There are 573 federally recognized American Indian (AI) and Alaska Native (AN) tribes in the US with an estimated 5.2 million AIAN people, not including state-recognized tribes and descendants of tribes no longer meeting federal recognition.¹ Despite advances in health care and greater access to care, AIAN communities continue to face significant health inequities such as lower health status, lower life expectancy, and higher disease burden when compared to the general US population.¹ These inequities can largely be attributed to the horrors of colonization, the impact of boarding schools on families, the removal of land and resources, and ongoing systemic racism that exacerbates adverse social drivers of health.² These historical traumas carry significant weight from generation to generation and negatively impact the health of our AIAN communities.

Providing a lens on outcomes in surgical fields, it is well documented that AIAN patients are more likely to present with higher stages of lung, breast, prostate, and colon cancer, and are less likely to receive curative therapies when compared to other races.³ This is in part due to poor access to care, as many reservations are in rural areas, and to underfunding and inadequate staffing of the Indian Health Service, which is the primary health delivery system for many Indigenous communities.³ Additionally, many of the health inequities faced by AIAN communities increase the overall risk of surgery. Common comorbidities such as obesity, diabetes, substance use, and renal failure increase the rates of intra- and postoperative complications,⁴ which can influence mortality rates and willingness of providers to offer curative therapies. In the field of urology, AIAN communities have lower rates of prostate cancer screening, delays in diagnosis, less access to treatment, and higher rates of mortality, all of which can be attributed in part to poor health care access.⁵

Given that the primary driver of the surgical health inequities observed in AIAN communities is systemic in nature, it follows that the means to address them should be systemic as well. While it is necessary for all surgeons to recognize the social and economic influences (driven by systemic racism) that negatively impact surgical diagnoses, care, and outcomes in AIAN communities, other systemic interventions should be employed. One sustainable strategy is increasing AIAN representation in surgery and surgical subspecialties, since racial concordance between patients and their surgeons improves communication, the quality of surgical care received, and attenuates the effects of mistrust of the medical system common in AI communities.⁶ Poor educational attainment is unfortunately widespread among AIANs, which leads to inequitable representation among medical students, residents, and fellows, which has untoward effects on the physician workforce.⁷ Currently, 0.3% of US urologists identify as AI or AN, though this percentage is less among surgeons in general (0.16%).^8,9 This stark disparity highlights the vital importance of diversification efforts in surgery, which provides an inclusive palette of voices, socioeconomic backgrounds, race, ethnicity, gender, and sexuality in efforts to improve surgical care and outcomes.

Increasing the number of AIAN surgeons and surgical subspecialists requires a multipronged approach. Augmenting educational opportunities for AIAN communities from elementary school through professional education programs is paramount.⁷ The creation of AIAN-specific “pathway programs” to medicine assists with academic preparation and medical school applications, which can overcome the lack of community mentorship and increase matriculation.¹⁰ AIAN medical students should be exposed to surgical careers early in their training in an open and inclusive way, being careful to check implicit and explicit biases.¹¹ Mentorship is essential for these nascent surgeons, particularly from faculty from underrepresented in medicine backgrounds.¹² While best done by AIAN senior surgeons, if there aren’t AIAN surgical faculty to serve as mentors at your institution, medical schools should consider sending their AIAN students to national conferences such as the Association of American Indian Physicians Annual Meeting to expand their sphere of mentorship. Particular attention should be paid to retention of AIAN surgical and surgical subspecialty residents. Adherence to antiracist principles, such as combating microaggressions, providing bias reduction training to the general faculty body, and creating an inclusive learning environment can avoid attrition of AIAN residents.¹¹ Contrarily (given the small pool of AIAN surgeons and surgical subspecialists), increasing the number of AIAN faculty members in a surgical department, via active recruitment and cluster hiring, will automatically increase opportunities for AIAN medical students and graduate medical education learners, not only by providing leadership for pathway programs and directed mentoring as above, but also opportunities for scholarship focused on attenuating AIAN surgical health inequities.

AIAN communities experience profound health inequities due to the lingering effects of colonization and ongoing systemic racism. A viable strategy to attenuate health inequities in surgical care and outcomes for AIANs is to increase the number of AIAN surgeons and surgical subspecialists, through stratified policies to increase AIAN matriculants to medical school, directed mentorship and ensuring surgical resident well-being and success.