When thinking about the impact of society on citizens’ health in the United States, there is no greater example of “the perfect storm” than the health crisis on many of Native American reservations. We reached out to two healthcare providers who worked with the IHS (Indian Health Service) on the Pine Ridge Reservation in South Dakota, Dr. Julie Womack and Gallaudet Howard, N.P, and here’s what they said.
The Perfect Storm:
First, we asked about what the most common health conditions are. First, Dr. Womack said: “On Pine Ridge -- and I would guess on most reservations -- it seems that everything is more common: diabetes, hypertension, dyslipidemia, substance use (ETOH in particular, but I'm guessing that with the current gang activity on Pine Ridge, you can get just about anything), sexually transmitted infections, GYN concerns. Pretty much everything. I guess it would probably be easier to list what is NOT more common: osteoporosis (people of color have lower rates than white people), and maybe HIV (but I don't know if this is from a lack of testing or if rates are really lower). If you look at the larger Native American population (including those who live in cities), I'm guessing that rates of HIV are probably similar to others. It's a question of access, however. If you are in a population with low prevalence, your risk is much lower” Mz. Howard agreed, also mentioning “Metabolic Syndrome”: “By far the most common complications on Pine Ridge were Type 2 Diabetes, something called Metabolic Syndrome (a genetic predisposition to diabetes, hypertension, heart trouble, and high cholesterol, which is like the trifecta of physiologic awfulness) and complications from Alcohol Use Disorder. Obesity was also common and didn't help any of the above.”
When asked why, both gave similar answers: Dr. Womack said “Why are most conditions more common? Poverty, primarily. There may be genetic predispositions for diabetes, for example -- the Tohono O'odham tribe has the highest rate of diabetes in the world. The Sioux (Pine Ridge) have high rates, but not as high as the Tohono O'odham. I would guess that Native populations may have higher rates of most metabolic conditions (diabetes, hypertension, dyslipidemia, cardiovascular disease) relative to others, but I still think that poverty, discrimination, poor treatment by the US government account for much of the elevated rates” Mz. Howard added: “The above were common because of a combination of genetics (it was a small gene pool) and social factors. Poverty is complex and multifactorial and seriously exacerbated, even created, the above problems. For instance, the rez is a food desert, where it's impossible to find fresh fruits and vegetables and where people eat a lot of government commodity food like cheese and potato chips. Therefore the diet ends up contributing to the rates of obesity and diabetes. There are few places to exercise, so that makes everything worse. People often grow up surrounded by Substance Use Disorder so are likely to adopt those patterns and also to be genetically susceptible. People can't find transport so it's hard to get to the doctor or the specialists, and folks spend a lot of time looking after other people, so then they don't look after themselves.”
One should notice that almost all of these individual health issues are the result of greater societal problems. Historically speaking, most of these specific problems did not exist until the United States’ cultural genocide of indigenous people, and we wondered if traditional indigenous lifestyles were healthier than the western styles currently imposed on life in reservations. Both agreed: “The Sun Dance and Sweat Lodges and the Lakota religion are a huge deal, and people who practice all these seem to find strength and community and support in an amazing way, which contributes to health of all kinds--being more active, being thinner (I'm not being judgy here: being overweight is just devastating to health: hypertension, heart disease, high cholesterol, joint pain, arthritis, knee and hip problems, and diabetes can all be avoided or mitigated with diet, exercise, reasonable weight, little to no alcohol, and no smoking)”, said Howard, later also talking about indigenous medicine, “I don't know much, but I do know it involves prayers and ceremony as well as herbs and such. I had a lot of patients who Sundanced, and they would have these big wounds from piercing, and those wounds never got infected. They were packed with some kind of herbal stuff from the medicine men.”
The Indian Health Service
But we would be remiss if we didn’t ask about the IHS, and how it differs from private healthcare systems. Howard’s response was quite straightforward: “Insurance coverage! Everyone who is covered by the IHS has cradle-to-grave free health care with free drugs. So you might have to mess around finding the best care and referrals to specialists and such, but everyone can GET care of SOME kind. In the private sector, it's all about what insurance covers. People don't get ANY care without insurance” Dr Womack went into further detail on the differences, and said “Oh my... the list [of differences] is long. Although I've spent a number of years at the VA (more as a researcher than as a clinician, but I have been a VA clinician), and the VA is quite similar to the IHS... the joys of working for a government organization... which does call into question the feasibility of a single payer system in the US, if the single payer is the US government... but I digress. When you work in healthcare that is not government run, the goal is profit. Lots of things are easily accessible -- we have a decent electronic health record, so I have easy access to my patients' health records. Things are run efficiently. If you don't work well, you'll likely be fired, so many of the people you work with are hard workers who more or less do their job. BUT -- on the flip side -- there are a number of things that I can't do in the private sector that I could do at the IHS. At Pine Ridge, I worked as a midwife. We could just admit pregnant women to the unit if we were concerned about them even though there wasn't a diagnosis attached to the admission. Not something that we can do in the private sector. There are restrictions on prescribing in both venues -- the pharmacy in the IHS had a formulary, and we had to follow the formulary in prescribing. Insurance companies have formularies as well. There's more paperwork involved if I want to prescribe outside of an insurance company's formulary, but it's more or less the same thing. I'm lucky in that the hospital system I work for has to provide free care to patients who cannot afford to pay for their health care. There's a process associated with getting people signed up, but my clinic has never turned anyone away because of an inability to pay.”
Looking to the Future
We had to ask about what policies could be useful in improving health on reservations, and the answer is complex. Dr. Womack pointed out that “this is a difficult thing to do. If we impose policies from the outside, it's colonialism all over again, and that's never worked well. This needs to come from the people. We're also a nation of individuals (and individualists)... no one wants anyone else to tell them how to live their lives... and that includes making decisions about their health care. Money would help, equality would help, ending racism would help, getting people jobs would help. Remember that the healthcare system is part of the superstructure. It won't change until the economy (the structure) changes” Howard agreed, but followed up with “But here's one thing: aggressively funding excellent schools with seasoned teachers and coaches, extensive after-school programs, peer-to-peer counseling programs, and school-based clinics (including mental health clinics). Another: providing gyms in each community and the transport to get to them. And then, residential and outpatient treatment, including suboxone, for Substance Use Disorder”
In response to Dr. Womack’s mention of individualism, we asked about what “Average Joe” can do to help (and if he should), and both practitioners’ responses were the same: “Work on the rez (any rez). Get to know people from the rez. Get a sense of what life is like for people. Teach, provide healthcare, whatever... it's all good and it's all important” said Dr. Womack, affirmed by Howard who said “Get a medical or teaching degree and then show up and stick around. Or, find a good program to donate to: Red Cloud Indian School or the Casey Family Foundation are both great.” They noted that the IHS helps pay off much of its staff’s loans from medical school. Howard also noted as general advice that people should “Talk about them a lot. Insist the culture and the place isn't forgotten out East! Seriously! Also, talk about the amazing pow wows and the traditions and medicine and ceremonies. Everyone always talks about poverty and desperation. But the rez is a lot more than that.”
Finally, after that important note, we asked Howard if there was anything else she’d like future medical workers to know, to which she responded “It's the best job in the world. Good for you! You'll love it. It's not easy, but it's amazing to be able to walk into any room in the world and basically have people be like, "Okay, glad you're here, please get to work helping me."
Thank you to Dr. Julie Womack and Gallaudet Howard, N.P, for telling us a little about their experience!