Health Equity and Social Disparity Native American Perspective Fifth Annual Eccles Family Rural West Conference Santa FE, New Mexico March 24, 2017 Bret A. Smoker, MD, MPH Indian Health Service Santa Fe Service Unit

Who Is Native American (or American Indian, or Indigenous . . .)? 5.2 million self-identify as American Indian/Alaska Native (AI/AN), 2.9 million as exclusive AI/AN1 US Congress gives “federal recognition” Tribes define membership2 1US Census Bureau (2012). The American Indian and Alaska Native Population: 2010, Issued January 2012. Referenced on US Census Bureau web site: http://www.census.gov/prod/cen2010/briefs/c2010br-10.pdf 2Bureau of Indian Affairs (2014). A Guide to Tracing American Indian & Alaska Native Ancestry. Office of Public Affairs-Indian Affairs. Washington, DC. Referenced on Bureau of Indian Affairs web site: http://www.bia.gov/cs/groups/public/documents/text/idc-002619.pdf

Legal Basis for Native American Rights And Health Care Services US Constitution Article I, Section 8 of US Constitution references “. . . Commerce . . . with the Indian Tribes . . .” 1871: Congress forbid further treaties between federal government and tribes (25 U.S.C. § 71)1 1921: Snyder Act 1955: Indian Health Service established 1975: PL—93-638 1976: Indian Healthcare Improvement Act 2010: Affordable Care Act; IHCIA permanently authorized 1Pevar SL (2004). The Rights of Indians and Tribes: The Authoritative ACLU Guide to Indian and Tribal Rights. 3rd edition. New York University Press. New York and London.

Overview of Indian Health Service IHS is an agency within DHHS 2.2 million AI/AN beneficiaries in 35 states Administratively divided into 12 Areas FY 2016 budget: $4.8 billion Over 40 inpatient facilities and more than 500 outpatient facilities nationwide IHS benefits provided in addition to, not in place of, benefits available to other citizens1 1Indian Health Service (2017). About IHS. Referenced on Indian Health Service website: http://www.ihs.gov/aboutihs/

Native American Health Disparities Annual per capita personal health care expenditures1 US all races: $9,523; IHS beneficiaries: $3,688 AI/AN vs. all-race US age-adjusted mortality2 4.7 times greater from chronic liver disease and cirrhosis 2.8 times greater from diabetes mellitus 2.4 times greater from unintentional injuries 1.8 times greater from homicide 1.6 times greater from suicide 1.6 times greater from chronic lower respiratory diseases 1Indian Health Service (2017). About IHS. Retrieved from Indian Health Service website: http://www.ihs.gov/aboutihs/ 2Indian Health Service (2014). Trends in Indian Health, 2014 Edition. IHS Office of Public Health Support, Division of Program Statistics

Native American Health Disparities In New Mexico AI/AN have worst outcomes in:1 Late or no prenatal care Diabetes death rates Adult obesity Youth obesity Adults 65+ ever receiving pneumonia vaccine Motor vehicle deaths Youth suicide Alcohol-related deaths 1New Mexico Department of Health (2013). Health Equity in New Mexico: A Report on Racial and Ethnic Health Disparities, 8th Edition. Referenced on NM Department of Health web site: http://nmhealth.org/publication/view/report/43/

The Health Impact Pyramid Adapted from: Frieden TR (2010). American Journal of Public Health, 100(4):590-5.

Network/Seek Sustainability Recommendations Network/Seek Sustainability Health Policy Find regional partners/avoid duplication/seek common goals Ensure research and interventions are community-based and community-directed Challenge the status quo; be a “social entrepreneur”1 with creative public-private partnerships Whenever possible, work low on the Health Impact Pyramid Respect [legitimate] institutions, both public and private Hold elected leaders and public institutions accountable Require health impact assessments with major public works2 Be strategic; remember that: Native Americans have unique rights, and Policies broadly benefiting marginalized communities can benefit Native Americans 2The Pew Charitable Trusts (2017). Health Impact Project: A Collaboration of the Robert Wood Johnson Foundation and The Pew Charitable Trusts. Referenced on The Pew Charitable Trusts web site: http://www.pewtrusts.org/en/projects/health-impact-project 1Gaist, PA, editor. Igniting the Power of Community: The Role of CBOs and NGOs in Global Public Health. 1st edition (2009). Springer Science and Business Media. New York.