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American Indian Health Disparities American Indian Health Disparities and Culturally Sensitive Counselingand Culturally Sensitive Counseling
Donald Warne, MD, MPHDonald Warne, MD, MPH
Oglala LakotaOglala Lakota
Executive DirectorExecutive Director
Aberdeen Area Tribal Chairmen’s Health BoardAberdeen Area Tribal Chairmen’s Health Board
HIV/STD/TB/Hepatitis SymposiumHIV/STD/TB/Hepatitis Symposium
May 20, 2010May 20, 2010
Fargo, NDFargo, ND
OverviewOverview
Overview of AI Health PolicyOverview of AI Health Policy AI Health Disparities & HIV/STD AI Health Disparities & HIV/STD Cultural Competence in AI HealthcareCultural Competence in AI Healthcare Strategies to reduce Health DisparitiesStrategies to reduce Health Disparities
AMERICAN INDIAN HEALTH POLICYAMERICAN INDIAN HEALTH POLICY
Do people have a legal right to Do people have a legal right to healthcare in the US? healthcare in the US?
Approximately $2.5 trillion spent Approximately $2.5 trillion spent annually on healthcare in the USannually on healthcare in the US
Nearly 50 million uninsured people in Nearly 50 million uninsured people in the USthe US
IHS AreasIHS Areas
Albuquerque
Portland Billings
CaliforniaPhoenix
Oklahoma
Nashville
NavajoTucson
Alaska
Aberdeen Bemidji
AAIHS / AATCHBAAIHS / AATCHB
INDIAN HEALTH SERVICEINDIAN HEALTH SERVICE
The Indian Health Service (IHS) is the principal The Indian Health Service (IHS) is the principal
federal health care provider and health advocate federal health care provider and health advocate
for Indian peoplefor Indian people
Its goal is to assure that comprehensive, Its goal is to assure that comprehensive,
culturally acceptable personal and public health culturally acceptable personal and public health
services are available and accessible to services are available and accessible to
American Indian and Alaska Native people American Indian and Alaska Native people
AI Health DisparitiesAI Health Disparities
Life Expectancy in Years:Life Expectancy in Years:MenMen WomenWomen TotalTotal
U.S. U.S. 74.174.1 79.5 79.5 76.976.9
AAIHSAAIHS 63.563.5 71.071.0 67.367.3
Disparity:Disparity: 10.610.6 8.5 8.5 9.6 9.6
Median age at death in SD (2007):Median age at death in SD (2007):
8181 Years in the General Population Years in the General Population
5959 Years in the AI Population Years in the AI Population
National Survey on Drug Use & HealthNational Survey on Drug Use & Health
AI/AN Substance Use DisordersAI/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 DisparitiesAmerican Indian Disparities
American Indian DisparitiesAmerican Indian Disparities
American Indian DisparitiesAmerican Indian Disparities
American Indian DisparitiesAmerican Indian Disparities
American Indian DisparitiesAmerican Indian Disparities
American Indian DisparitiesAmerican Indian Disparities
HIV/AIDS in Minnesota: Annual Review
SOURCE:U.S. HIV/AIDS Surveillance Report, Year-end 2007National Center for HIV, STD, and TB Prevention, CDC
HIV/AIDS in Minnesota: Annual Review
SOURCE:U.S. HIV/AIDS Surveillance Report, Year-end 2007National Center for HIV, STD, and TB Prevention, CDC
HIV/AIDS in Minnesota: Annual Review
U.S. State-Specific AIDS Rates per 100,000 PopulationYear 2007
U.S. State-Specific AIDS Rates per 100,000 PopulationYear 2007
SOURCE:U.S. HIV/AIDS Surveillance Report, Year-end 2007National Center for HIV, STD, and TB Prevention, CDC
0
5
10
15
20
25
30
35
40
N
Y
F
L
D
E
S
C
P
A
N
J
T
X
N
C
I
L
A
Z
A
L
C
O
A
R
W
A
M
I
H
I
N
M
K
S
N
E
N
H
W
I
M
T
I
A
S
D
N
D
Minnesota (3.8)
WI (3.6)
ND (1.3)
Illinois (10.5)
New York (24.9)
IA (2.5)
Overall U.S. Rate = 12.4
SD (1.9)
0
5
10
15
20
25
30
35
40
N
Y
F
L
D
E
S
C
P
A
N
J
T
X
N
C
I
L
A
Z
A
L
C
O
A
R
W
A
M
I
H
I
N
M
K
S
N
E
N
H
W
I
M
T
I
A
S
D
N
D
Minnesota (3.8)
WI (3.6)
ND (1.3)
Illinois (10.5)
New York (24.9)
IA (2.5)
Overall U.S. Rate = 12.4
SD (1.9)
HIV TestingHIV Testing
Integral to HIV prevention, treatment, and care efforts
HIV TestingHIV Testing
R e d u ce d m o rb id ity & m o rta lity Im p ro ve q u a lity o f life
L in k ing to m e d ica l ca re & serv ices
M o d ify b e ha v io r to red u ce ris k o f tran sm iss ion
P re ve n tin g sp re a d o f d isea se
E a rly kn o w le d ge o f H IV sta tus
CDC, MMWR, Vol. 55, NO. RR14: September2006.CDC, MMWR, Vol. 52, NO. 15: April 2003.
HIV/AIDS cases by year of diagnosis, 2004-2007HIV/AIDS cases by year of diagnosis, 2004-2007
2004 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
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
Co-Morbidities in HIV + American Indians
Disparities in risks for chronic diseasesDiabetesAlcoholism / SACancerHeart Disease
~ 50 years ago, leading health problems-infectious diseases, malnutrition, and infant mortality
www.cdc.gov/mmwr/preview/mmwrhtml/ss5207al.htm
AI Health DisparitiesAI Health Disparities
Death rates from preventable diseases among Death rates from preventable diseases among AIs are significantly higher than among non-AIs are significantly higher than among non-Indians:Indians:
Diabetes 208% greaterDiabetes 208% greater Alcoholism 526% greaterAlcoholism 526% greater Accidents 150% greaterAccidents 150% greater Suicide 60% greaterSuicide 60% greater
Indian Health Service. Regional Differences in Indian Health 2002-2003
Diabetes Death RatesDiabetes Death Rates (Rate/Per 100,000 Population) (Rate/Per 100,000 Population)
Alcohol Related Death RatesAlcohol Related Death Rates (Rate/Per 100,000 Population) (Rate/Per 100,000 Population)
MedicalMedical
BehavioralBehavioral
AI Resource DisparitiesAI Resource Disparities
Per capita medical expenditures in 2005Per capita medical expenditures in 2005federal budget:federal budget:
Indian Health Service $2,130Indian Health Service $2,130 Medicaid recipients $5,010Medicaid recipients $5,010 VA beneficiaries $5,234VA beneficiaries $5,234 Medicare $7,631Medicare $7,631 Bureau of Prisons $ 3,985Bureau of Prisons $ 3,985
AI Healthcare Resource DisparitiesAI Healthcare Resource Disparities
Bureau of Prisons
A BRIEF HISTORY OF A BRIEF HISTORY OF MEDICINEMEDICINE
•2000BC—Here, eat this root2000BC—Here, eat this root
•1000AD—That root is heathen, here say 1000AD—That root is heathen, here say this prayerthis prayer
•1800AD—That prayer is superstition, here 1800AD—That prayer is superstition, here drink this drink this potionpotion
•1900AD—That potion is snake oil, here 1900AD—That potion is snake oil, here swallow this swallow this pillpill
•1950AD—That pill is ineffective, here take 1950AD—That pill is ineffective, here take this this antibioticantibiotic
•2000AD—That antibiotic is artificial, here 2000AD—That antibiotic is artificial, here eat this eat this rootroot
MODERNMODERN TRADITIONALTRADITIONAL
•ModelModel Allopathic Allopathic HolisticHolistic
MODERNMODERN TRADITIONALTRADITIONAL
““Medicine” PhysicalMedicine” PhysicalSpiritualSpiritual
MODERNMODERN TRADITIONALTRADITIONAL
•ProviderProvider PhysicianPhysician HealerHealer
MODERNMODERN TRADITIONALTRADITIONAL
•SymbolSymbol Serpent & Staff Serpent & Staff Medicine WheelMedicine Wheel
MEDICINE WHEELMEDICINE WHEEL
SPIRITUALSPIRITUAL
MENTALMENTAL
PHYSICALPHYSICAL
EMOTIONALEMOTIONAL
Traditional Systems of Traditional Systems of DiagnosisDiagnosis
PRAYEPRAYERR
MEDITATIOMEDITATIONN
COUNSELINCOUNSELINGG
HERBSHERBS
Key ComponentsKey Components: Ceremony, Family Ceremony, Family & & Community Community ParticipationParticipation
MEDICINE WHEELMEDICINE WHEEL
VALUESVALUES
DECISIONSDECISIONS
ACTIONSACTIONS
REACTIONSREACTIONS
MEDICINE MEDICINE WHEEL & WHEEL &
Traditional Traditional ValuesValues
FORTITUDFORTITUDEE
WISDOMWISDOM
COURAGECOURAGE
GENEROSITYGENEROSITY
UP—HONOR
DOWN—RESPECT
WITHIN—HUMILITY
MEDICINE WHEELMEDICINE WHEEL
BELIEFSBELIEFS
ATTITUDESATTITUDES
ACTIVITIESACTIVITIES
FEELINGSFEELINGS
MEDICINE WHEEL MEDICINE WHEEL & Public Health& Public Health
CULTURALCULTURAL
EDUCATIONALEDUCATIONAL
ENVIRONMENTALENVIRONMENTAL
SOCIALSOCIAL
Ed McGaa, Eagle ManEd McGaa, Eagle Man
Native American Indians learned how to live Native American Indians learned how to live with the earth on a deeply spiritual plane. with the earth on a deeply spiritual plane. The plight of the non-Indian world is that it The plight of the non-Indian world is that it has lost respect for Mother Earth, from has lost respect for Mother Earth, from whom and where we all come.whom and where we all come.
Mother Earth Spirituality, 1990
Ed McGaa, Eagle ManEd McGaa, Eagle Man
We all start out in this world as tiny seeds—We all start out in this world as tiny seeds—no different from our animal brothers and no different from our animal brothers and sisters, the deer, the bear, the buffalo, or the sisters, the deer, the bear, the buffalo, or the trees, the flowers, the winged people. trees, the flowers, the winged people. Mother Earth is our real mother, because Mother Earth is our real mother, because every bit of us truly comes from her, and every bit of us truly comes from her, and daily she takes care of us.daily she takes care of us.
Mother Earth Spirituality, 1990
Rick Two DogsRick Two Dogs
We need to understand that the primary We need to understand that the primary reason our people are so afflicted with reason our people are so afflicted with addiction, poverty, abuse and strife, is that addiction, poverty, abuse and strife, is that our way of life was taken from us. our way of life was taken from us. Everything was taken. And nothing was Everything was taken. And nothing was replaced.replaced.
Wounded Warriors: A Time For Healing, 1995
Substance Abuse and Substance Abuse and thethe
Medicine WheelMedicine Wheel
• What greater grief than the loss of What greater grief than the loss of one’s native landone’s native land
• EuripidesEuripides 485-406 B.C.485-406 B.C.
Alcohol Related Death RatesAlcohol Related Death Rates (Rate/Per 100,000 Population) (Rate/Per 100,000 Population)
Suicide Death RatesSuicide Death Rates (Rate/Per 100,000 Population) (Rate/Per 100,000 Population)
MEDICINE MEDICINE WHEEL and WHEEL and
Health BehaviorHealth Behavior
VALUESVALUES
DECISIONDECISIONSS
ACTIONACTIONSS
REACTIONREACTIONSS
MEDICINE MEDICINE WHEEL and WHEEL and
Health BehaviorHealth BehaviorDECISIONDECISION
SSSUBSTANSUBSTANCE ABUSECE ABUSE
NEGATIVE NEGATIVE EMOTIONEMOTION
SS
MEDICINE WHEELMEDICINE WHEEL
SPIRITUASPIRITUALL
MENTAMENTALL
PHYSICAPHYSICALL
EMOTIONAEMOTIONALL
CULTURAL COMPETENCECULTURAL COMPETENCE
DefinitionsDefinitions
•Culture: Culture: The totality ofThe totality of socially transmitted socially transmitted behavioral patterns, beliefs, values, customs and behavioral patterns, beliefs, values, customs and thought characteristics of a population that guides thought characteristics of a population that guides world view and decision making.world view and decision making.
•Cultural Competence:Cultural Competence: The ability of systems The ability of systems to provide care to patients with diverse values, to provide care to patients with diverse values, beliefs and behaviors, including tailoring care to beliefs and behaviors, including tailoring care to meet patients’ social, cultural and linguistic needs.meet patients’ social, cultural and linguistic needs.
CULTURAL COMPETENCECULTURAL COMPETENCE
BarriersBarriers
•AI/AN under-representation in healthcare AI/AN under-representation in healthcare leadership and workforce.leadership and workforce.
0%
5%
10%
15%
20%
25%
30%
S&E MedSchoolFaculty
PublicHealthFaculty
City orCountyHealth
Officials
TotalURM
URM Health and Science URM Health and Science WorkforceWorkforce
DISPARITIES: Health Staff/100,000 people
AI/ANAI/AN USUS GapGap
MDsMDs 73.973.9 220.6220.6 66% lower66% lower
DDSsDDSs 24.024.0 61.861.8 61% lower61% lower
Nurses 229.0Nurses 229.0 849.9849.9 73% lower73% lower
RPhRPh 42.842.8 71.371.3 40% lower40% lower
AI Health Related FacultyAI Health Related Faculty
• AI/AN faculty in medical schools are AI/AN faculty in medical schools are underrepresentedunderrepresented
– 0.1% American Indian0.1% American Indian
– Few specialistsFew specialists
• 16% of Public Health School Faculty are 16% of Public Health School Faculty are URMURM
• >12% Vacancy Rate in IHS Health >12% Vacancy Rate in IHS Health ProfessionsProfessions
CULTURAL COMPETENCECULTURAL COMPETENCE
BarriersBarriers
•AI/AN under-representation in healthcare AI/AN under-representation in healthcare leadership and workforce.leadership and workforce.
•Systems of care poorly designed to meet the Systems of care poorly designed to meet the needs of diverse patient populations.needs of diverse patient populations.
•Poor communication between providers and Poor communication between providers and patients of different racial, ethnic or cultural patients of different racial, ethnic or cultural backgrounds.backgrounds.
•Cultural disconnect between health beliefs & Cultural disconnect between health beliefs & value systemsvalue systems
CULTURAL COMPETENCECULTURAL COMPETENCE
BenefitsBenefits
•Improved communicationImproved communication
•Improved quality of careImproved quality of care
•Reduction in health disparitiesReduction in health disparities
•Community Participation in healthcare practice Community Participation in healthcare practice and researchand research
CULTURAL COMPETENCECULTURAL COMPETENCE
Purnell’s Model:Purnell’s Model:
Person, Family, Community, SocietyPerson, Family, Community, Society
•Unconsciously incompetentUnconsciously incompetent
•Consciously incompetentConsciously incompetent
•Consciously competentConsciously competent
•Unconsciously competentUnconsciously competent
CULTURAL COMPETENCECULTURAL COMPETENCE
Strategies—Strategies—Organizational Organizational
•Expand AI/AN healthcare leadership Expand AI/AN healthcare leadership development programsdevelopment programs
•Hire and promote AI/AN in healthcare Hire and promote AI/AN in healthcare workforceworkforce
•Involve community members in healthcare Involve community members in healthcare organization’s planning and quality organization’s planning and quality improvement strategies & trainingimprovement strategies & training
CULTURAL COMPETENCECULTURAL COMPETENCE
Strategies—Strategies—ClinicalClinical
•Cross-cultural training as a required, integrated Cross-cultural training as a required, integrated component of training and professional component of training and professional development of healthcare providersdevelopment of healthcare providers
•Quality improvement efforts that include Quality improvement efforts that include culturally and linguistically appropriate patient culturally and linguistically appropriate patient survey methodssurvey methods
•Patient education regarding navigating the Patient education regarding navigating the healthcare system—active involvementhealthcare system—active involvement
CULTURAL COMPETENCECULTURAL COMPETENCE
Personal PerspectivesPersonal Perspectives
•Modern vs Traditional Health Beliefs Modern vs Traditional Health Beliefs regarding chronic disease and health regarding chronic disease and health behaviorbehavior
SPIRITUASPIRITUALL
MENTALMENTAL
PHYSICAPHYSICALL
EMOTIONALEMOTIONAL
Medicine Wheel & Cultural Medicine Wheel & Cultural CompetenceCompetence
Traditional Medicine ServicesTraditional Medicine Services
• Talking CirclesTalking Circles
• Healing CeremoniesHealing Ceremonies
• Herbal RemediesHerbal Remedies
• SmudgingSmudging
• Sweat LodgeSweat Lodge
• CounselingCounseling
• Regionally Specific RemediesRegionally Specific Remedies
• 70% of urban & 90% of reservation AI people 70% of urban & 90% of reservation AI people use traditional medicineuse traditional medicine
Sample ProgramsSample Programs
•Winslow HospitalWinslow Hospital
•Medicine Man Medicine Man on Staffon Staff
•Hogan on Hogan on Hospital Hospital GroundsGrounds
•Medicine Medicine Man’s Man’s AssociationAssociation
Sample ProgramsSample Programs
•PIMCPIMC
•Traditional Traditional Cultural Advocacy Cultural Advocacy CommitteeCommittee
•Sweat Lodge on Sweat Lodge on Hospital GroundsHospital Grounds
•Intake FormIntake Form
•Urban IssuesUrban Issues
Sample ProgramsSample Programs
•Hu Hu Kam Memorial HospitalHu Hu Kam Memorial Hospital
•Traditional Healers on StaffTraditional Healers on Staff
•BHCBHC
•RBHARBHA
•DECDEC
•PL 93-638PL 93-638
BLACK ELKBLACK ELK
Of course it was not I who cured. Of course it was not I who cured. It was the power from the outer It was the power from the outer world, and the visions and world, and the visions and ceremonies had only made me ceremonies had only made me like a hole through which the like a hole through which the power could come to the two-power could come to the two-leggeds. If I thought that I was leggeds. If I thought that I was doing it myself, the hole would doing it myself, the hole would close up and no power could close up and no power could come through.come through.
Donald Warne
dwarne@aatchb.org
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