It Takes a Whole Indian Village . . .Steps to Decreasing Health Disparities

11th Annual Summer Public Health Research Video Conference on

Minority HealthChapel Hill, North Carolina

June 20-21

Presented by:Carole Anne Heart, Executive DirectorAberdeen Area Tribal Chairmen’s Health Board1770 Rand RoadRapid City, South Dakota 57702execdir@aatchb.orgwebsite: www.aatchb.org

Compelling evidence that race and ethnicitycorrelate with persistent, and often increasinghealth disparities among the U.S populationsdemands national attention.

DHHS

The Causes of Health Disparities:

• health care access• resources• treatment• outcomes• patient beliefs• provider biases• stereotyping• health status for racial and ethnic patients• patient-physician relationship• healthcare delivery system• language problems• understanding culture

Impact of Epidemics

For relatively self contained communities, the consequences of such catastrophes can scarcely be imagined. It meant devastation far worse than that wrought by warfare. Epidemics meant not only the sudden loss of parents, children and beloved friends but the destruction of entire cultures and economies. When warriers died, the entire nation became more vulnerable to predatory neighbors. When hunters died, the food supply shrank. When medicine men died, the spiritual world disintegrated. When young women died in large numbers, the community lost its capacity to reproduce. When the elderly died, collective memory went with them.

Fergus Bordewich, “Killing the White Man’s Indian,” 1996

The Facts:

• The unemployment rate on the Pine Ridge is 80% compared to 42% on Spirit Lake reservation. It is only 4.6% for the entire U.S. population. • The median income is $6,700 compared to

national median income of $30,056.00. • In the American Indian population, 43.1%

are under the age of five years lives below the poverty line compared to 20.1% of the white population. • In the age group of 18-64, 27% live below

the poverty line compared to 11.0% of the white population.

Trends in Indian Health, 1999

More Facts:

Unintentional injuries is the second leading cause of death for all ages, the foremost is motor vehicle accidents. It is fourth leading cause of death for U.S. males.

Aberdeen has the highest rate of death by

alcoholism 108.7%, of all the 12 regions, the lowest is OK at 21.7%.

14.1% have attained less than 9th grade education compared to 8.9% of the white population.

Trends in Indian Health Stats:

• Cardiovascular disease is now the leading cause of mortality among AI/AN people.• AI/AN have the highest prevalence of type 2 diabetes in the world, 2.6X the national average.• Rates of substance abuse among 12 year

olds and older is highest among AI/AN, 14%.

• AI/AN die at higher rates than other

Americans: alcoholism 0- 770% tuberculosis – 750% diabetes – 420 % accidents – 280% homicide – 210% suicide – 190 %

Health IssuesBehavioral Health

• Alcoholism– 6 out of 10 leading causes

of death of children are alcohol related

• Suicides– 72% higher than All

Races• Domestic Violence

– In New Mexico Indian women make up 3% of population yet are 14% of shelter population

48.7

20.0

15.0

6.710.4

7.3

0.0

10.0

20.0

30.0

40.0

50.0

60.0

Alcoholism Suicides Homicides

Chart indicates deaths per 1000 people. Blue = AI, Burgundy = U.S. Average

“The disease of alcoholism now constitutes an epidemic on the reservation. The effects ofthis disease have been devastating, widespread and pervasive, and have very nearly destroyed the basic structure of the family as a viable unit of tribal society and it has become evident with the passageof time and futility of effort that no meaningfullasting progress can ever be realized by the Tribeuntil this disease is brought under some degree ofcontrol”Gregg Bourland, Past Chairman, Cheyenne River Sioux Tribe, 1991

More Stats from Trends:

• AI/AN life expectancy is almost 6 years less than the general population. • Other estimates put the rate for Oglala male at 55 years • Infants die at a rate of 8/1,000 live births, compared to 7.2/ 1000 for US• Injuries cause 75% of all deaths among AI/AN from age 19 and younger.• Injuries are the leading cause of death for

AI/AN ages 1-44. Deaths from car crashes, pedestrian accidents, fir and drowning have decreased but overall death rate from preventable injuries is 2X as high.

WHAT IS AN INDIAN?

“Indians who did not conform to white expectations were harder to define. In 1869, the Supreme Court ofNew Mexico Territory declared that the Pueblos were not actually Indians, since they were ‘honest, industrious, and law-abiding citizens’ and exhibited ‘virtue, honesty and industry to their more civilized neighbors.’ However, after receiving agents’ reports of drunkenness, dancing, and debauchery, the Court reversed itself and declared that the Pueblos were Indians after all”

Taken from: Killing the Whiteman’s Indian, Fergus Bordewich,1996

12 Areas of IHS

Barriers to Healthcare Local Level• Lack of Funding leading to weak infrastructure• Communication between Tribes• Communication between AATCHB/IHS• Severe under funding of IHS programs• Lack of Grant writers/professional staff• Territoriality or turf issues• Fuzzy Personal/Professional boundaries• Metro doesn’t understand rural• Cultural misunderstanding• Racism, prejudice, discrimination

AATCHB Role and Activities

• Advocacy• Policy Analysis• Legislative Updates• Information dissemination to Tribes• Networking• Monitoring Legislative process• Creating Congressional support• Increasing Funding Base for Operations• Involving the Community

The True Founding Fathers

AATCHB

CIRCLE OF HEALTH

ALCOHOL

EMS

NPHS

CHR

HEALTH DIRECTORS PHS

NURSES

SOCIAL SERVICES

MENTAL HEALTH

GPTCHB SPOT MATRIXSTRENGTHS

+ Strong leadership+ Growth, progressive, track

record+ EPI Center+ Collaboration - tribes, fed.,

state govts & universities+ Diversity of membership+ Focus on health+ HB relationship w/ nat’l orgs.+ Grants & ear-marked

funding

PROBLEMSTHREATS- Lack of effective communications --

internal & external- Lack of adequate $$- Too many priorities/lack of focus- Vast distances--travel, costs,

communications, coordination- Poor attendance/quorums/

changing delegates– Lack of training/orientation of Board

members- Don’t get our message out- Integrating diversity of members

Disunity of chairman

CUR

REN

T/IN

TER

NA

L FUTU

RE/EX

TERN

AL

+ Responsiveness to community

+ Unity of Aberdeen area tribes

+ HB ability to advocate for AA tribes in

Washington.

- Health not a priority of tribal chairmen.

- Technology -- inadequate and lack of staff training or willingness to use.

– Weak or inadequate partnerships

–- Lack of sustainable funding- Lack of focus on unmet

needs–- Lack of sustainable funding–- Advocacy - not fairly

integrating all the needs of tribes

- Lack of org. infrastructure (operational, personnel, mgt. systems

•OPPORTUNITIES

Start with theend in mind-have

a prioritizedplan

•CommitmentMandatefor BoardMembers

• Public RelationsProgram

“Our” Chairman’sHealth Board

OrientationProgram for Tribal councils,

local & area HBs

Focus groups forlarger meetings

• Set up tribale-mail system 4Tribal HD’sTribal Chairs&Councils

October 28, 2004

Corporate &other sponsorsfor less restricted $$

• Find new ways todeal w/ majordecision making & resolutions between mtgs.

Use Technologyto plan & meet+Conf. Calls+Video conf.

RefineBylaws

Lack of ability to change quickly

Treaty opposition

Substandard services-diminished health status

Strengthen Partner-ships

Page 4

How is AATCHB responding? • Creating a stable, credible organization• Establishing a Strategic Long Range Plan• Creation of the Northern Plains Tribal Epi ~ NARCH, MCH, Academic Liaison, Injury Prevention• Supporting the Northern Plains Healthy Start ~SIDS/FAS Prevention Video ~ Rites of Passage Program ~ Breastfeeding Conference• Finding Partners• Sponsoring Conference/Seminars ~ First Cancer Conference ~ IRB Trainings (3) ~ Grant Writing ~ First Ever Tobacco Training ~ First Asthma Conference (July)

Trust responsibility functions have not kept pace with the demands of a growing population, inflation or disease burden. Communications between tribes/AATCHB/IHS/Feds and States needs greater attention National Politics: Indian Issues are not a priority Treaty obligations have been diluted Rural isolation, poverty and cultural differences AA tribes are predominantly non-self governance Facilities, healthcare professionals and specialized care is not on same level as facilities off reservation Tribal infrastructure needs strengthening

Barriers to Health Care National Level

IHS Appropriations Per Capita Compared to Other Federal Health Expenditure Benchmarks

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

MedicareExpenditures per

Enrollee

Medical Care forVeterans

Administration Users

US Per CapitaExpenditures forPersonal Medical

Services

Acute Medical Carefor Medicaid

Enrollees

Medical Care forFederal Prison

Inmates

FEHB Medical CareBenchmark per IHS

User

IHS Appropriations &Collections Per User

5,915

Non-Medical

2002

619

1,914

3,7253,8033,879

5,0655,214

19991999

1998

1999

20011999

IHS

MedicalCare

March 2003

Yearof LastPublishedData

Forecastto 2003

COMMUNITY ORIENTED HEALTH POLICYCOMMUNITY ORIENTED HEALTH POLICY

ORGANIZATIONALCAPACITY

WORKFORCECAPACITY &

COMPETENCY

INFORMATION &DATA SYSTEMS

HEALTH PROGRAMS CLINICAL SERVICES

PREVENTION

RESEARCH

Doctrine of Discovery• Gave the discovering power or party, the first right of occupation if there were no previous inhabitants.• IF there were inhabitants, the

discovering power had the first right to trade with, and to negotiate with, the newly discovered people issues of allegiance, sovereignty, and land sharing.

Trust• assured reliance on the character, ability, strength, or truth of someone or something,• one in which confidence is placed,• reliance on future payment for property or merchandise as delivered,

• Something committed or

entrusted to one to be use or cared for in interest or another.

“For AI/AN people, the federal responsibilityto provide health services represents a “pre-paid”entitlement, paid for by the cession ofover 400 million acres of land to the U.S.In many of the treaties negotiated betweenTribes and US, specific provisions for basichealthcare, such as the services of a physicianand the construction and maintenance ofhospitals and schools were included.”

Sally Smith, before the Senate Select Committee on Indian Affairs

“Sadly, our national honor has been repeatedly blemished by our failure to Live up to our word and to extend a fragment of the human respect that first greeted visitors to these shores. The Tribal structures have, however, survived, and sovereignty, in a real, although diminished form, has continually been acknowledged by the courts. Such sovereignty must be encouraged; for it is by the strengthening of tribal bonds and culture that not only Indian people will be served, but our national honor as well.” Larry B. Levanthal, Quare, University of Minnesota Law School, 1977

Children can change the World

“Each child is an adventure into a better life — an opportunity to change the old pattern and make it new.” Hubert H. Humphrey (1911–78)

“The world is an evil place, not because of evil people but because of those who sit back and do nothing about it.”

Albert Einstein