1. 1 2015 AMSUS Meeting The Society of Federal Health Professionals 2 Dec 2015 – San Antonio, TX RADM Dawn Wyllie, MD, MPH Chief Medical Officer/Deputy Director Bemidji Area IHS

2. “Cross-Cultural Medicine in the USPHS: Caring for American Indian/Alaska Native Patients in the Indian Health Service”

3. Disclosures The presenter has no financial interests or relationships to disclose. Presentation based on public information and personal experience, does not represent USPHS, IHS This continuing education activity is managed and accredited by Professional Education Services Group in cooperation with AMSUS. Neither PESG,AMSUS, nor any accrediting organization support or endorse any product or service mentioned in this activity. PESG and AMSUS staff has no financial interest to disclose. Commercial support was not received for this activity.

4. Objectives At the conclusion of this activity the participant will be able to: Compare 3 American Indian values/beliefs with contemporary Euro-American society and describe 2 American Indian wellness and disease concepts Describe a unique cultural aspect of American Indian/Alaska Native Heath Care Discuss cultural considerations in clinical practice in order to improve provider-patient relationships and health care delivery

5. Journey – Clinical Rotations University of Washington, School of Medicine WAMI Program (1981-1985): –1 st yr Seattle Indian Health Board –2 nd yr - Community Health Advance Program Saturday free clinic - health care to underserved –3 rd & 4 th yrs - Indian Health Service: Family Medicine - Nez Perce Reservation, ID Psychiatry - Alaska Native Medical Center, Anchorage & Dillingham, AK –4 th yr - McCormick Hospital, Chang Mai, Thailand Pwo-Karen Tribe, Mae Hong Son on Burmese Border Hansen’s Disease @ McKean Leprosy Hospital

6. Journey – Clinical Rotations UC San Francisco, Family & Community Medicine Residency, CA –San Francisco Native American Health Center –SF General Hospital Refugee Clinic Primarily Latin American and SE Asian (limited/ non-English speaking) patients UC Davis, School of Medicine, CA –Clinica Tepati, Sacramento Saturday Free Clinic – health care to underserved, primarily Hispanics Mentorship and support are important components

7. Journey - Career National Health Service Corps - Scholarship Recipient 9/10/1988 Commissioned as a Medical Officer in the U.S. Public Health Service (PHS), assigned to IHS Call to active duty - Tohono O’Odham Reservation, Sells, AZ Active Duty 27 years, worked in 4 Areas: Tucson, California, Great Plains, Bemidji

8. Journey PHS Career in IHS Served in 4 IHS Areas –Tucson (AZ): 2 Tribes Tohono O’odham Nation: 28, 000 members –California: 103 Tribes Chapa-De IHP: Maidu, Miwok, Washoe, Wintun –Bemidji Area Office (MN, WI, MI, IL, ID): 34 Tribes Chippewa/Ojibwe, Sioux/Dakota, Ho-Chunk, Menominee, Ottawa/Odawa, Oneida, Potawatomi, Stockbridge-Munsee Mohican –Aberdeen (IA, NE, ND, SD): 17 Tribes Sisseton-Wahpeton Reservation IHS Delegate, 1998 “Healing Our Spirits Worldwide International Conference”, Rotorua, New Zealand –Maori Tribe

9. Indian Health Service An agency within the Department of Health and Human Services (HHS), established in 1955 Mission... In partnership, to raise the physical, mental, social, and spiritual health of American Indians and Alaska Natives to the highest level Goal... to assure that comprehensive, culturally acceptable personal and public health services are available and accessible to American Indian and Alaska Native people Foundation... to uphold the Federal Government's obligation to promote healthy American Indian and Alaska Native people, communities, and cultures and to honor and protect the inherent sovereign rights of Tribes

10. IHS Agency Priorities 10 Renew and strengthen our partnership with Tribes and Urban Indian Health Program Bring reform to the IHS Improve the quality of and access to care Ensure that our work is transparent, accountable, fair, and inclusive Robert Mc Swain

11. Special Government to Government Relationship Direct Federal Government relationship with 567 sovereign Tribes Relationship established in 1797 based on Article 1 Section 8 of US Constitution: –“Congress regulates commerce among states…and with Indian Tribes.” –Given form and substance by numerous treaties, laws, Supreme Court decisions, and Executive Orders

12. American Indian/ Alaska Native History Extermination < 1871 Broken Treaties Assimilation > 1871 Boarding Schools Reservation dissolution Federal Termination of Tribes Relocation 1950’s – 1960’ Tribal Self-Determination 1970’s to current Re-Affirmed Tribes and New “Federally Recognized” Tribes

13. Passage of Landmark Legislation 1921 Snyder Act was passed by Congress authorized funding for the health care of Indian people 1954 PL 83-568 transferred health care from the Bureau of Indian Affairs to the Surgeon General of the USPHS within the Department of Health, Education and Welfare “…all functions of the Secretary of the Interior relating to the conservation of the health of Indians…” However the budget or appropriations from Congress remain under the Department of Interior 1975 Indian Self-Determination Act 1976 Indian Health Care Improvement Act (IHCIA) 1991 Self Governance

14. IHS Agency Today  Relationship with Congress  Congress is the legislative branch of the U.S. Government  Congress passes appropriations, allocating funding to IHS  HHS executes and implements laws passed by Congress  Relationship to U.S. Department of Health and Human Services (HHS)  IHS elevated to Agency status, is one of eleven Operating Divisions within the HHS which is an Executive Branch of the U.S. Government  Budget Formulation, PFSA, Tribal Mgmt 14

15. The 2 nd - 25+ Years of IHS ~1980-present  Federal budget process  Addressing health disparities  Professional excellence  Modern health facilities  Tribal consultation  Organizational change  Growth of Tribal Management 15

16. CALIFORNIA TUCSON BEMIDJI NASHVILLE ALBUQUERQUE NAVAJO ALASKA AK TN NC MS AL SC LA FL PA NY ME MA CT RI * * NV UT AZ BILLINGS MT WY * OKLAHOMA CITY KS OK TX * * IN MN MI WI * CA * * CO NM Note: Texas is administered by Nashville, Oklahoma City, and Albuquerque. *Area Office WA OR ID * PORTLAND PHOENIX * ND SD NE IA * ABERDEEN Indian Health Service Area Offices Hospitals Health Centers Urban Programs 16

17. A Rural Health Care System in 35 States

18. IHS Demographics Who We Serve  567 Federally Recognized Tribes  Long process for official Federally recognition of Tribes: Re-cognized & newly recognized  2010 Census: 2.3 million people AI alone = 09% total US population  User Population ~ 1.2 million  Tribal size ranges from ~200 to ~40,000  Staff = Civil Servants, PHS Commissioned Corps Officers, Direct Tribal or Urban Program Hire 18

19. Indian Health Care Primary Concerns Health Disparities of this underserved population Limited Access (specialty care, high cost medications, etc) Inadequate funding to address health care needs Priorities Close the health care gap, maintain & improve patient care Strengthen Public health and Environmental infrastructure Community based primary care; Culturally relevant care Enhance opportunities for tribal participation and control Partner with Tribes and collaborate with other entities to enhance resources, support to tribes

20. Health Disparities Leading causes of death –Cardiovascular Disease –Cancer Colorectal Lung Gyn: Cervical, Breast Prostate –Unintentional Injuries and Suicide –Diabetes –Chronic Lower Respiratory Disease Lifestyle Contributors: Obesity, Smoking 20

21. Health Disparities Cardiac Disease

22. Health Disparities Cerebrovascular Disease

23. Health Disparities Cancer

24. Health Disparities Diabetes

25. What Contributes to Health Disparities ? Social barriers Education level Economic barriers Inadequate appropriations Health Literacy level Geographic barriers Access barriers Resources/Financial Lack of personal health insurance Cultural Awareness

26. LNF 26

27. Health Disparities – Education

28. Health Disparities Notes: % teens who are high school dropouts: % of teenagers between ages 16 and 19 who are not enrolled in school and are not high school graduates. Persons who have a GED or equivalent are included as graduates in this measure % teens not attending school and not working: % of teenagers between ages 16 and 19 who are not enrolled in school (full- or part-time) and not employed (full- or part-time). Source: Annie E. Casey Foundation 2008 “Kids Count” Project

29. Health Literacy What is it? “ The ability of an individual to access, understand, and use health-related information and services to make appropriate health decisions.” Health History Forms Medication Bottles Appointment Slips Informed Consents Discharge Instructions Health Education Materials, Food Labels Insurance Application

30. Who Are American Indian/ Alaska Native People? The original inhabitants of this country Diverse people from many tribes Distinct history, languages, cultures, traditions, social networks, governments Dual citizenship in any one of many different tribes May have red or blonde hair, be blue or green eyed, look like another ethnic race, as well as having the prevailing stereotypical characteristics

31. DIVERSITY! Indian people have differing: Identity: tribal, cultural, bi-cultural, non-traditional orientation Cultures, values, and practices; Language/communication styles; Lifestyles; geography; Incomes, employment rates, education; Health & illness beliefs; Family structures/kinship relationships; Spirituality & religious customs

32. Importance of Spirituality Spirituality Ritual Dreams Healing Practices Inter-Tribal Celebrations

33. Cultural Considerations Religion/Spirituality Presiding religious/spiritual official Ceremony (may be a blending Christianity & Traditional Spirituality) American Indian Symbols - the use & practice of: –Tobacco* Cedar –Eagle Feathers* Sacred Pipe –Medicine Bag* Smudging –Sweat Lodge* Indian Names

34. Expression of Voice Language Stories –Oral Tradition Drum and Song

35. The Next Generation View of Children –Blessing/Gift Number of Children Child Care Customs –Experiential learning Role of Parents/Grandparent/ and Extended Family –Woman’s role as family caregiver

36. General American Indian Values Show Respect to Others - Each Person Has a Special Gift Share What You Have - Giving Makes You Richer Know Who You Are - You Are a Reflection on Your Family Accept What Life Brings - You Cannot Control Many Things Have Patience - Some Things Cannot Be Rushed Live Carefully - What You Do Will Come Back to You Take Care of Others - You Cannot Live Without Them Honor Your Elders - They Show You the Way in Life Pray for Guidance - Many Things Are Not Known See Connections - All Things Are Related

37. American Indian Concepts of Health / Wellness Results from harmony with nature Is a balance between mind, body, emotions, & spirit/soul, not the absence of disease Relationships are an essential component Spirituality/religion & medicine are inseparable The spirit existed before it came to the body & will exist after the body dies Each of us is responsible for our own health “Life-ways” are necessary to maintain health

38. American Indian Concepts of Disease Damage to mind, body, emotions, &/or spirit can produce disease in same or different realm Illness is an opportunity to purify one’s soul Natural un-wellness is caused by the violation of a sacred or tribal taboo Unnatural wellness is caused by evil Dis“ease” is felt by the individual & their family

39. American Indian Concepts of Healing Healing of one realm can bring about healing in another Spiritual realm is the most important Total treatments heal the mind, body, emotions, & spirit/soul Life comes from the Great Spirit from which all healing begins Mother Earth contains numerous remedies for our illnesses Traditional healers can be either men or women, young or elder, recognized by their community

40. American Indian Concepts Traditional Indian Medicine (TIM) Openly practiced until 1887 when the Dawes’ Act was passed by the US Congress, a provision made TIM illegal Today, a majority of the 2+ million Indians consult traditional healers 70% of Urban and 90% of Reservation based Indians use TIM

41. Cultural Considerations Traditional American Indian Healers What traditional healers do best & different from contemporary clinicians: Pray, Listen, Time Native patients often go to traditional practitioner before seeking contemporary medical care Native patients seldom reveal their use of traditional healing methods and medicines Native patients value the healer’s advice over the physician’s if a disagreement arises

42. Cultural Considerations in Clinical Practice Native American and Euro-American Cultural Values and Behaviors Please review handout comparing Native American and Euro-American Culture and Behaviors

43. Cultural Considerations Language and Communication (verbal & non-verbal) Bilingual &/or Interpreter-translator What is not said is also important Word Phrasing - words have power to shape reality Individual speech style/pattern

44. Guidelines for Health Care Professionals Understand the culture of the people you’re caring for Understand your own cultural beliefs, biases, communication style Listen, be open-minded, avoid labeling Ask rather than assume Be respectful, courteous, & have a cooperative attitude Respect the therapeutic partnership of traditional healers and medicines with contemporary medicine

45. Journey – Closing Comments Medicine is art, science, life-long experiential learning Spirit of adventure, create opportunities, own path Be adaptable, open to change, take a risk Maintain a positive attitude, optimism, enthusiasm, passion, realism, self-confidence Strive to stay in balance, use humor Develop positive support systems early, along the way Listen to constructive feedback, avoid negative energy Seek out mentors, become a mentor, inspire Be compassionate and culturally attuned Contribute in ways that make a difference in the lives of those you serve

46. Obtaining CME/CE Credit If you would like to receive continuing education credit for this activity, please visit: http://amsus.cds.pesgce.com This information may also be found in the 2015 program

47. Resources/ Websites Indian Health Service: www.ihs.govwww.ihs.gov Trends in Indian Health: 2014 Edition https://www.ihs.gov/dps/index.cfm/publications/trends20 14/https://www.ihs.gov/dps/index.cfm/publications/trends20 14/ U.S. Public Health Service Commissioned Corps: http://usphs.gov/ U.S. Surgeon General: www.surgeongeneral.govwww.surgeongeneral.gov 47

48. Contact Info Dawn Wyllie, MD, MPH, FAAFP RADM, US Public Health Service Chief Medical Officer/Deputy Area Director Bemidji Area Indian Health Service 522 Minnesota Ave, NW Bemidji, MN 56601 Email: dawn.wyllie@ihs.govdawn.wyllie@ihs.gov