A Forgotten Peoples; The Healthcare Disparities of Native Americans
In the United States, Native Americans suffer some of the poorest health outcomes. The US Indian Health Service (IHS) has documented that Native Americans die at younger ages with reports showing that 25% of deaths occur before the age of 45, compared to 15% of African-Americans and 7% of whites. [1] They also die at higher rates than other Americans in a variety of categories including chronic lower respiratory diseases, chronic liver disease and cirrhosis, diabetes mellitus, unintentional injuries, assault/homicide, and intentional self-harm/suicide. [2] The IHS is an agency within the Department of Health and Human Services responsible for providing federal health services to federally recognized Native Americans. The IHS itself however has been on the Government Accountability Office (GAO) “high risk” list since 2017 due to their vulnerabilities to fraud, waste, abuse, and mismanagement. [3] For example in 2018, the GAO published a study showing a 25% average vacancy rate for physicians, nurses, and other care providers within the IHS. [4] We must find a means by which we can adequately support and treat Native Americans, a people that have suffered tremendously at the hands of colonizers, and continue to suffer through generational trauma and a lack of healthcare resources.
Linda Loveless is a member of the Turtle Mountain Chippewa Tribe based on the Turtle Mountain Indian Reservation, a tribe of 32,365 registered members in Belcourt, North Dakota. Linda’s father, Louie Falcon, died of sarcoma cancer in 2015. While being treated for shingles at the Trenton Indian Service Area Clinic, Louie started to complain of knee pain. He was told the knee pain was secondary to the shingles diagnosis. The pain worsened, and he was seen by additional physicians who informed him that he most likely had arthritis and prescribed medication for the pain. Louie ended up becoming very ill and unable to walk. He was seen at the local hospital in Williston that sent him to a larger hospital in Bismarck for care. He was diagnosed with sarcoma cancer and told it was likely that the cancer formed around his knee and spread from there. This cancer is a slow growing kind and could have been treated if caught at an earlier stage. [5] The local clinics tend to fare well for treating things like blood pressure and shingles, but are unable to provide care beyond things in the realm of those diagnoses. It seems that the larger hospitals are the only places that may be equipped to handle more advanced medical conditions, however not everyone lives near a larger hospital or has the means to get to one.
There are many documented instances of malpractice within the IHS system. Wilmer Spotted Wood visited an IHS hospital in Winnebago, Nebraska with documented severe back pain and ashen skin, but was sent home. Hours after he was discharged, a nurse read a test result showing his kidneys were shutting down. A phone message was left for Wilmer informing him to avoid calcium products like the antacid Tums and come back in two days. He died at home due to kidney failure. Wakanda Gonsalves, a high school senior, sought medical attention at an IHS clinic in Sisseton, South Dakota after she started coughing up blood. The clinic sent her home with cough syrup, an inhaler, and anti-anxiety medication. She died two nights later in bed due to a blood clot in her lung. In a court deposition, the IHS contracted physician who treated her stated he did not follow up after an irregular blood test, or review an X-ray showing a lung abnormality. [6]
Were these deaths avoidable? Not necessarily. Could better healthcare practices have had an effect on these outcomes? In my opinion, yes. What could help IHS offer better care? The same thing that controls everything else — money. Through the IHS, the United States spends just over one-third of the money that is spent per capita on healthcare nationwide on Native Americans. In 2019, the IHS received $5.6 billion and an additional $1.2 billion in reimbursements through Medicaid and other programs. In comparison, the National Congress of American Indians, a broad coalition of tribes, is calling for a six fold increase to $36 billion phased in over 12 years in order to fully fund the agency. [7]
Will the United States consider Native American lives worth $36 billion? Or will this country remain true to its history as colonizers, and continue to oppress these peoples via modern day genocide through healthcare?
Further compounding upon issues like those described above is that there has been an ongoing shortage of Native American doctors for some time. This may contribute to worse outcomes due to cultural differences and understanding of day-to-day challenges.
“People tend to comply better when they feel their physicians have a better understanding of who they are and where they come from,” — Dr. Mary Owen, director of the Center of American Indian and Minority Health at the University of Minnesota Duluth campus. [8]
The number of medical schools actively recruiting and training Native students is also few. Gerald Hill, MD, chairman of the Klamath Tribes Health Advisory Committee and a member and past president of the Association of American Indian Physicians (AAIP) suggests racial bias could be a contributing factor.
“In 2017, the number of medical school applicants who identified as American Indian and Alaska Native alone, and not American Indian and Alaska Native plus another race/ethnicity, was just 100 — and a mere 42 matriculated. During the 20 years that I sat on the admissions committees of four different medical schools, I unfortunately too often saw racial bias contribute to the rejection of AI-AN candidates. In addition, representation on medical school faculties is dismal, with only 167 faculty reporting as American Indian and Alaska Native alone, a tiny 0.1% of the nationwide and total.” [9]
IHS offers a number of loan repayment programs for Native American health professionals, which may offer a solution to the financial barrier to this field. One of these programs provides up to $20,000 per year towards education loans. The repayment is in exchange for a two year commitment to work at an IHS facility identified as having a staffing need. [10] While this program may assist in the financial burden, it has its disadvantages. Through this program, many people complete their mandatory 2 years and then relocate. This prevents consistency of care for their patients as they are forced to continuously create a rapport with a new physician, and re-establish an understanding of their medical history and current needs. Adding to this issue is that many of the physicians are recent medical school graduates and lack experience which can lead to misdiagnoses and poor outcomes.
In the face of these challenges, however, some institutions are developing solutions that could be a blueprint for the future. The Cherokee Nation and Oklahoma State University (OSU) have created a new partnership to help support a higher education for Native Americans. The OSU College of Osteopathic Medicine at the Cherokee Nation will be the first tribally affiliated medical school in the United States. The new medical college will be located on the Cherokee Nation Health Services campus. Construction of the 84,000 square foot facility started just last month, and is set to be complete in 2020. [11]
Although it is unfortunate that it has taken until 2020 for something of this scale to be put into place, I can only hope this is the first of many steps in the right direction. Poor access, lack of funding, constant physician changes and lack of experience, and non-Native physicians in the field all contribute to healthcare disparities in the Native American communities. How many more lives will be affected before this continued neglect is addressed?
Works cited:
https://www.ihs.gov/dps/includes/themes/responsive2017/display_objects/documents/Trends2014Book508.pdf page 63 [1]
https://www.ihs.gov/newsroom/factsheets/disparities/ [2]
https://www.gao.gov/highrisk/improving_federal_management_serve_tribes/why_did_study#t=0 [3]
https://www.gao.gov/assets/700/693940.pdf [4]
Email interview with Linda Loveless, May 2019 [5]
https://news.aamc.org/diversity/article/confronting-crisis/ [9]
