Candida King Bird lies on a table in a dark exam room and watches the wall monitor as a health worker sweeps an ultrasound wand over her round belly.

A chubby face with pudgy nose and ample lips emerges on the screen.

"Oh my God, she is so cute," says King Bird as tears roll down her cheeks.

The Portland mom, a member of the Ojibwe tribe, comes weekly to

. Her sixth pregnancy poses risks because she is diabetic and 38. Doctors plan to deliver her daughter by cesarean section next week.

Invisible Nations

Enduring ills

The Oregonian focuses on the often-overlooked minority of urban Native Americans and their enduring health disparities. Upcoming stories will focus on the epidemic of diabetes; the traumas that fracture health; risky pregnancies; and solutions that have bubbled up in unlikely places.

Her baby is up against higher risks not only getting into the world, but also surviving in it as a Native American. Compared to the average American, the child is twice as likely to be diabetic, get asthma, smoke, develop liver disease or become pregnant as a teen. She also is more likely to be injured in an accident; drink and use drugs; become obese; or commit suicide. She is more likely to live a shorter life.

Map

»

By most measures, Native Americans' health problems exceed the average, and it's even worse for urban Indians who can't tap social and health services available on distant reservations.

The problem's not new, but some of the solutions are.

Native Americans have built their own health organizations that mix Native traditions and Western medicine. They have acted on a fundamental truth -- what people do at home with diet, exercise, conflict and lifestyle more profoundly affects health than what a doctor prescribes in the clinic. Their innovative practices have produced successes, gained wide admiration and are reflected in the prevention-oriented team approach at the heart of Oregon's health reforms.

Well-documented assaults on Native identity and culture -- boarding schools, tribal termination, relocation, a ban on religion and language -- eroded the health of generation after generation.

Urban Indians are still "treated as outsiders," says Dr.

, part Cherokee and professor of psychiatry and preventive medicine at OHSU. "There is a tribe out there called Other, and that is us."

It wasn't that way 207 years ago, when Lewis and Clark floated through, the obvious outsiders among the thriving nations of Multnomah, Kathlamet, Clackamas, Tualatin, Molalla, Chinook and others.

Today thousands of people from nearly 300 tribes live on this same land.

About 2 percent of the metro area's 2 million people identify as Native American or part Native. That amounts to about 30,000 of 102,000 statewide, including nine reservations. Another 9,000 live across the river in Clark County.

With so few spread so thinly, they are overlooked in government studies that allocate services by numbers. Their children are overenrolled in foster care and underenrolled in health insurance and Head Start.

Urban Indians "are a hidden minority unlike any other group," says Mario Garrett, a San Diego State University gerontologist and researcher for the

. He sees no government effort to address their needs.

"They have no voice," he says. "They are invisible."

NUMBERS CAN LIE

Although tribes on reservations accurately track their populations and health problems, tracks get murky for urban Indians, particularly in death.

Look at diabetes, for example. Federal agencies put the Native death rate from the disease at nearly three times the average American. Yet Multnomah County reports only 14 Natives died from causes related to diabetes between 2005 and 2009.

Also in that period, only 205 Native Americans died from all causes -- 41 a year out of 16,000 -- which gives Natives in Multnomah County a lower death rate than the general population. That contradicts a higher national death rate as well as a life expectancy that's three to five years shorter.

Off the reservation, morticians and health providers often fail to recognize Native Americans because they don't look Native or have a non-Native surname, says Victoria A. Warren-Mears, director of the epidemiology center of the Northwest Portland Area Indian Health Board. One study found 83 percent of Native Medicare recipients labeled as other races -- 47 percent as white.

Health profile

In the metro area, how Native American health compares to the general population:

21 percent

of Native Americans have asthma compared to 9 percent of general population

.

31 percent

smoke compared to 15 percent

31 percent

are obese compared to 24 percent

15 percent

report frequent mental distress* compared to 9 percent.

20 deaths

per 100,000 to liver disease compared to 9

29 percent

in poverty compared to 12

Nearly all single Native women

with young children live in poverty.

Source:

Urban Indian Health Institute in Seattle for 2005-2009

*

Stress, depression or problems with emotions more than 14 days a month.

Chronic misclassification and underreporting vary across the country, but it's worse in cities. Skewed and understated statistics make precise comparisons impossible.

Complicating matters, fewer Natives are insured, and many are not enrolled with the 566 federally recognized tribes, which entitles them to federal health care.

"We have experienced a lot of loss as Indian people," said Dr. Donald Warne, director of the

in Sioux Falls, S.D. "There is not a pill that is going to address that."

ROOTS OF DISPARITIES

The federal government made a deal. In exchange for taking Native land, it would provide health care. That promise became institutionalized in 1955 as

The agency provides an average of $2,690 per person a year, less than what federal prisoners get. The U.S. average spent on health care is $6,826.

If you're going to get sick, do it by summer, Natives say, before the IHS budget dries up.

IHS sends 1 percent of its money to cities, 99 percent to reservations. In the metro area, home to about 30 percent of the state's Native population, that money flows to the

(NARA). This year NARA received $2.6 million, about $571 per patient. Private insurance, Medicare, Medicaid and county contributions cover the rest of NARA's $15 million budget. To pay for specialists, NARA partly relies on doctors who donate services. It's also part of a group of safety-net clinics that negotiates with hospitals for specialty care.

"We know the need is bigger than we can meet," says Jackie Mercer, chief executive officer. Still, NARA's budget has grown sevenfold since Mercer became its head 13 years ago.

"People can feel the spirit of NARA and how it heals," she says. "We do a lot with a little."

(NAYA) in Northeast Portland also has bloomed over the past decade and tackled problems that undermine health: homelessness, unemployment, lack of prenatal care and poor nutrition.

"The way you are really going to impact health is to address issues around housing, poverty and stress," says Nichole Maher, executive director of the $8 million-a-year operation.

Many Native Americans, particularly elders who grew up when their spiritual health practices were illegal, are wary of doctors and Western medicine. Some have found doctors demeaning or even abusive.

a local Shoshone-Bannock storyteller and poet, says he's been reluctant to see white doctors after one pulled two of his teeth in 1949 without a painkiller.

Those same elders likely grew up on reservations, where health services were basically nonexistent before the IHS. They depended on government rations of flour, lard and salt, a far cry from their traditional healthy diet of fish, game, fruit, berries, nuts and roots. Diet and a sedentary reservation life fueled obesity and diabetes.

One mid-March day, 21 elders eat roast buffalo and rice at NAYA for lunch. Some had just completed an hour of tai chi downstairs. Eight spent at least part of their childhood on reservations. Dan Foster, 81, a Paiute, wasn't on the Klamath Reservation long, though. Police snatched him and four siblings off a field in 1935 and shipped them to a boarding school near Salem. He never lived on the reservation or with his family again.

Boarding schools, reservations, relocations and other government controls are the legacy of colonialism, says Terry Cross, a Seneca and executive director of Portland-based

"The basic, underlying message of colonialism is: You are not smart enough to take care of yourself so we have to control everything," he says. "It is devastating to the human spirit."

His mother, beaten in school for speaking her language, grew up in fear. Cross, 59, and his generation grew up angry.

The generation now coming of age, he says, "are the get-down-to-business folks," like those who lead NAYA and NARA.

"People are learning their culture," he says. "They are rejecting the colonial lie."

TURNING TO TRADITION

Philip Archambault, 74, was born Hunkpapa Lakota Sioux and raised on the reservation that spans the North and South Dakota border. But it was at NARA he learned about the talking circle, the sweat lodge ceremony, the drums and other practices he now oversees as NARA's traditional cultural director.

He regained his spiritual bearings in 1982 on Mount Hood, when he knelt before the sacred tree and asked the Great Spirit for permission to participate in the Sun Dance, a sacred ceremony that tests endurance. He spent four days without food or water on the mountain.

"The more it hurts," he says, "the more you pray."

Such religious practices were illegal when Archambault grew up. In high school, he saw federal agents imprison a couple for using their pipe in a ceremony. It was not until 1978 that the government again allowed tribes' spiritual traditions.

"Culture is about learning about yourself as a human being and what you value," says Archambault as he leads about 20 men and women at NARA's alcohol and drug program. "People who lose their spirituality are the ones who commit suicide."

Like Archambault, King Bird latched on to her culture for stability, sobriety and health. She sees it as a path to help her daughter beat the odds.

"I'm thinking of naming her Mishiike Meteh," says the mom. It means turtle heart in Ojibwe. Elders tell her the turtle cannot move without sticking out its neck, and after it dies and crosses over, its heart continues to beat awhile.

King Bird's already collecting plumes for the headdress her daughter will wear at powwows.

"She is going to dance."

This story is produced with the assistance of the Dennis A. Hunt Fund for Health Journalism, administered by The California Endowment Health Journalism Fellowships, a program of the University of Southern California's Annenberg School for Communication & Journalism.