oversimplifies the issue by only measuring provider density. Although this is one way to quantify access to care, it fails to account for the numerous challenges faced by AIAN peoples. Many dermatologists limit the number of Medicaid patients they see, and some may not accept Indian Health Service Purchased and Referred Care patients.2Creadore A. Desai S. Li S.J. et al.Insurance acceptance, appointment wait time, and dermatologist access across practice types in the US.JAMA Dermatol. 2021; 157: 181-188Crossref PubMed Scopus (28) Google Scholar Dermatologists may also be inaccessible to AIAN patients independent of insurance (eg, communication methods, wait time, and cultural competency), rendering the existence of dermatology providers a moot point).3Kohn L.L. Introcaso C.E. A cultural context for providing dermatologic care to American Indian and Alaskan Native communities through telehealth.JAMA Dermatol. 2019; 155: 884-886Crossref Scopus (3) Google Scholar Challenges of tribal enumeration also complicate the use of census data in elucidating disparities in AIAN care. Self-identification is difficult as different definitions of AIAN exist that could exclude individuals belonging to federally unrecognized tribes or those who do not meet thresholds set by the legacy of blood quantum.4Liebler C.A. Counting America’s first peoples.Ann Am Acad Pol Soc Sci. 2018; 677: 180-190https://doi.org/10.1177/0002716218766276Crossref PubMed Scopus (12) Google Scholar Logistical issues pose problems as well: many reservation homes lack mailing addresses; most AIANs are dispersed in cities and suburbs; and AIANs are a highly mobile group.4Liebler C.A. Counting America’s first peoples.Ann Am Acad Pol Soc Sci. 2018; 677: 180-190https://doi.org/10.1177/0002716218766276Crossref PubMed Scopus (12) Google Scholar Direct efforts by the federal government to count AIAN peoples are complicated by their historical relationship with the US government, with a great deal of distrust remaining to this day.4Liebler C.A. Counting America’s first peoples.Ann Am Acad Pol Soc Sci. 2018; 677: 180-190https://doi.org/10.1177/0002716218766276Crossref PubMed Scopus (12) Google Scholar These factors bear acknowledgment if we are to accurately depict the realities faced by AIANs. The challenges facing AIAN communities are multifactorial; no simple solution exists. Undoubtedly, more dermatologists serving Indian Country—as Nguyen and Bray1Nguyen B. Bray F.N. Access to dermatologic care in Indigenous American communities.J Am Acad Dermatol. 2022; 87: 904-906https://doi.org/10.1016/j.jaad.2022.04.026Abstract Full Text Full Text PDF Scopus (0) Google Scholar propose—would improve the current situation. However, our future efforts should focus on training AIAN dermatologists who possess the background to deliver culturally relevant, patient-centered care and research in the tribal communities they serve.5Kohn L.L. Manson S.M. Dermatology on American Indian and Alaska Native reservations.in: Brodell R.T. Byrd A.C. Firkins S.C. Nahar V.K. Dermatology in Rural Settings. Springer, Cham2021: 117-127Crossref Google Scholar These physicians could, together with allied physicians of all backgrounds who themselves have benefited from a greater understanding of AIAN peoples, empower tribal health organizations to develop a workforce and body of research meeting the specific needs of AIAN peoples. Tribal communities are already working hard to improve their health and our efforts must be rooted in developing trusting, respectful relationships with AIAN dermatologists and allies leading the way. None disclosed.