Disparities in Postmastectomy Reconstruction Use among American Indian and Alaska Native Women

Upon reviewing the July of 2024 issue of Plastic and Reconstructive Surgery, we were particularly struck by the article entitled “Disparities in Postmastectomy Reconstruction Use among American Indian and Alaska Native Women,” by White et al.1 Historically, such issues within the American Indian/Alaska Native (AI/AN, Native) communities have been underrepresented in plastic surgery literature. We are pleased to see this important topic brought to light, and express our gratitude to the authors for highlighting a matter deeply personal to our communities. The authors commendably identify factors and trends in postmastectomy reconstruction in AI/AN communities using the National Cancer Database, despite its inherent limitations. As AI/AN professionals in the medical field, we want to highlight the value in discussing solutions, including tribal health care delivery systems, and systemic inequities that contribute to poor outcomes and access, alongside defining disparities that persist. While the Snyder Act serves as a foundational legal basis for the provision of health care services to AI/AN communities,2 the current landscape of health care delivery to AI/AN people in the present and future has been dictated by 75 years of federal tribal health policy that were not mentioned. These policies are critical to understand and consider, as nearly 60% of facilities funded through the Indian Health Service (IHS) are operated by tribes.2,3 In a Viewpoint article in Plastic and Reconstructive Surgery–Global Open, we delve into the importance of tribal sovereignty and self-governance in health care as fundamental to expanding care and reducing disparities in reconstructive access and outcomes for AI/AN populations.4 The unique status of tribal nations and their right to self-governance provide a framework within which health care can be tailored to meet the specific needs of Native communities.2 Furthermore, although the authors highlight AI/AN perceptions of Western medicine, it is equally important to address the broader systemic issues. These include the invisibility of AI/AN communities within academic research and health care delivery systems, implicit bias impacting the care of AI/AN patients, and the chronic underinvestment in these areas.2,5 Achieving equitable care for AI/AN communities requires a concerted effort to recognize and address the power differentials within the health care system. This means ensuring that resource allocation and investment are equitable and that AI/AN communities are meaningfully included in health care decision-making processes. We are grateful to the authors for providing visibility of deficits in care and outcomes for AI/AN communities within plastic surgery. We encourage ongoing discussions and evaluations to continue highlighting these disparities and to develop and implement solutions aimed at achieving equity in health care for AI/AN people. This urgency of implementing solutions to decrease disparities cannot be overstated, given the significant gaps that persist in reconstructive access.1,6 Above all, discussions about disparities in care and outcomes for AI/AN populations should always be accompanied by practical, tangible solutions that are informed by the present policy landscape, including federal and tribal policies, and guided by the insights of tribal health care leaders. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication.