It is no secret that American Indian populations experience significantly higher rates of disease, including chronic illnesses and their effects. Diabetes, cancer, heart disease, mental health disorders, substance abuse, and preventable health problems such as obesity and injury all impact American Indians and Alaska Natives (AIAN) disproportionately. The sobering result is AIAN people have a life expectancy that is five years shorter than the rest of the overall U.S. population, according to the Indian Health Service, the federal health system serving 2 million of the 5.2 million AIAN in the United States.
There are many reasons for the overall grim state of physical and mental health in Indian Country. Any one reason taken alone is enough to negatively impact a person’s health. But combined, the results can be catastrophic for not just the individual, but also for families, communities, and even subsequent generations.
That is the bad news. The good news is that tribal colleges and universities (TCUs) are working in their communities to identify the factors that negatively impact health and are training the next generation of healthcare workers to deal with them. And they are making a difference—not just in the lives of their students, but in the lives of future patients.
FACTORS CONTRIBUTING TO POOR HEALTH IN INDIAN COUNTRY
Poverty is one factor that impacts health. Unemployment and poverty can contribute to health problems regardless of one’s race, ethnicity, or physical address. Poverty can limit access to doctors, the kinds of food one eats, and the choices a person makes. For American Indians, cultural barriers can also impact health. According to Indian Health Service studies, these barriers can include lack of access to healthcare providers who are Native, or providers who do not have knowledge of tribal language and culture.
TCUs are training the next generation of healthcare workers and delivering culturally competent care, often in remote, rural areas.
Finally, an individual’s physical address—specifically, living in remote, rural areas—directly impacts health. As part of a legislative mandate to improve access to healthcare and other public services, the U.S. Department of Agriculture’s Economic Research Service mapped remote and rural areas, creating four levels denoted as “Far and Remote Areas” as part of its project. Why? Because people in rural areas experience different levels of accessibility to goods and services—including healthy foods and public social services—depending on their degree of remoteness. Montana, for example, has such a small population that it received the federal designation of a Far and Remote Area (FAR). In states like Montana, which is home to seven TCUs (the greatest number in any state), tribal colleges serve many of these FAR communities, often located on or near Indian reservations.
American Indian and Alaskan Natives are well acquainted with the concept of how place impacts spiritual wellness. The remote, rural, and reservation areas where many AIAN people live are not just places on the map—they are also spiritual homelands, and being rooted in place can positively impact physical wellness. The other side of the coin is the great physical distances people have to travel to get preventative or other healthcare. People must often delay seeking healthcare for logistical and economic reasons, such as a lack of reliable or affordable transportation. Chronic, ongoing medical conditions go untreated. People delay getting preventative care, especially in winter when driving conditions are often treacherous or roads impassable.
Distance also contributes to people’s access to affordable fresh food, including fruits and vegetables. According to the Centers for Disease Control and Prevention (CDC), geographic areas that do not provide access to affordable fruits, vegetables, whole grains, low-fat milk, and other foods for a healthy diet are “food deserts.” The CDC says many studies suggest that food deserts may negatively affect a person’s health, but more research is needed to determine how access to food can influence the types of foods consumers purchase and eat.
Another impact on both physical and mental health, especially with AIAN communities, is historical trauma. It was Maria Yellow Horse Brave Heart, a Lakota professor of social work who today serves as the director of Native American and Disparities Research in Community Behavioral Health at the University of New Mexico, who coined the term “historical trauma.” She was conducting research near the Pine Ridge reservation in South Dakota when she realized the emotional and psychological wounds she saw spanning across generations were the result of more than 500 years of abuse inflicted on AIAN people through massacres, land theft, displacement of families, and removal of children to boarding schools where they were forced to discard their Native identities. The term was expanded to encompass the psychological issues that all Native communities grapple with as a result of this systematic abuse.
Many reservations, classified as “Far and Remote Areas,” are also “food deserts” with a lack of access to fresh, healthy foods.
In similar research that reinforces Brave Heart’s findings, Rachel Yehuda, a pioneering psychiatrist and neuroscientist at Mount Sinai School of Medicine in New York, found that children of survivors of historical trauma are four times more likely to have depression and anxiety—and unusual levels of cortisol, a hormone released in response to stress. The result is that these children are genetically more vulnerable to illnesses caused or exacerbated by stress, including cancer, diabetes, hypertension, and substance abuse. The research shows this vulnerability is passed on to their children as well. Judith Herman, a professor of clinical psychiatry at Harvard Medical School and a distinguished fellow of the American Psychiatric Association, wrote in her book Trauma and Recovery that restoring a sense of empowerment among people suffering from trauma and its effects is one way to promote healing.
THE REMEDY: DIET, EXERCISE, AND TCUs
According to the United Health Foundation’s 2015 annual report, America’s Health Rankings, many health conditions, such as heart disease, type II diabetes, strokes, cancer, and high blood pressure are preventable through lifestyle change such as diet, exercise, and stress reduction. Combined with culturally appropriate healthcare, the results can be even better.
TCUs have been working on the front lines in Native communities to improve the mental and physical health of their communities in a number of ways. They have created health curriculum to “grow their own” health professionals in the region, with the goal of creating a talented pool of healthcare professionals who are familiar with the unique needs of their communities while addressing those needs in a culturally relevant way. TCUs also provide programs for the whole community, such as nutrition classes, new mother/well baby classes, smoking cessation and exercise programs, and health centers for community use.
Stone Child College, located in rural central Montana on the Rocky Boy reservation, is a two-year tribal college offering culturally relevant programs to train healthcare workers through its Rural Health Initiative, funded by a grant from the Northwest Area Foundation. To date, 35 students enrolled in the first course of the Rural Health Curriculum, and 28 completed it with a grade of “C” or better.
The Rocky Boy reservation typifies many reservations in demographics. It is located a great distance from other communities. Havre, the nearest town, is 30 miles away, and Great Falls is approximately 100 miles from the reservation. Although there is a health clinic at the reservation, people needing more care must travel to the hospital in Havre or to Great Falls. Unemployment on the reservation is 70%. And many community members suffer from a myriad of health issues due to poverty, distance, and historical trauma.
LaVerne Parker, a registered nurse who serves as the director of the college’s Rural Health Initiative program, says there is a health clinic on the reservation, which most people use for their first line of healthcare. But Parker says that living in a remote place makes it hard to find and keep providers at the clinic. Most work on a contract basis, and when their contract is up they leave and a new provider begins, creating a gap in continuity of care. Patients must begin anew developing a relationship with their healthcare provider and vice versa, impacting the quality of care. Fortunately, Parker says, most of the nurses there are from the community and understand the issues the patients face, making them better able to serve them. Those issues include culture, historical trauma, poverty, and racism. The program’s curriculum addresses these issues and how to handle personal struggles as a Native student seeking a higher education.
Tribal colleges are finding solutions for promoting culturally appropriate holistic healing in an intimate, community-based way—not just for patients, but for the students themselves using empowerment tools. This coming year, students at Stone Child College’s Rural Health Initiative will participate in an ethnography project to record interviews with elders to learn about historical trauma and what elders did to move forward with their lives. The interviews will relate positive messages the elders wish to share and how the younger generations can embrace their culture to raise healthy, well-adjusted children. The curriculum reinforces the principle that the Cree people are resilient and imaginative and have the spiritual strength to live in harmony, using culturally appropriate healing practices that honor traditional values in contemporary contexts.
Parker says many of the students at the college have lost their traditional and spiritual beliefs, and the cultural component of the Rural Health Initiative educates them about the struggles their ancestors experienced. Students report that it has helped to establish a sense of belonging with their ancestors and their community. In the coming months, the college will complete a research study about adverse childhood experiences and how they impact health.
Students also learn about their tribes’ traditional healing practices, the experiences of other Native people pursuing their passions, and how that might impact their own lives. For example, students read The Scalpel and the Silver Bear by Dr. Lori Alvord—the first Navajo woman to become a board-certified surgeon—to understand how she was able to meld Western medicine with her traditional tribal beliefs and practices to become a successful physician. In her book, Alvord discusses “incorporating Navajo philosophies of balance and symmetry, respect and connectedness” into her practice to the great benefit of her patients.
Fortunately mainstream medicine has come around, and today it is accepted practice that cultural values and belief systems impact a patient’s behavior and attitudes about their healthcare, as well as their interactions with and expectations about treatment. When healthcare providers understand the culture of their patients, along with the potential conflicts and partnerships between Western and traditional healing paths, they are better able to plan and implement treatment. Research has shown that when medical practitioners respect patients’ cultural needs and beliefs the happy result is better medical outcomes.
This is also true not just with healthcare itself, but with programs to educate healthcare providers. Parker says that when Stone Child College looks to partner with other institutions or organizations, they’re not seeking to work with those who are paternalistic, but rather those who do not seek to confine them to a specific role. Accordingly, Stone Child has opted to partner with Salish Kootenai College (SKC), another Montana tribal college. Parker says SKC treats them as partners and is welcoming to Native culture. Perhaps this is why SKC, a bachelor’s degree-granting tribal college, ranks 11th in the United States among the top institutions for American Indian students in the fields of registered nursing, nursing administration, nursing research, and clinical, according to the U.S. Department of Education, National Center for Educational Statistics, Integrated Postsecondary Data System (IPEDS).
But respect alone for another’s cultural beliefs often is not enough. According to research, patients are also more likely to accept and receive medical treatment from caregivers who share their language, culture, and ethnicity. The United Health Foundation, established by United Health Group in 1999 as a private nonprofit dedicated to improving health and healthcare, is committed to the idea of developing tomorrow’s healthcare workforce and ensuring that diverse communities have access to quality, culturally competent care. TCUs have been filling that need across the nation. Twenty-one TCUs offer healthcare curriculum and are committed to developing professionals to serve their communities. As of fall 2013, 2,021 students (comprising 11% of all majors) were majoring in health and nursing—one of the top majors, according to the American Indian Higher Education Consortium’s database. Because most TCUs are two-year degree and certificate-granting institutions, students desiring a bachelor’s degree or higher begin their education and then transfer to a four-year institution. Some go on to mainstream institutions to earn bachelor’s and master’s degrees and return to their communities to work and teach. Jessica Zephier, for example, serves as chair of the Nursing Department at Oglala Lakota College and started her college career there before transferring to the University of Nebraska Medical Center’s College of Nursing. Many other students choose to continue at a tribal college offering a four-year degree.
To help produce an even greater number of Native healthcare professionals, the American Indian College Fund is partnering with the United Health Foundation to create the United Health Foundation Tribal Scholars Program. Designed to provide scholarships to exemplary American Indian students from Minnesota, New Mexico, and Arizona, all of which are located in United Health Care’s service area, the program includes career development and networking opportunities for students studying in the healthcare fields.
“Creating a future health workforce that can meet people’s distinct healthcare needs is critical to building healthier communities and helping people live healthier lives,” says Chris Stidman, president of United Health Foundation. “We are honored to partner with the American Indian College Fund to support these students. It is these types of important partnerships that will help increase people’s access to the culturally competent care they need and deserve, which in turn helps reduce disparities in healthcare and improve health outcomes.”
ONE TCU GRADUATE CAN MAKE A DIFFERENCE
Providing educated healthcare workers is not the only way that TCUs create healthier communities. Dominic Clichee (Navajo) is an epidemiologist in the Navajo Nation who started at a TCU. Clichee earned a bachelor’s degree in business at Haskell Indian Nations University in 2010. He says healthcare was never part of his career plan, but it was at the Nike Corporation working on their N7 program, first as an intern in the summer and later as an employee, that he saw the impact the organization made on health by promoting physical activity. It was there that he decided to pursue a master’s degree in public health at the University of Arizona. He graduated in 2013 and returned home to Fort Defiance on the reservation to help bring change to his own community, where he says he is familiar with the culture, land, and individuals. Today Clichee is the acting marketing director for the Fort Defiance Indian Hospital Board, where he tracks and monitors infectious and chronic diseases and develops interventions to improve the health of his community. Some of Clichee’s work includes providing data to monitor disease and deliver public health efforts to impact it. Those programs include education and other efforts that increase the community’s access to information and tools that will help them make healthier choices.
One program includes working to improve the eating habits of community members to fight diabetes, cancer, heart disease, high blood pressure, and obesity—not always easy in a food desert. “We work with the hospital to track and provide food prescriptions. These are vouchers that can be used at the farmer’s market for healthy fruit and vegetables,” Clichee explains. “The farmer turns in the voucher and we pay the farmer. We also work with restaurants to have them highlight healthy food on their menus or to encourage them to include healthy options on their menus.”
Another exciting part of Clichee’s job is increasing community and healthcare links. Clichee says two mobile health units are being sent into the community to provide simple, preventative care. For example, elder-care clinics provide information about injury and fall prevention. The units provide women’s clinics and annual check-ups as well. Care is also being provided at chapter houses through a health hour each week.
Now that the technology infrastructure has been developed in the Fort Defiance service unit, plans are being made to provide care through live video streaming, contingent on compliance with Medicare and Medicaid systems. Clichee says that a community healthcare provider at one of the 16 chapter houses can consult with patients who cannot leave their home by using live streaming, as all networks at the chapter houses have electronic patient records.
The healthcare picture in Indian Country is slowly changing thanks to programming at tribal colleges and universities, and because of the good work TCU graduates are doing. As alumni return home to serve their communities in a professional capacity, their implementation of technology married with their understanding of the forces that shape health, their cultures, languages, and traditions are bound to change Native lives for the better, one person at a time.
Dina Horwedel, J.D., is the director of public education for the American Indian College Fund.