2015 AMSUS Meeting
The Society of Federal Health Professionals
2 Dec 2015 – San Antonio, TX
RADM Dawn Wyllie, MD, MPH
Chief Medical Officer/Deputy Director
Bemidji Area IHS
1
“Cross-Cultural Medicine
in the USPHS: Caring for American
Indian/Alaska Native Patients in the
Indian Health Service”
Disclosures
• The presenter has no financial interests or relationships to
disclose.
• Presentation based on public information and personal
experience, does not represent USPHS, IHS
• This continuing education activity is managed and accredited
by Professional Education Services Group in cooperation with
AMSUS.
• Neither PESG,AMSUS, nor any accrediting organization
support or endorse any product or service mentioned in this
activity.
• PESG and AMSUS staff has no financial interest to disclose.
• Commercial support was not received for this activity.
Objectives
At the conclusion of this activity the participant
will be able to:
• Compare 3 American Indian values/beliefs with
contemporary Euro-American society and describe 2
American Indian wellness and disease concepts
• Describe a unique cultural aspect of American
Indian/Alaska Native Heath Care
• Discuss cultural considerations in clinical practice in
order to improve provider-patient relationships and
health care delivery
Journey – Clinical Rotations
•
University of Washington, School of
Medicine WAMI Program (1981-1985):
– 1st yr Seattle Indian Health Board
– 2nd yr - Community Health Advance Program
•
Saturday free clinic - health care to underserved
– 3rd & 4th yrs - Indian Health Service:
•
•
Family Medicine - Nez Perce Reservation, ID
Psychiatry - Alaska Native Medical Center, Anchorage
& Dillingham, AK
– 4th yr - McCormick Hospital, Chang Mai, Thailand
•
•
Pwo-Karen Tribe, Mae Hong Son on Burmese Border
Hansen’s Disease @ McKean Leprosy Hospital
Journey – Clinical Rotations
• UC San Francisco, Family & Community Medicine
Residency, CA
– San Francisco Native American Health Center
– SF General Hospital Refugee Clinic
• Primarily Latin American and SE Asian (limited/ non-English
speaking) patients
• UC Davis, School of Medicine, CA
– Clinica Tepati, Sacramento
• Saturday Free Clinic – health care to underserved, primarily
Hispanics
• Mentorship and support are important components
Journey
- Career
• National Health Service Corps - Scholarship
Recipient
• 9/10/1988 Commissioned as a Medical Officer in the
U.S. Public Health Service (PHS), assigned to IHS
• Call to active duty - Tohono O’Odham Reservation,
Sells, AZ
• Active Duty 27 years, worked in 4 Areas: Tucson,
California, Great Plains, Bemidji
Journey
PHS Career in IHS
• Served in 4 IHS Areas
– Tucson (AZ): 2 Tribes
• Tohono O’odham Nation: 28, 000 members
– California: 103 Tribes
• Chapa-De IHP: Maidu, Miwok, Washoe, Wintun
– Bemidji Area Office (MN, WI, MI, IL, ID): 34 Tribes
• Chippewa/Ojibwe, Sioux/Dakota, Ho-Chunk, Menominee,
Ottawa/Odawa, Oneida, Potawatomi, Stockbridge-Munsee
Mohican
– Aberdeen (IA, NE, ND, SD): 17 Tribes
• Sisseton-Wahpeton Reservation
• IHS Delegate, 1998 “Healing Our Spirits Worldwide
International Conference”, Rotorua, New Zealand
– Maori Tribe
Indian Health Service
• An agency within the Department of Health and
Human Services (HHS), established in 1955
• Mission... In partnership, to raise the physical, mental, social,
and spiritual health of American Indians and Alaska Natives to
the highest level
• Goal... to assure that comprehensive, culturally acceptable
personal and public health services are available and accessible
to American Indian and Alaska Native people
• Foundation... to uphold the Federal Government's obligation to
promote healthy American Indian and Alaska Native people,
communities, and cultures and to honor and protect the inherent
sovereign rights of Tribes
IHS Agency Priorities
Robert Mc Swain
Renew and strengthen our partnership with Tribes
and Urban Indian Health Program
Bring reform to the IHS
Improve the quality of and access to care
Ensure that our work is transparent, accountable, fair,
and inclusive
10
Special Government to
Government Relationship
• Direct Federal Government relationship with 567
sovereign Tribes
• Relationship established in 1797 based on
Article 1 Section 8 of US Constitution:
– “Congress regulates commerce among states…and
with Indian Tribes.”
– Given form and substance by numerous treaties,
laws, Supreme Court decisions, and Executive
Orders
American Indian/
Alaska Native History
• Extermination < 1871
• Broken Treaties
• Assimilation > 1871
• Boarding Schools
• Reservation dissolution
• Federal Termination of Tribes
• Relocation 1950’s – 1960’
• Tribal Self-Determination 1970’s to current
• Re-Affirmed Tribes and New “Federally Recognized” Tribes
Passage of Landmark Legislation
• 1921 Snyder Act was passed by Congress authorized
funding for the health care of Indian people
• 1954 PL 83-568 transferred health care from the Bureau
of Indian Affairs to the Surgeon General of the USPHS
within the Department of Health, Education and Welfare
• “…all functions of the Secretary of the Interior relating to the
conservation of the health of Indians…”
• However the budget or appropriations from Congress remain
under the Department of Interior
• 1975 Indian Self-Determination Act
• 1976 Indian Health Care Improvement Act (IHCIA)
• 1991 Self Governance
IHS Agency Today
 Relationship with Congress



Congress is the legislative branch of the U.S. Government
Congress passes appropriations, allocating funding to IHS
HHS executes and implements laws passed by Congress
 Relationship to U.S. Department of Health and
Human Services (HHS)


IHS elevated to Agency status,
is one of eleven Operating Divisions
within the HHS which is an Executive
Branch of the U.S. Government
Budget Formulation, PFSA, Tribal Mgmt
14
The 2nd - 25+ Years of IHS
~1980-present

Federal budget process

Addressing health disparities

Professional excellence

Modern health facilities

Tribal consultation

Organizational change

Growth of Tribal Management
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Indian Health Service Area Offices
Hospitals
WA
MT
BILLINGS
OR
*PORTLAND
CA
CALIFORNIA
*
*
SD
WY
UT
WI
ME
MI
*
ABERDEEN
Urban Programs
BEMIDJI
*
NE
NV
MN
ND
ID
Health Centers
NY
IA
IN
CO
PA
PHOENIX
MA
CT
RI
KS
AZ
NAVAJO
ALASKA
*
*
NM
*
TX
*
MS
OKLAHOMA
AK
TUCSON
*
ALBUQUERQUE
CITY
TN
OK
NC
*
AL
SC
NASHVILLE
LA
FL
*Area Office
Note:
Texas is administered
by Nashville, Oklahoma City,
and Albuquerque.
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A Rural Health Care
System in 35 States
IHS Demographics
Who We Serve
 567 Federally Recognized Tribes
 Long process for official Federally recognition of
Tribes: Re-cognized & newly recognized
 2010 Census: 2.3 million people AI alone =
09% total US population
 User Population ~ 1.2 million
 Tribal size ranges from ~200 to ~40,000
 Staff = Civil Servants, PHS Commissioned Corps
Officers, Direct Tribal or Urban Program Hire
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Indian Health Care
Primary Concerns
• Health Disparities of this underserved population
• Limited Access (specialty care, high cost medications, etc)
• Inadequate funding to address health care needs
Priorities
•
•
•
•
•
Close the health care gap, maintain & improve patient care
Strengthen Public health and Environmental infrastructure
Community based primary care; Culturally relevant care
Enhance opportunities for tribal participation and control
Partner with Tribes and collaborate with other entities to
enhance resources, support to tribes
Health Disparities
• Leading causes of death
– Cardiovascular Disease
– Cancer
•
•
•
•
Colorectal
Lung
Gyn: Cervical, Breast
Prostate
– Unintentional Injuries and Suicide
– Diabetes
– Chronic Lower Respiratory Disease
• Lifestyle Contributors: Obesity, Smoking
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Health Disparities
Cardiac Disease
Age-Adjusted Deaths due to Diseases of the Heart
(ICD-10 I00-I09,I11,I13,I20-I51; per 100,000)
2011-2013
300.0
257.2
250.0
212.0
199.2
200.0
171.3
169.8
168.7
162.3
150.0
121.4
92.7
100.0
76.8
50.0
0.0
All Races
AI/AN
Asian / Pacific Islander
United States
Bemidji Area
Black
White
Health Disparities
Cerebrovascular Disease
Age-Adjusted Deaths due to Cerebrovascular diseases
(ICD-10 I60-I69; per 100,000)
2011-2013
60.0
49.7
50.0
40.0
37.0
36.2
36.1
31.4
30.0
49.3
35.7
34.9
30.6
25.6
20.0
10.0
0.0
All Races
AI/AN
Asian / Pacific Islander
United States
Bemidji Area
Black
White
Health Disparities
Cancer
Age-Adjusted Deaths due to Malignant Neoplasm
(ICD-10 C00-C97; per 100,000)
2011-2013
250.0
210.2
200.0
193.8
185.5
166.2
168.6
166.3
166.2
150.0
110.4
103.3
103.2
100.0
50.0
0.0
All Races
AI/AN
Asian / Pacific Islander
United States
Bemidji Area
Black
White
Health Disparities
Diabetes
Age-Adjusted Deaths due to Diabetes Mellitus
(ICD-10 E10-E14; per 100,000)
2011-2013
60.0
54.0
50.0
38.9
40.0
36.4
35.8
30.0
21.3
21.2
21.1
20.0
19.8
19.5
15.8
10.0
0.0
All Races
AI/AN
Asian / Pacific Islander
United States
Bemidji Area
Black
White
What Contributes to
Health Disparities ?
•
•
•
•
Social barriers
Education level
Economic barriers
Inadequate
appropriations
• Health Literacy level
•
•
•
•
Geographic barriers
Access barriers
Resources/Financial
Lack of personal
health insurance
• Cultural Awareness
LNF
26
Health Disparities – Education
Health Disparities
Teen Education and Employment
2006
20%
16%
15%
10%
11%
7% 8%
5% 6%
% teens who are high
school dropouts
% teens not attending
school and not working
5%
0%
U.S. All Races
U.S. White
U.S. AI/AN
Notes:
% teens who are high school dropouts: % of teenagers between ages 16 and 19 who are not enrolled in school and are not high
school graduates. Persons who have a GED or equivalent are included as graduates in this measure
% teens not attending school and not working: % of teenagers between ages 16 and 19 who are not enrolled in school (full- or
part-time) and not employed (full- or part-time).
Source: Annie E. Casey Foundation 2008 “Kids Count” Project
Health Literacy
• What is it?
“ The ability of an individual to access,
understand, and use health-related information
and services to make appropriate health
decisions.”
• Health History Forms
• Medication Bottles
• Appointment Slips
• Informed Consents
• Discharge Instructions
• Health Education Materials, Food Labels
• Insurance Application
Who Are American Indian/
Alaska Native People?
• The original inhabitants of this country
• Diverse people from many tribes
• Distinct history, languages, cultures, traditions,
social networks, governments
• Dual citizenship in any one of many different
tribes
• May have red or blonde hair, be blue or green
eyed, look like another ethnic race, as well as
having the prevailing stereotypical
characteristics
DIVERSITY!
Indian people have differing:
• Identity: tribal, cultural, bi-cultural, non-traditional
orientation
• Cultures, values, and practices;
• Language/communication styles;
• Lifestyles; geography;
• Incomes, employment rates, education;
• Health & illness beliefs;
• Family structures/kinship relationships;
• Spirituality & religious customs
Importance of Spirituality
•
•
•
•
•
Spirituality
Ritual
Dreams
Healing Practices
Inter-Tribal Celebrations
Cultural Considerations
Religion/Spirituality
• Presiding religious/spiritual official
• Ceremony (may be a blending Christianity &
Traditional Spirituality)
• American Indian Symbols - the use & practice of:
–
–
–
–
Tobacco
Eagle Feathers
Medicine Bag
Sweat Lodge
* Cedar
* Sacred Pipe
* Smudging
* Indian Names
Expression of Voice
• Language
• Stories
– Oral Tradition
• Drum and Song
The Next Generation
• View of Children
– Blessing/Gift
• Number of Children
• Child Care Customs
– Experiential learning
• Role of Parents/Grandparent/
and Extended Family
– Woman’s role as family caregiver
General American Indian Values
•
•
•
•
•
•
•
•
•
•
Show Respect to Others - Each Person Has a Special Gift
Share What You Have - Giving Makes You Richer
Know Who You Are - You Are a Reflection on Your Family
Accept What Life Brings - You Cannot Control Many
Things
Have Patience - Some Things Cannot Be Rushed
Live Carefully - What You Do Will Come Back to You
Take Care of Others - You Cannot Live Without Them
Honor Your Elders - They Show You the Way in Life
Pray for Guidance - Many Things Are Not Known
See Connections - All Things Are Related
American Indian Concepts of
Health / Wellness
• Results from harmony with nature
• Is a balance between mind, body, emotions, & spirit/soul,
not the absence of disease
• Relationships are an essential component
• Spirituality/religion & medicine are inseparable
• The spirit existed before it came to the body & will exist
after the body dies
• Each of us is responsible for our own health
• “Life-ways” are necessary to maintain health
American Indian Concepts of
Disease
• Damage to mind, body, emotions, &/or spirit can produce
disease in same or different realm
• Illness is an opportunity to purify one’s soul
• Natural un-wellness is caused by the violation of a
sacred or tribal taboo
• Unnatural wellness is caused by evil
• Dis“ease” is felt by the individual & their family
American Indian Concepts of
Healing
• Healing of one realm can bring about healing in another
• Spiritual realm is the most important
• Total treatments heal the mind, body, emotions, & spirit/soul
• Life comes from the Great Spirit from which all healing begins
• Mother Earth contains numerous remedies for our illnesses
• Traditional healers can be either men or women, young or elder,
recognized by their community
American Indian Concepts
Traditional Indian Medicine (TIM)
• Openly practiced until 1887 when the Dawes’
Act was passed by the US Congress, a
provision made TIM illegal
• Today, a majority of the 2+ million Indians
consult traditional healers
• 70% of Urban and 90% of Reservation based
Indians use TIM
Cultural Considerations
Traditional American Indian Healers
• What traditional healers do best & different from
contemporary clinicians: Pray, Listen, Time
• Native patients often go to traditional practitioner before
seeking contemporary medical care
• Native patients seldom reveal their use of traditional
healing methods and medicines
• Native patients value the healer’s advice over the
physician’s if a disagreement arises
Cultural Considerations
in Clinical Practice
Native American and Euro-American
Cultural Values and Behaviors
• Please review handout comparing Native American and
Euro-American Culture and Behaviors
Cultural Considerations
Language and Communication
(verbal & non-verbal)
• Bilingual &/or Interpreter-translator
• What is not said is also important
• Word Phrasing - words have power to shape
reality
• Individual speech style/pattern
Guidelines for
Health Care Professionals
• Understand the culture of the people you’re
caring for
• Understand your own cultural beliefs, biases,
communication style
• Listen, be open-minded, avoid labeling
• Ask rather than assume
• Be respectful, courteous, & have a
cooperative attitude
• Respect the therapeutic partnership of
traditional healers and medicines with
contemporary medicine
Journey – Closing Comments
•
•
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Medicine is art, science, life-long experiential learning
Spirit of adventure, create opportunities, own path
Be adaptable, open to change, take a risk
Maintain a positive attitude, optimism, enthusiasm,
passion, realism, self-confidence
Strive to stay in balance, use humor
Develop positive support systems early, along the
way
Listen to constructive feedback, avoid negative
energy
Seek out mentors, become a mentor, inspire
Be compassionate and culturally attuned
Contribute in ways that make a difference in the lives
of those you serve
Obtaining CME/CE Credit
If you would like to receive continuing
education credit for this activity, please visit:
http://amsus.cds.pesgce.com
This information may also be found in the
2015 program
Resources/ Websites
• Indian Health Service: www.ihs.gov
• Trends in Indian Health: 2014 Edition
• https://www.ihs.gov/dps/index.cfm/publications/trends20
14/
• U.S. Public Health Service Commissioned Corps:
http://usphs.gov/
• U.S. Surgeon General: www.surgeongeneral.gov
47
Contact Info
• Dawn Wyllie, MD, MPH, FAAFP
RADM, US Public Health Service
Chief Medical Officer/Deputy Area Director
Bemidji Area Indian Health Service
522 Minnesota Ave, NW
Bemidji, MN 56601
Email: dawn.wyllie@ihs.gov