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University of North Carolina Chapel Hill MHCH/PUBH Understanding and Addressing Health Disparities in the US

University of North Carolina Chapel Hill MHCH/PUBH Understanding and Addressing Health Disparities in the US. “Raising Awareness of American Indian/Alaska Native Health Issues” Dean S. Seneca, MPH, MCURP Health Scientist Policy, Tribal Portfolio Portfolio Management Program

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University of North Carolina Chapel Hill MHCH/PUBH Understanding and Addressing Health Disparities in the US

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  1. University of North Carolina Chapel Hill MHCH/PUBH Understanding and Addressing Health Disparities in the US “Raising Awareness of American Indian/Alaska Native Health Issues” Dean S. Seneca, MPH, MCURP Health Scientist Policy, Tribal Portfolio Portfolio Management Program Office of the Chief of Public Health Practice Centers for Disease Control and Prevention

  2. The American Indian and Alaska Native people have long experienced lower health status when compared with other Americans. Lower life expectancy and the disproportionate disease burden exist because of inadequate education, disproportionate poverty, discrimination in the delivery of health services, and cultural differences. These are broad quality of life issues rooted in economic adversity and poor social conditions. American Indian/Alaska Native Health Disparities

  3. American Indians and Alaska Natives born today have a life expectancy that is 2.4 years less than the U.S. all races population (74.5 years to 76.9 years, respectively; 1999-2001 rates), and American Indian and Alaska Native infants die at a rate of nearly 12 per every 1,000 live births, as compared to 7 per 1,000 for the U.S. all races population (2002-2004 rates). American Indian/Alaska Native Health Disparities

  4. American Indians and Alaska Natives die at higher rates than other Americans from tuberculosis (750% higher), alcoholism (550% higher), diabetes (190% higher), unintentional injuries (150% higher), homicide (100% higher) and suicide (70% higher). (Rates adjusted for misreporting of Indian race on state death certificates; 2002-2004 rates. ) American Indian/Alaska Native Health Disparities

  5. Given the higher health status enjoyed by most Americans, the lingering health disparities of American Indians and Alaska Natives are troubling. In trying to account for the disparities, health care experts, policymakers, and Tribal Leaders are looking at many factors that impact upon the health of Indian people, including the adequacy of funding for the Indian health care delivery system. American Indian/Alaska Native Health Disparities

  6. Who is an Indian? • Tribes establish criteria for membership • 1/4 tribal blood, BIA Standard • a descendant of a tribal member • or a person recognized by the tribal members as a member. • Alaska Native: The term collectively refers to Eskimos, Aleuts, and American Indians who are indigenous to Alaska. • American Indian: This includes enrolled members of Federal and/or State recognized tribes as well as people who are self-identified as “American Indian” on the U.S. Census and other similar reports.

  7. What is an Indian Tribe? Any Indian tribe, band, Nation, rancheria, Pueblo, or other organized group or community, including any Alaska Native village, group, regional, or village corporation as defined in or established by the Alaska Native Claims Settlement Act, and is recognized as eligible for the special programs and services provided by the United States to Indians through government to government relationships, specifically treaties. A tribe may be federally recognized, state recognized, or self-recognized.

  8. What is a Reservation? • The geographic area reserved by treaty or other law for a federally recognized Indian tribe. • Navajo Nation -

  9. 1790 Forced Inland 1890 Vanquished 1830 Indian Country 1492 Arrival of Columbus 1860 Immigration Stampede 2090 Indian Country? = Reservation Lands Map of Thanks to RUSSELL PUBLICATIONS INDIAN COUNTRY

  10. Tribal Sovereignty • Treaty Tribes have a Nation to Nation relationship with the US. Government • Tribes are Sovereign Nations • States do not have jurisdiction on tribal lands • Movement towards Tribal Self-Governance • Tribes make and enforce your own Laws

  11. 1608-1830, “Treaties” – The Marshall Trilogy historic cases Johnson v. McIntosh, Cherokee Nation v. Georgia, and Worcester v. Georgia all recognized Indian Nations as Sovereign Entities. The Supreme Court found that Tribes were no longer territorially separate from the United States. Tribes (a) could not transfer lands to or sign treaties with any other colonizing power and (b) had placed themselves under the protection of the United States. Federal Indian Policy

  12. 1830-1850, “Removal Policy” – Indian Removal Act policies moved the Tribes west of the Mississippi into the Louisiana and Northwest Territories. 1850-1871, “Removal Shifts to Reservation System” – Over 100 treaties created moving Tribes to new, smaller territories or confined them to smaller territories reserved from their aboriginal territory. Federal Indian Policy Continued

  13. 1871-1928, “Assimilation and Allotment Era” – The United States sold or gave Indian Land to non Indians to make Indians Assimilate into non-Indian communities. Resulted in (a) the loss of 90 out of 138 million acres of land and (b) the displacement of thousands of Indians. “Indian Reorganization Act of 1934” – The Act reaffirmed that tribal governments had inherent powers. 1943 – 1968, “Termination” – Reversed many of the reforms made in the 1930’s by terminating many federal state tribal relationships. Promoted assimilation of Indians into mainstream society. Federal Indian Policy Continued

  14. 1968 – Present – “Self Determination” – In 1968, PL 280 was amended to require the consent of Indian Nations before state could assume jurisdiction. This era of various presidential policy statements and legislative acts that benefited Indians, strengthened tribal governments, reaffirmed tribal sovereignty and ended the termination period. Federal Indian Policy Continued

  15. Existed between 1870-1928 Movement attributed to Manifest Destiny philosophy Mission: to educate Indian children and assimilate them into the European language and culture. Allow the Indian people to become self-sufficient, and therefore reduce government spending. “Social Evolution” of the Indian expectations included: - Speaking English - Learning a vocation - Practicing farming Founded to expand the land available to the Europeans and confine the Indian people. Result-assimilation failed and Indian culture survived, but Native children suffered serious repercussions Reservation Boarding School System

  16. Fort Simcoe, Washington

  17. Apache Children at Carlisle Indian School

  18. Apache Children at Carlisle Indian School 4 months later

  19. American Indian Facts Data According to the U.S. Census 2000 Population Data of AI/AN in United States: -4.1 million Geographic Distribution: -West (43%) -Midwest (17%) -South (31%) -Northeast (9%)

  20. Demographics, 1990 Census U.S. NativesAll Races 24 yrs. 33 yrs. $19,900 $30,000 32% 13% 66% 75% Median Age Median Income Below Poverty High School

  21. Demographics, 2000 Census U.S. NativesAll Races 28 yrs. 35.3 yrs. $31,799 $42,148 25.9% 11.3% 70.9% 80.4% Median Age Median Income Poverty Rate High School

  22. Public Law 93-638 • To Provide maximum Indian Participation in the Government and education of Indian People. • To provide for the full participation of Indian Tribes in programs and services conducted by the federal government. • After Careful review Congress finds: • The prolonged federal domination of Indian service programs has served to retard rather than enhance the progress of Indian people and their communities by depriving Indians of full opportunity to develop leadership skills crucial to the realization of self-government • The Indian people will never surrender their desire to control their relationships both among themselves and with non-Indian governments, organizations and persons

  23. Public Law 93-638 Cont. Contracting: allows the Tribes to take over planning and implementation of any or all federal services. Tribes can requests permission from the IHS to redesign those parts of the health care system they are responsible to address. Compacting:Tribes enter into funding agreements where they assume control over the planning, and delivery of some or all federal services. Tribes can do what ever they want with the funding as long as it is intend for the desired purpose. Direct Service:The Federal government provides a service directly to the tribe.

  24. Common Values Among Natives • Sharing and generosity • Allegiance to family, community and tribe • Respect for Elders • Non-Interference • Orientation to present time • Harmony with Nature • Respect for status of the Woman and the Child

  25. A belief in an unseen power, Great Mystery or Creator All things in the universe are related Worship reinforces bonds between the individual, family and community (our relatedness) Spirituality is intimately connected to our health Common Beliefs Related to Spirituality

  26. Respective Core Values Traditional NativeMain Stream Society, U.S. Cooperative Competitive Group/Tribal Emphasis Freedom, Progress, Efficiency Extended Family Important Individualism Modesty Sexy Patience/Passive (SW) “Getting Ahead in Life” Generous/Non-Materialistic Material Comfort Respect for Age Youth Spirituality External Conformity Indirect Criticism Direct Criticism Harmony with Nature Conquest of Nature

  27. Operate within a government-to-government relationship with federally-recognized Tribes Consult, to the greatest extent practicable and to the extent permitted by law, with Indian tribal governments before taking actions that affect federally recognized tribes. Assess the impact of executive department and agency activities on tribal trust resources and assure that tribal rights and concerns are considered. Take appropriate steps to remove procedural impediments to working directly and effectively with tribal governments on activities that affect the trust responsibility and/or governmental rights of tribes. Presidential Memorandum on Government-to-Government Relations with AI/AN Tribal Governments

  28. Executive Order 13175 of November 6, 2000“Consultation and Coordination with Indian Tribal Governments” • Funding Principles • Policy Making Criteria • Consultation • Increasing Flexibility for Indian Tribal Waivers

  29. AI/AN Public Health:Challenges/Obstacles • Few AI/AN public health professionals • Limited familiarity with AI/AN policies • Complexities/logistics – over 500 tribes • Public health legislation/legal foundations • Lack of public health infrastructure • Funding issues

  30. AI/AN (1992-1994) Age-Adjusted Death Rates Compared to U.S. All Races (1993) Source: Trends in Indian Health, 1997 IHS Epidemiology

  31. Billings 58,794 Portland 158,892 California 132,740 Phoenix 150,540 Nashville 78,745 Tucson 28,980 Navajo 223,029 Oklahoma 318,691 Albuquerque 82,818 Alaska 109,780 2001 IHS Service Population* by Area Total Population: 1,540,129 Aberdeen 102,758 Bemidji 94,362 IHS Epidemiology *Projected from 1990 Census

  32. Heart disease Cancer Unintentional injuries Diabetes Stroke Chronic liver disease and Cirrhosis Chronic lower respiratory diseases Suicide Influenza and Pneumonia Nephritis, Nephrotic Syndrome, & Nephrosis Ten Leading Causes of Death for American Indians/Alaska Natives in U.S.,2003 Source: Health, United States, 2005, Table 31.http://www.cdc.gov/NCHS/data/hus/hus05.pdf#summary

  33. AI/AN Heart disease Cancer Unintentional injuries Diabetes Stroke Chronic liver disease & Cirrhosis Chronic lower respiratory diseases Suicide Influenza and Pneumonia Nephritis, Nephrotic Syndrome, & Nephrosis Ten Leading Causes of Death in the U.S. in 2004 for AI/AN as Compared to the Nation U.S. • Heart disease • Cancer • Stroke • Chronic lower respiratory diseases • Unintentional injuries • Diabetes • Alzheimer’s Disease • Influenza and Pneumonia • Nephritis, Nephrotic Syndrome, & Nephrosis • Septicemia Source: Health, United States, 2005, Table 31.http://www.cdc.gov/NCHS/data/hus/hus05.pdf#summary

  34. Age-Adjusted Death Rate Per 100,000 Persons By Race & Hispanic Origin For All Causes U.S., 2004 Source: Health, United States, 2007, Table 29.http://www.cdc.gov/NCHS/data/hus/hus05.pdf#summary

  35. Age-Adjusted Death Rates per 100,000 Persons by Race for All Causes: U.S. & IHS Service Area - 1997 Source: Health, United States, 2005, Table 31. And IHS Trends in Indian Healthhttp://www.cdc.gov/NCHS/data/hus/hus05.pdf#summary

  36. Age-Adjusted Death Rate American Indians & Alaska Natives, Adjusted (3-Year) Rate Per 1,000 Population American Indians & Alaska Natives, Actual (3-Year) U.S. All Races (1-Year) U.S. White (1-Year) Source:IHS Trends in Indian Health, 2000-2001, Table 4.11, p.69.

  37. Deaths by Age and Race Percent Distribution Source:IHS Trends in Indian Health, 2000-2001, Table 4.14, p.75.

  38. Age-Adjusted Death Rates per 100,000 Persons by Race for Cerebrovascular Diseases: U.S. & IHS Service Area - 1997 Source: Health, United States, 2007, Table 29.http://www.cdc.gov/NCHS/data/hus/hus05.pdf#summary

  39. Age-Adjusted Malignant Neoplasm Death Rates, 1973-1997 Rate Per 100,000 Population U.S. All Races American Indians & Alaska Natives, Adjusted American Indians & Alaska Natives, Actual 1973 1975 1980 1985 1990 1995 1997 Calendar Year Source:IHS Trends in Indian Health, 2000-2001, Table 4.33, p.109.

  40. Age-Adjusted Lung Cancer Death Rates Per 100,000 Population U.S. All Races American Indians & Alaska Natives, Adjusted American Indians & Alaska Natives, Actual 1973 1975 1980 1985 1990 1995 1997 Calendar Year Source:IHS Trends in Indian Health, 2000-2001, Table 4.35, p.113.

  41. Age–Adjusted Death Rates Per 100,000 Persons By Race & Hispanic Origin For Unintentional Injuries: U.S. Source: Health, United States, 2007, Table 29.http://www.cdc.gov/NCHS/data/hus/hus05.pdf#summary

  42. Age-Adjusted Death Rates per 100,000 Persons by Race for Unintentional Injuries: U.S. & IHS Service Area - 1997

  43. Unintentional Injuries Age-Adjusted Death Rates, per 100,000 PersonsU.S. and Selected States, 1995-1997 Source: Health, United States, 2007,

  44. Unintentional Injuries Age-Adjusted Death Rates per 100,000 Persons U.S. and Selected States 1995-1997 Source: Health, United States, 2007

  45. Age Adjusted Death Rates Per 100,000 Persons By Race & Hispanic Origin For Motor Vehicle-Related Injuries: U.S.,2004 Source: Health, United States, 2007, Table 29.http://www.cdc.gov/NCHS/data/hus/hus05.pdf#summary

  46. Age-Adjusted Death Rates per 100,000 Persons by Race for Motor Vehicle-related Injuries: U.S. & IHS Service Area - 1997

  47. Age-Adjusted Mortality Rates Per 100,000 Persons By Race/Ethnicity for Suicide: U.S., 2004. Source: Health, United States, 2007, Table 29.http://www.cdc.gov/NCHS/data/hus/hus05.pdf#summary

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