KHI News Service

Great disparities continue

KU center will focus on improving Native American health and workforce

By Dave Ranney | August 02, 2010

In the spring of 1837, smallpox ravaged the tribes of the upper Missouri.

The disease all but wiped out the Mandans. By 1838, it also had killed large percentages of the Blackfeet, Crow, Pawnee, Assiniboine and Arikara.

Historian Clyde D. Dollar called it “one of the most virulent, destructive and disruptive epidemics known on the American continent.”

Tens of thousands are thought to have died, most of them Native Americans.

Times are better now. Smallpox has been eradicated. Heart disease, cancer and type 2 diabetes are now the leading deadly illnesses among American Indians and they kill more slowly than smallpox did 170 years ago.

But almost two centuries later, Native Americans are still more likely than whites or other ethnic minorities to suffer from a variety of health problems.

Great disparities

“American Indians suffer some of the greatest health disparities in the country,” said Christine Daley, an assistant professor of preventive medicine and public health at the University of Kansas School Of Medicine. “They have the highest rates of smoking of any ethnic group by far, at 41 percent. In some parts of the country, it can be as high as 80 percent. They also have the highest rates of obesity and diabetes and some of the highest rates of cancer mortality, which, unfortunately, are coupled with low rates for mammography, pap smears, and colon cancer screening.”

Daley has spent the past 15 years studying issues affecting American Indian health. She now is leading a major initiative aimed at addressing the disparities.

Betty Nioce, medical records administrator at the Kickapoo Nation Health Clinic, stands with grandson, Chavis Nioce, who will be attending the University of Kansas this fall for a degree in sports medicine. Betty Nioce’s daughter, Janet, is a nurse

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The initiative, announced last week, will benefit from a five-year, $7.5 million grant from the National Center for Minority Health and Health Disparities, a division of the National Institutes of Health.

The grant will be used to underwrite the Center for American Indian Community Health at the KU School of Medicine.

Officials plan to launch major studies on diet, exercise and tobacco use among tribal college students. There also is a study planned on why American Indian women fail to get repeat mammograms.

The community health center also will work with tribal colleges, high schools, junior high schools, and Haskell Indian Nations University to develop a “pipeline” for encouraging more American Indian students to pursue careers in medicine and public health.

“Right now, there are so few American Indians in any of the health care professions that any increase would be a huge jump,” said Daley, who also teaches an introduction to community health course at Haskell.

Based in Lawrence, Haskell is one of 10 American Indian colleges offering four-year degrees.

Daley said that while the community health center’s mission will be national in scope, much of its research will be in Kansas.

According to the 2000 census, almost 25,000 American Indians live in Kansas with more than half residing in six counties: Douglas, Johnson, Montgomery, Sedgwick, Shawnee, and Wyandotte.

Four tribes have reservations in Kansas:

• Prairie Band Potawatomi Indian Nation, near Holton.

Prairie Band Potawatomi Health Center

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• Kickapoo Nation, near Horton.

• Sac and Fox Nation, near Reserve

• Iowa Tribe, near White Cloud.

The Kickapoo, Sac and Fox, and Iowa reservations are in Brown County. Almost 9 percent of the county’s population is American Indian.

The Kickapoo and Prairie Band Potawatomi each have a primary care clinic on their reservations. Both clinics are funded by the federal Indian Health Service and supported, in part, by the tribes.

Indian Health Service also operates a clinic in Lawrence and supports Hunter Health Clinic, a safety-net clinic in Wichita.

Underfunded services

Though all four IHS clinics provide access to basic care, they are underfunded and hardly in a position to tackle some of the broader, social-determinant issues that contribute to some Indian health problems, said Dr. K. Allen Greiner, an associate professor at the medical center and a principle investigator at the community health center.

“Indian Health Service provides some medical care for many American Indian groups, but it’s been underfunded for decades - if not forever,” Greiner said. “It is inadequately able, oftentimes, to get people the care they need.”

This inadequacy, he said, hinders access to care and, in turn, promotes disparity.

KHI News Service

Dances and other festivities marked KU Medical Center's July 30 announcement that it was forming a center dedicated to researching American Indian health issues and recruiting young Native Americans to the health care field. Pictured dancing is Tyson White Shield.

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“A lot of things drive health disparities,” Greiner said, “and one of the big ones is access to services. When people don’t get medical care, their rates of death and disability due to disease increase.”

Greiner helped announce receipt of the grant during a ceremony Friday at Haskell.

The community care center, he said, will be looking for ways to improve and expand access to care.

“Sometimes we blame the victim,” Greiner said. “We blame people for their behaviors, whether it’s smoking, or how much they exercise, or what they eat. But we need to realize there’s a context for all those things and we need to help people overcome those challenges.”

Daley said trust is sure to be an issue.

Neither Daley nor Greiner is American Indian and the tribes have had plenty of reasons to mistrust the dominant culture.

“There have been past abuses,” Daley said. “Unfortunately, some have been more current. There are a lot of trust issues and rightfully so.”

Getting started, Daley said, the community health center will have to generate much of its own data because there is a dearth of research on Native American health disparities.

“We’ll be starting out several steps behind where other researchers are,” she said, referring to groups that study other minority populations.

“There’s a lot of data out there that’s tribe-specific or part-of-the-country specific, but, frankly, it’s not very good,” Daley said. “There have been huge longitudinal studies on different populations’ health behaviors and outcomes that have spanned 30 years, but in the native community there’s been one.”

The lone study, she said, focused on heart disease among American Indians.

“In a lot of instances,” Daley said, “we don’t have data that tells us what’s going on now.”

Historical trauma

J.B Kinlacheeny, a graduate student in KU’s Department of Preventive Medicine and Public Health, said that for American Indians, history has contributed to current health problems.

“There is what I call historical trauma,” said Kinlacheeny, who is Navajo. “Our people have been relocated, removed, oppressed, assimilated and put on reservations – there are problems stemming from that alone. You name it, it’s all in there.”

The only way to bridge this trauma, he said, is through education.

“The pipeline for students that they are talking about needs to be there,” said Kinlacheeny, a recent Haskell graduate.

Kinlacheeny said he’d seen many fellow students, especially those from reservations, leave school because they found themselves far from their families and without replacement support systems.

“If there had been some retention services,” he said, “some of them, I think, would have stayed.”

Daley said the plan is for the community health center’s research to be defined and conducted by American Indians.

Shelley Bointy, a member of the Fort Peck Assiniboine and Sioux tribes in Montana, has been named project director.

Shelley Bointy

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“This isn’t going to be a group of researchers coming in from the outside, determining what people need,” Bointy said. “It’s going to be native people determining for ourselves what we think our needs are, what we want to see addressed as a community and across the United States.”

Personal responsibility

Harvey Ross runs the Kickapoo Nation Health Clinic. He said he would be interested to see how the approaches to addressing the social determinants of health for American Indians might differ from those for society at-large.

“The biggest health issues we’re confronted with, I’d say, are obesity and diabetes,” Ross said. “That’s because it’s cheaper and faster to eat high-calorie food and then, with our sedentary lifestyles, we don’t do enough to burn those calories off.”

Angie Thomas, a registered nurse at the Kickapoo Nation Health Clinic, waits on the results of a blood test in a closet-size room that serves as the clinic’s laboratory. “We’ve had a lot of infections, lately,” she said. Thomas, who is Kickapoo, started out as a certified nurse's aide and later took night classes in Kansas City to earn a degree in nursing.

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Ross, who is Kickapoo, said dealing with obesity and diabetes required high doses of personal responsibility.

“At some point, it all comes down to people being responsible for their own health,” he said. “It doesn’t matter how many physicians, nurses, administrators or front-line people you have. The individual has to be proactive, the responsibility lies with them.

“It’s like that on the reservation,” he said. “It’s like that in America as a whole.”

But he also said it was unrealistic to expect much change until the Indian Health System clinics are adequately funded and reservation economies are strengthened.

“My funding is based on a formula that says we have enough money to meet 52 percent of our total needs,” he said. “We used to get tribal money - $400,000 two years ago, $240,000 last year, and $90,000 in the current year.”

The reduction, he said, was due to declines in casino revenues.

“It’s all because of the economy,” Ross said. “And with the economy the way it is, there’s really not much hope in that money ever being restored.”

Think local

Ross said he welcomed efforts to steer more American Indians to health-care careers but that he wasn’t sure the reservation clinics would see the benefits of that anytime soon.

“The pay is going to have to be competitive to get them to come here. It’s not competitive now. Most of the people here are underpaid,” he said. “The other thing is that the person is going to need to be local, by that I mean a Navajo isn’t going to go through school and then work on the (Kickapoo) reservation. They’re going to want to go home and work on their reservation. A Kickapoo is going to be the same way.”

Ross said he knows of four registered nurses who are Kickapoo. One works at the clinic full-time, another is part-time.

Damon Jacobs, a pharmacy student engaged in post-doctoral research at KU, attended the announcement ceremony at Haskell.

“The state of Indian health is not good and hasn’t been good for a long time,” he said. “I grew up on different reservations around the country and it’s the same story wherever you go.”

Jacobs is Ogallala Sioux. He graduated from Haskell before earning a doctorate at the University of North Carolina-Chapel Hill. He welcomed news of the grant but said that it was a small step in what is sure to be a long journey.

“I think this is a great start,” he said, “but it’s for five years and I doubt very much that we’re going to see any measurable differences in five years. The kinds of changes we’re talking about here today take place over generations. I liked what they were saying about creating a pipeline and getting more students involved in health care but I also think that seed needs to be planted the day that child is born.

“That ‘seed’ is that education is in their future and it’s available to them,” he said. “That’s where this has to start. I just hope the commitment that we heard about today is for more than five years. It needs to be long enough that the students who are coming up today can change the way their kids grow up. That’s when we’ll see change.”