According to the Meriam Report of 1928, which painted a damning picture of life at the boarding schools, students sometimes had no access to soap, and had to share towels, cups and beds. This led to major outbreaks of trachoma, measles and tuberculosis. The influenza pandemic of 1918-19 also hit the boarding schools hard.

In most cases school officials failed to notify parents of the sickness until their children died, often in agonizing solitude. Many were buried in school cemeteries, in wooden coffins made by their classmates.

"Indian children … in the residential schools… die at a much higher rate than in their villages," Duncan Campbell Scott, the Canadian government's deputy superintendent of Indian Affairs, said in the 1920s. "But this does not justify a change in the policy of this department, which is geared toward a final solution of our Indian Problem."

Evidence suggests that in this matter Scott's US counterparts were of a similar view.

In a letter to his father, a Sicangu chief, dated March 31, 1881, Luther Standing Bear (1868-1939), who attended the Carlisle school, wrote:

"Day before yesterday, one of the Sioux boys died. His name is Alvan. He was a good boy always. So we were very glad for him. Because he is better now than he was on Earth. I think you maybe don't know what I mean. I mean he has gone in heaven."

In the same letter, the boy urged his father, "I want you must give up Indian way." Similar sentiments were expressed as he wrote the previous year: "Now always let us try to speak English and work and write and be good and be right and let us do right everything that is best way and Capt. Pratt what he says."

Jacki Thompson Rand, a professor of American Indian studies at the University of Illinois Urbana-Champaign, said in an interview with Vox, an American news website: "If you were a child who had any spirit at all, they made it their business to take it right out of you."

A crushing sense of shame, long pumped into the hearts of students who were reminded daily of the "inferiority" of their race, led not only to mental and physical instability, but also to debilitating and lifelong self-hatred.