How does IHS relate administratively to the high alcoholism mortality rate?

From 1969 to 1990 the alcoholism mortality rate for American Indians/Alaska Natives (AI/AN) has been steadily decreasing. Compared to the U.S. All Races overall rate decrease of 7.8% in that time period, the AI/AN rate has decreased 33.6%, a remarkable fourfold decrease in the mortality rate due to alcoholism. In the decade from 1978 to 1988 the rate decreased from 64.5/100,000 in 1978 to 37.3/100,000 in 1988, a decrease of 42.2%. The comparable figures for U.S. All Races were 8.1/100,000 in 1978 and 7.0/100,000 in 1988, a decrease of 13.6%. During this decade (1978 to 1988) the Indian Health Service (IHS) embarked upon a major effort to assimilate and to expand alcoholism programs then transferred from the National Institute on Alcohol Abuse and Alcoholism (NIAAA) by incorporating those programs into the IHS health delivery system. The number of programs has more than doubled (158/400) since the transfer was completed in 1983. Funds, moreover, have quadrupled ($20/$82.3 million in 1993). The actual funds expended by IHS from Fiscal Year (FY) 1981 through FY 1993 were $559,916,000. Despite the dramatic increase in numbers of programs and total funds applied to the reduction of alcoholism mortality, available data reveal an increase in alcoholism mortality of 40.3% from 1986 to 1990. This article reviews and questions the relationship of allocations, per capita expenditures, and service components available to reduce alcoholism mortality by IHS Areas in light of the increase in the mortality rate and the fourfold increase in the budget. The data appear to show little relationship of mortality rate with allocations, the number of service components available, or per capita expenditures.