American Indian Health Disparities and Culturally Sensitive Counseling

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

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

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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

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IHS Areas
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AAIHS / AATCHB
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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

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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

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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

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American Indian Disparities
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American Indian Disparities
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American Indian Disparities
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American Indian Disparities
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American Indian Disparities
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American Indian Disparities
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HIV/AIDS in Minnesota Annual Review
SOURCEU.S. HIV/AIDS Surveillance Report,
Year-end 2007National Center for HIV, STD, and
TB Prevention, CDC
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HIV/AIDS in Minnesota Annual Review
SOURCEU.S. HIV/AIDS Surveillance Report,
Year-end 2007National Center for HIV, STD, and
TB Prevention, CDC
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U.S. State-Specific AIDS Rates per 100,000
PopulationYear 2007

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

• Integral to HIV prevention, treatment, and care
  efforts

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HIV Testing
CDC, MMWR, Vol. 55, NO. RR14 September2006. CDC,
MMWR, Vol. 52, NO. 15 April 2003.
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HIV/AIDS cases by year of diagnosis, 2004-2007
http//minorityhealth.hhs.gov/templates/content.as
px?ID3026
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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.ht
m
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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
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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
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Diabetes Death Rates (Rate/Per 100,000
Population)
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Alcohol Related Death Rates (Rate/Per 100,000
Population)
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Medical
Behavioral
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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

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AI Healthcare Resource Disparities
Bureau of Prisons
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A BRIEF HISTORY OF MEDICINE

• 2000BCHere, eat this root
• 1000ADThat root is heathen, here say this prayer
• 1800ADThat prayer is superstition, here drink
  this potion
• 1900ADThat potion is snake oil, here swallow
  this pill
• 1950ADThat pill is ineffective, here take this
  antibiotic
• 2000ADThat antibiotic is artificial, here eat
  this root

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MODERN TRADITIONAL

• Model Allopathic Holistic

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MODERN TRADITIONAL
Medicine Physical Spiritual
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MODERN TRADITIONAL

• Provider Physician Healer

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MODERN TRADITIONAL

• Symbol Serpent Staff Medicine Wheel

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MEDICINE WHEEL
MENTAL
SPIRITUAL
PHYSICAL
EMOTIONAL
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Traditional Systems of Diagnosis
MEDITATION
PRAYER
HERBS
COUNSELING
Key Components Ceremony, Family Community
Participation
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MEDICINE WHEEL
DECISIONS
VALUES
ACTIONS
REACTIONS
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MEDICINE WHEEL Traditional Values
WISDOM
FORTITUDE
COURAGE
GENEROSITY
UPHONOR
WITHIN HUMILITY
DOWNRESPECT
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MEDICINE WHEEL
ATTITUDES
BELIEFS
ACTIVITIES
FEELINGS
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MEDICINE WHEEL Public Health
EDUCATIONAL
CULTURAL
ENVIRONMENTAL
SOCIAL
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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
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Ed McGaa, Eagle Man
We all start out in this world as tiny seedsno
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
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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
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Substance Abuse and theMedicine Wheel

• What greater grief than the loss of ones native
  land
• Euripides
• 485-406 B.C.

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Alcohol Related Death Rates (Rate/Per 100,000
Population)
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Suicide Death Rates (Rate/Per 100,000 Population)
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MEDICINE WHEEL and Health Behavior
DECISIONS
VALUES
ACTIONS
REACTIONS
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MEDICINE WHEEL and Health Behavior
DECISIONS
SUBSTANCE ABUSE
NEGATIVE EMOTIONS
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MEDICINE WHEEL
MENTAL
SPIRITUAL
PHYSICAL
EMOTIONAL
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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.

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CULTURAL COMPETENCE

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

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URM Health and Science Workforce
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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

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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
• gt12 Vacancy Rate in IHS Health Professions

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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

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CULTURAL COMPETENCE

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

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CULTURAL COMPETENCE

• Purnells Model
• Person, Family, Community, Society
• Unconsciously incompetent
• Consciously incompetent
• Consciously competent
• Unconsciously competent

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CULTURAL COMPETENCE

• StrategiesOrganizational
• Expand AI/AN healthcare leadership development
  programs
• Hire and promote AI/AN in healthcare workforce
• Involve community members in healthcare
  organizations planning and quality improvement
  strategies training

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CULTURAL COMPETENCE

• StrategiesClinical
• 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 systemactive involvement

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CULTURAL COMPETENCE

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

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Medicine Wheel Cultural Competence
MENTAL
SPIRITUAL
PHYSICAL
EMOTIONAL
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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

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Sample Programs

• Winslow Hospital
• Medicine Man on Staff
• Hogan on Hospital Grounds
• Medicine Mans Association

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Sample Programs

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

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Sample Programs

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

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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.
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Donald Warne dwarne_at_aatchb.org