1. 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

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

3. 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

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

6. AAIHS / AATCHB

8. 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

9. AI Health Disparities Life Expectancy in Years: Men Women Total
U.S
AAIHS
Disparity:
Median age at death in SD (2007):
81 Years in the General Population
59 Years in the AI Population

10. National Survey on Drug Use & Health
AI/AN Substance Use Disorders
In , AI/ANs were more likely than other racial groups to have a past year alcohol use disorder (10.7 v 7.6 percent)
In , 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

11. American Indian Disparities

12. American Indian Disparities

14. American Indian Disparities

15. American Indian Disparities

17. American Indian Disparities

18. American Indian Disparities

19. 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

20. 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

21. 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

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

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

24. 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

25. 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.

26. 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

27. 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

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

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

31. Medical
Behavioral

32. 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

33. AI Healthcare Resource Disparities
Bureau of Prisons

35. 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

36. MODERN TRADITIONAL
Model Allopathic Holistic

38. MODERN TRADITIONAL
“Medicine” Physical Spiritual

40. MODERN TRADITIONAL
Provider Physician Healer

42. MODERN TRADITIONAL
Symbol Serpent & Staff Medicine Wheel

45. MEDICINE WHEEL
MENTAL
PHYSICAL
SPIRITUAL
EMOTIONAL

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

47. MEDICINE WHEEL
DECISIONS
ACTIONS
VALUES
REACTIONS

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

49. MEDICINE WHEEL
ATTITUDES
ACTIVITIES
BELIEFS
FEELINGS

50. MEDICINE WHEEL & Public Health
EDUCATIONAL
ENVIRONMENTAL
CULTURAL
SOCIAL

51. 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

52. 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

54. 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

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

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

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

63. MEDICINE WHEEL and Health Behavior
DECISIONS
ACTIONS
VALUES
REACTIONS

64. MEDICINE WHEEL and Health Behavior
DECISIONS
SUBSTANCE ABUSE
NEGATIVE EMOTIONS

65. MEDICINE WHEEL
MENTAL
PHYSICAL
SPIRITUAL
EMOTIONAL

66. 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.

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

68. URM Health and Science Workforce

69. DISPARITIES: Health Staff/100,000 people AI/AN US Gap
MDs % lower
DDSs % lower
Nurses % lower
RPh % lower

70. 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

71. 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

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

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

74. 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

75. 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

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

78. Medicine Wheel & Cultural Competence
MENTAL
PHYSICAL
SPIRITUAL
EMOTIONAL

79. 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

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

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

83. Sample Programs Hu Hu Kam Memorial Hospital
Traditional Healers on Staff
BHC
RBHA
DEC PL

86. 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.

87. Donald Warne