SPH report: Health status of American Indians/Alaska Natives continues to decline – Part 3

March 2, 2016

Editor’s note: This is the third post in a three part series. The first and second posts can be found here and here. The complete report can be found here.

Throughout this series we’ve provided you with an overview of a recent report by Linda Frizzell, Ph.D., assistant professor in the University of Minnesota School of Public Health that shows the overwhelming and persistent health disparities American Indians and Alaska Natives (AI/AN) face.

The conclusion of the series will highlight some additional challenges AI/ANs endure, and Frizzell will provide some recommendations for policymakers to improve AI/AN health.

Behavioral health

The stigma of mental/behavioral health disorders is a national problem. Among AI/ANs, there are a wide range of beliefs concerning illness, healing and health. Each tribe has varying cultural traditions which are the foundation of how each tribe maintains their own holistic view and wellbeing for their citizens.

“Suicide is catastrophic in Indian Country. Last year there was a state of emergency declared on the Pine Ridge Reservation,” said Frizzell. “It was reported there were five suicides in one month. There needs to be a coordinated, multidisciplinary effort involving federal, state, tribal and local health officials to address this important public health issue.”

The American Psychiatric Association recommends the following responses and approaches to address the barriers to mental/behavioral health services for AI/ANs:

  • Increase awareness of mental/behavioral health and chronic disease connections, e.g. diabetes
  • Conduct stigma awareness training with gatekeepers
  • Educate providers about unique mental/behavioral health issues
  • Increase presence of AI/ANs in research (as researchers and participants)
  • Advocate for policies that promote social justice, equity and equality
  • Increase comprehensive, affordable, mental/behavioral health insurance coverage for all
  • Focus on prevention and early intervention
  • Develop systems that allow the integration of traditional healing and spiritual practices
  • Increase use of technologies (e.g. telepsychiatry) to better serve remote populations
  • Increase person-centered services and respect for the role of the family

Public health model adoption

The report states public health financial support in Indian Country is virtually non-existent. And while the majority of the U.S. population has access to government-sponsored, accredited health departments, behavioral health facilities, and alcohol and substance abuse treatment facilities, these facilities and services are rare in Indian Country.

When combined with disproportionate levels of poverty, health disparities, historical trauma and injustices and adverse childhood experiences, Frizzell says these problems seem insurmountable.

In regards to the Affordable Care Act’s (ACA) trend to start practicing health services using the public health model, policymakers should consider changing health services to meet the needs of AI/ANs by targeting funding and investments in public health infrastructure to fight some of the immense disparities. Public health is the science of protecting and improving the health of communities through education, promotion of healthy lifestyles and research for disease and injury prevention. Perhaps the most difficult of developing public health assets is the definition of “community.”

One would be hard pressed to find any two “communities” with exactly the same culture, subcultures, economic structure, health issues and factors that bind a group of residents to function and be responsive to the wellness of others. Often policymakers consider their own definition of a “community” without consideration or knowledge of historical human groupings. Additionally, there is often an assumption by policymakers that a given geographic rural area or “town” is a single “community.”

These assumptions often preclude actual groups of citizens, i.e. “communities,” the freedom to be recognized as such, and results in a forced definition of community. Policymakers need to understand that it is not unusual for rural geographic areas, with small populations, to have more than one “actual community.”

In an effort to protect AI/AN health, Frizzell recommends the following basic principles in dealing with services for AI/ANs (the complete list of recommendations can be found here):

  • Explicitly require that Center for Medicare and Medicaid Services, (CMS) assess proposed legislative and regulatory changes that affect tribes and conduct meaningful tribal consultation prior to submitting legislative changes, issuing new regulations, and policies that affect AI/ANs.
  • Include “tribes,” “tribal organizations,” and “tribal” when listing governmental entities (e.g. federal, state, tribal and local).
  • Include specific wording acknowledging the Indian Health Service, tribes and tribal organizations, and urban Indian services (ITUs) as a special type of provider essential for AI/AN access to Medicaid, Medicare and SCHIP programs.
  • Respect traditional practices and customs.

Frizzell says it is critical that when federal, state, or local guidance and regulations are issued that they are compatible with Indian law and customs. This can only be achieved through a formal government to government consultation. History has repeatedly shown that only tribes can provide clarity on how proposed laws/rules/regulation are interpreted as it applies to their citizens.

Finally, in Frizzell’s experiences in providing health services and in administering health programs in AI/AN communities, the amount of needless suffering and loss of life related to preventable and treatable illness makes IHS funding a matter of social justice and civil rights. This issue needs to be a national priority for all public health advocates, not just for the AI/AN population.

Frizzell says resources and services available to AI/AN persons from across the Department of Health and Human Services and other agencies need to be expanded to meet the public health, clinical, research and workforce needs of this population.