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

1. It Takes a Whole Indian Village . . . Steps to Decreasing Health Disparities 11th Annual Summer Public Health Research Video Conference on Minority Health Chapel Hill, North Carolina June 20-21 Presented by: Carole Anne Heart, Executive Director Aberdeen Area Tribal Chairmen’s Health Board 1770 Rand Road Rapid City, South Dakota 57702 execdir@aatchb.org website: www.aatchb.org

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

3. 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

4. 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

5. 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

6. 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.

7. 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 %

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

9. “The disease of alcoholism now constitutes an epidemic on the reservation. The effects of this 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 passage of time and futility of effort that no meaningful lasting progress can ever be realized by the Tribe until this disease is brought under some degree of control” Gregg Bourland, Past Chairman, Cheyenne River Sioux Tribe, 1991

10. 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.

11. WHAT IS AN INDIAN? “Indians who did not conform to white expectations were harder to define. In 1869, the Supreme Court of New 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. 12 Areas of IHS

13. 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

14. 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

15. The True Founding Fathers

17. CIRCLE OF HEALTH HEALTH DIRECTORS PHS NURSES NPHS SOCIAL SERVICES ALCOHOL AATCHB EMS CHR MENTAL HEALTH

18. GPTCHB SPOT MATRIX October 28, 2004 OPPORTUNITIES • Find new ways todeal w/ majordecision making & resolutions between mtgs. STRENGTHS • +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 •CommitmentMandatefor BoardMembers +Responsiveness to community + Unity of Aberdeen area tribes +HB ability to advocate for AA tribes in Washington. Corporate &other sponsorsfor less restricted $$ Start with theend in mind-have a prioritizedplan • Set up tribale-mail system 4Tribal HD’sTribal Chairs&Councils Focus groups forlarger meetings Use Technologyto plan & meet+Conf. Calls+Video conf. OrientationProgram for Tribal councils, local & area HBs • Public RelationsProgram “Our” Chairman’sHealth Board Strengthen Partner-ships RefineBylaws PROBLEMS CURRENT/INTERNAL FUTURE/EXTERNAL - Health not a priority of tribal chairmen. - Technology -- inadequate and lack of staff training or willingness to use. –Weak or inadequate partnerships –- Lack of sustainable funding - Lack of focus on unmet needs –- Lack of sustainable funding –- Advocacy - not fairly integrating all the needs of tribes - Lack of org. infrastructure (operational, personnel, mgt. systems THREATS - Lack of effective communications --internal & external - Lack of adequate $$ - 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 Lack of ability to change quickly Treaty opposition Substandard services-diminished health status Page 4

19. 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)

20. Barriers to Health Care National Level • 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

22. COMMUNITY ORIENTED HEALTH POLICY PREVENTION RESEARCH HEALTH PROGRAMS CLINICAL SERVICES ORGANIZATIONAL CAPACITY WORKFORCE CAPACITY & COMPETENCY INFORMATION & DATA SYSTEMS

23. 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.

24. 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.

25. “For AI/AN people, the federal responsibility to provide health services represents a “pre- paid”entitlement, paid for by the cession of over 400 million acres of land to the U.S. In many of the treaties negotiated between Tribes and US, specific provisions for basic healthcare, such as the services of a physician and the construction and maintenance of hospitals and schools were included.” Sally Smith, before the Senate Select Committee on Indian Affairs

26. “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

27. 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)

28. “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