American Indian Health Disparities and Culturally Sensitive Counseling Donald Warne, MD, MPH Oglala Lakota Executive Director Aberdeen Area Tribal Chairmen’s Health Board HIV/STD/TB/Hepatitis Symposium May 20, 2010 Fargo, ND

Overview Overview of AI Health Policy AI Health Disparities & HIV/STD Cultural Competence in AI Healthcare Strategies to reduce Health Disparities

AMERICAN INDIAN HEALTH POLICY Do people have a legal right to healthcare in the US? Approximately $2.5 trillion spent annually on healthcare in the US Nearly 50 million uninsured people in the US

IHS Areas Alaska Albuquerque Portland Billings California Phoenix Oklahoma Nashville Navajo Tucson Alaska Aberdeen Bemidji

AAIHS / AATCHB

INDIAN HEALTH SERVICE The Indian Health Service (IHS) is the principal federal health care provider and health advocate for Indian people Its goal is to assure that comprehensive, culturally acceptable personal and public health services are available and accessible to American Indian and Alaska Native people

AI Health Disparities Life Expectancy in Years: Men Women Total U.S. 74.1 79.5 76.9 AAIHS 63.5 71.0 67.3 Disparity: 10.6 8.5 9.6 Median age at death in SD (2007): 81 Years in the General Population 59 Years in the AI Population

National Survey on Drug Use & Health AI/AN Substance Use Disorders In 2002-2005, AI/ANs were more likely than other racial groups to have a past year alcohol use disorder (10.7 v 7.6 percent) In 2002-2005, AI/ANs were more likely than other racial groups to have a past year illicit drug use disorder (5.0 v 2.9 percent) Rates of past year marijuana, cocaine, and hallucinogen use disorders were higher among AI/ANs than other racial groups

American Indian Disparities

American Indian Disparities

American Indian Disparities

American Indian Disparities

American Indian Disparities

American Indian Disparities

SOURCE: U.S. HIV/AIDS Surveillance Report, Year-end 2007 National Center for HIV, STD, and TB Prevention, CDC HIV/AIDS in Minnesota: Annual Review

Minnesota Department of Health For adults and adolescents living with HIV/AIDS, prevalence rates per 100,000 population are shown for 33 states and 5 U.S. dependent areas with confidential name-based HIV infection surveillance. Areas with the highest prevalence rates in 2006 were New York, the U.S. Virgin Islands, Florida, New Jersey, and Louisiana. The following 33 states and 5 U.S. dependent areas have had laws or regulations requiring confidential name-based HIV infection surveillance since at least 2003: Alabama, Alaska, Arizona, Arkansas, Colorado, Florida, Idaho, Indiana, Iowa, Kansas, Louisiana, Michigan, Minnesota, Mississippi, Missouri, Nebraska, Nevada, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, Wisconsin, Wyoming, American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, and the U.S. Virgin Islands. The data have been adjusted for reporting delays. SOURCE: U.S. HIV/AIDS Surveillance Report, Year-end 2007 National Center for HIV, STD, and TB Prevention, CDC HIV/AIDS in Minnesota: Annual Review

Minnesota Department of Health U.S. State-Specific AIDS Rates per 100,000 Population Year 2007 HIV/AIDS in Minnesota: Annual Review SOURCE: U.S. HIV/AIDS Surveillance Report, Year-end 2007 National Center for HIV, STD, and TB Prevention, CDC

HIV Testing Integral to HIV prevention, treatment, and care efforts

HIV Testing CDC, MMWR, Vol. 55, NO. RR14: September2006. CDC, MMWR, Vol. 52, NO. 15: April 2003.

HIV/AIDS cases by year of diagnosis, 2004-2007 2005 2006 2007 % of total 2007 cases American Indian/Alaska Natives 177 180 163 228 0.5% White 10,836 10,818 10,815 12,556 28% Total Population 38,398 38,032 38,531 44,084 http://minorityhealth.hhs.gov/templates/content.aspx?ID=3026

HIV testing issues among American Indians Perceived HIV risk HIV testing Confidentiality Misclassified in terms of race/ethnicity on data forms CDC, MMWR, Vol. 52, No. SS07: August, 2003. www.cdc.gov/hiv/resources/factsheets/aian.htm

Co-Morbidities in HIV + American Indians Disparities in risks for chronic diseases Diabetes Alcoholism / SA Cancer Heart Disease ~ 50 years ago, leading health problems-infectious diseases, malnutrition, and infant mortality www.cdc.gov/mmwr/preview/mmwrhtml/ss5207al.htm

AI Health Disparities Death rates from preventable diseases among AIs are significantly higher than among non-Indians: Diabetes 208% greater Alcoholism 526% greater Accidents 150% greater Suicide 60% greater Indian Health Service. Regional Differences in Indian Health 2002-2003

Diabetes Death Rates (Rate/Per 100,000 Population)

Alcohol Related Death Rates (Rate/Per 100,000 Population)

Medical Behavioral

AI Resource Disparities Per capita medical expenditures in 2005 federal budget: Indian Health Service $2,130 Medicaid recipients $5,010 VA beneficiaries $5,234 Medicare $7,631 Bureau of Prisons $ 3,985

AI Healthcare Resource Disparities Bureau of Prisons

A BRIEF HISTORY OF MEDICINE 2000BC—Here, eat this root 1000AD—That root is heathen, here say this prayer 1800AD—That prayer is superstition, here drink this potion 1900AD—That potion is snake oil, here swallow this pill 1950AD—That pill is ineffective, here take this antibiotic 2000AD—That antibiotic is artificial, here eat this root

MODERN TRADITIONAL Model Allopathic Holistic

MODERN TRADITIONAL “Medicine” Physical Spiritual

MODERN TRADITIONAL Provider Physician Healer

MODERN TRADITIONAL Symbol Serpent & Staff Medicine Wheel

MEDICINE WHEEL MENTAL PHYSICAL SPIRITUAL EMOTIONAL

Traditional Systems of Diagnosis MEDITATION HERBS PRAYER COUNSELING Key Components: Ceremony, Family & Community Participation

MEDICINE WHEEL DECISIONS ACTIONS VALUES REACTIONS

MEDICINE WHEEL & Traditional Values WISDOM COURAGE FORTITUDE GENEROSITY UP—HONOR WITHIN— HUMILITY DOWN—RESPECT

MEDICINE WHEEL ATTITUDES ACTIVITIES BELIEFS FEELINGS

MEDICINE WHEEL & Public Health EDUCATIONAL ENVIRONMENTAL CULTURAL SOCIAL

Ed McGaa, Eagle Man Native American Indians learned how to live with the earth on a deeply spiritual plane. The plight of the non-Indian world is that it has lost respect for Mother Earth, from whom and where we all come. Mother Earth Spirituality, 1990

Ed McGaa, Eagle Man We all start out in this world as tiny seeds—no different from our animal brothers and sisters, the deer, the bear, the buffalo, or the trees, the flowers, the winged people. Mother Earth is our real mother, because every bit of us truly comes from her, and daily she takes care of us. Mother Earth Spirituality, 1990

Rick Two Dogs We need to understand that the primary reason our people are so afflicted with addiction, poverty, abuse and strife, is that our way of life was taken from us. Everything was taken. And nothing was replaced. Wounded Warriors: A Time For Healing, 1995

Substance Abuse and the Medicine Wheel What greater grief than the loss of one’s native land Euripides 485-406 B.C.

Alcohol Related Death Rates (Rate/Per 100,000 Population)

Suicide Death Rates (Rate/Per 100,000 Population)

MEDICINE WHEEL and Health Behavior DECISIONS ACTIONS VALUES REACTIONS

MEDICINE WHEEL and Health Behavior DECISIONS SUBSTANCE ABUSE NEGATIVE EMOTIONS

MEDICINE WHEEL MENTAL PHYSICAL SPIRITUAL EMOTIONAL

CULTURAL COMPETENCE Definitions Culture: The totality of socially transmitted behavioral patterns, beliefs, values, customs and thought characteristics of a population that guides world view and decision making. Cultural Competence: The ability of systems to provide care to patients with diverse values, beliefs and behaviors, including tailoring care to meet patients’ social, cultural and linguistic needs.

CULTURAL COMPETENCE Barriers AI/AN under-representation in healthcare leadership and workforce.

URM Health and Science Workforce

DISPARITIES: Health Staff/100,000 people AI/AN US Gap MDs 73.9 220.6 66% lower DDSs 24.0 61.8 61% lower Nurses 229.0 849.9 73% lower RPh 42.8 71.3 40% lower

AI Health Related Faculty AI/AN faculty in medical schools are underrepresented 0.1% American Indian Few specialists 16% of Public Health School Faculty are URM >12% Vacancy Rate in IHS Health Professions

CULTURAL COMPETENCE Barriers AI/AN under-representation in healthcare leadership and workforce. Systems of care poorly designed to meet the needs of diverse patient populations. Poor communication between providers and patients of different racial, ethnic or cultural backgrounds. Cultural disconnect between health beliefs & value systems

CULTURAL COMPETENCE Benefits Improved communication Improved quality of care Reduction in health disparities Community Participation in healthcare practice and research

CULTURAL COMPETENCE Purnell’s Model: Person, Family, Community, Society Unconsciously incompetent Consciously incompetent Consciously competent Unconsciously competent

CULTURAL COMPETENCE Strategies—Organizational Expand AI/AN healthcare leadership development programs Hire and promote AI/AN in healthcare workforce Involve community members in healthcare organization’s planning and quality improvement strategies & training

CULTURAL COMPETENCE Strategies—Clinical Cross-cultural training as a required, integrated component of training and professional development of healthcare providers Quality improvement efforts that include culturally and linguistically appropriate patient survey methods Patient education regarding navigating the healthcare system—active involvement

CULTURAL COMPETENCE Personal Perspectives Modern vs Traditional Health Beliefs regarding chronic disease and health behavior

Medicine Wheel & Cultural Competence MENTAL PHYSICAL SPIRITUAL EMOTIONAL

Traditional Medicine Services Talking Circles Healing Ceremonies Herbal Remedies Smudging Sweat Lodge Counseling Regionally Specific Remedies 70% of urban & 90% of reservation AI people use traditional medicine

Sample Programs Winslow Hospital Medicine Man on Staff Hogan on Hospital Grounds Medicine Man’s Association

Sample Programs PIMC Traditional Cultural Advocacy Committee Sweat Lodge on Hospital Grounds Intake Form Urban Issues

Sample Programs Hu Hu Kam Memorial Hospital Traditional Healers on Staff BHC RBHA DEC PL 93-638

BLACK ELK Of course it was not I who cured. It was the power from the outer world, and the visions and ceremonies had only made me like a hole through which the power could come to the two-leggeds. If I thought that I was doing it myself, the hole would close up and no power could come through.

Donald Warne dwarne@aatchb.org