american indian health disparities and culturally sensitive counseling donald warne, md, mph oglala...

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