Why Obesity and Heart Disease Hit Harder in Indian Country

Woman from the Confederated Tribes of Warm Springs prepares salmon. (Photo: Alyssa Macy)

Woman from the Confederated Tribes of Warm Springs prepares salmon. (Photo: Alyssa Macy)

And how to fix it.

By Francie Diep, Pacific Standard

The Navajo Nation covers 27,413 square miles. Serving that entire area, the territory has just 10 grocery stores. This means that, in order to get fresh, affordable produce, some Navajo Nation residents must drive at least 155 miles round-trip, according to one recent study.

This makes the Navajo Nation, like many other American Indian reservations, a food desert—a region in the United States where residents can’t easily buy fresh, healthy, affordable food. (Because of their setting, these food deserts are unlike those that normally show up in the news, which tend to be in urban centers.) In recent years, American public health researchers and policy experts have done a lot to document the effects of food deserts on people’s health, and to suggest solutions. Yet, in all that talk, nothing quite seemed like it would work for the people Crystal Echohawk and Janie Simms Hipp serve. “The policy levers were off,” Hipp says. “They were not a good fit because of the uniqueness of Indian Country.”

Hipp is an agriculture lawyer who directs a research institute at the University of Arkansas School of Law. Echohawk runs her own consulting firm in Colorado that advises non-profits working on American Indian issues. Together, they advocate for American Indians to gain better access to healthy food, which would in turn reduce rates of obesity, diabetes, and other diet-related ills that run rampant in the Native American population as a whole. Over 80 percent of American Indian and Alaska Native adults are overweight or obese; about half of American Indian children are at an unhealthy weight; and it’s estimated 30 percent of American Indians and Alaska Natives have pre-diabetes. Compare those statistics to American adults in general, two-thirds of whom are overweight or obese, and 27 percent of whom are estimated to have pre-diabetes.

“Oftentimes, when conversations are had with policymakers or philanthropy or public health, people just turn away and say, ‘We don’t know where to start. The problems are too big for us to solve.’ But there’s no shortage of opportunity for real change.”

Conventional fixes probably won’t work. But Echohawk and Hipp have ideas for what will. Together with lawyer-activist Wilson Pipestem, they put together a report for the American Heart Association about how to address the unique burden of diet-related disease that the U.S.’s indigenous people carry. “I think, oftentimes, when conversations are had with policymakers or philanthropy or public health, people just turn away and say, ‘We don’t know where to start. The problems are too big for us to solve,'” Echohawk says. “But there’s no shortage of opportunity for real change.”

Pacific Standard recently talked over the phone with Echohawk and Hipp about what makes it hard to stay healthy while living on reservations and trust lands—what’s collectively called Indian Country—and how a local food movement and cultural programs can make it easier:

What are some examples of policy ideas for reducing obesity that weren’t good fits for Indian Country?

Janie Hipp: I’d served for six years or so with the Bush and Obama administrations at the U.S. Department of Agriculture. I was always struck when policy, at the national level, was really bearing down on food deserts. They talked about encouraging retail food outlets to carry more healthy food products or fresher produce. That’s great, but if you have no retail food outlet, then you’re actually talking about a whole different policy arena that you need to wrap your head around.

Crystal Echohawk: There’s just the assumption that people already had outlets, that they were in urban centers. There’s also the lack of understanding of tribes as sovereign nations and their ability to institute a level of policy change over their tribal citizens. Now, a lot of the policy change that is being advocated is at the state level. But when we really look at the biggest levers of change in Indian Country, we look at the level of tribal government and we also look at federal because of the government-to-government relationship that tribes have with the federal government.

I saw that the Navajo Nation this year instituted a tax on junk food. It also made fresh fruits and vegetables tax-free. I can’t imagine a state doing that. New York City tried to institute a sugary-drinks tax and it failed.

CE: There’s immense opportunity for real change in Indian Country. What Navajo Nation did, I think, is just one example. There are just so many more opportunities aside from a tax.

What’s one of your favorite ideas for improving healthy food access in Indian Country?

JH: The vast majority of the foods that are raised for human consumption on our reservations leave the borders of the reservation. If the levers are pulled in such a way that feeding people healthy, local food comes first, before you feed folks outside of those reservation boundaries—you can do both—then we are within reach of having a major shift in our health. And oh, by the way, [by selling locally grown food locally] we also can build strong rural and remote economies.

Why does all the food leave?

JH: What is lacking in all rural communities—it’s not just Indian Country, but the lack is more profound—is the infrastructure necessary to do the harvesting, grading, packing, storage, freezing, all of those things that allow you to store and move food around more locally. Re-building those infrastructure pieces, or building them outright, is an important piece that can’t be ignored.

What’s wrong with growing food on tribal land and having that shipped out, and then having something else shipped in, instead?

JH: Being able to retain as much healthy local food around our communities as possible is going to lead to fresher produce being available to us. On the meat side, that’s been a phenomenon for years, where livestock is raised on our reservations, but they leave the reservation boundaries and, in many cases, never return. Or they make a circuitous route across the U.S. before they get back. Think about the cost associated with that. All you have to do is go into a grocery store close by any of our remote reservations and you will noticeably see the cost of food is much higher, and that’s not even talking about Alaska.

Why do you think American Indians have higher rates of obesity and diabetes than Americans in general?

CE: Poverty is a root cause. It’s a lot cheaper to go to McDonald’s and order stuff off the Dollar Menu than it is to go in and buy fruits and vegetables in a store when you’re looking at many families that are surviving on one paycheck and feeding a dozen people.

Another important component is how we’re addressing historical trauma within Native American people. There’s been increasing research out there linking trauma to health disparities. When you look at the history regarding Native Americans, of forced removal, of genocide, the boarding schools, it’s layer upon layer of trauma that Native American people, over generations, have sustained

Telehealth Project Aims To Improve Health Care Access for Inland Empire Tribes

By Lauren McSherry, California Healthline

A health care system serving nine American Indian tribes in the Inland Empire is using telehealth to reach patients in remote areas and address rising rates of diabetes, a particular problem among American Indians.

Riverside-San Bernardino County Indian Health serves nine tribes in the expansive Inland Empire region of Southern California. The region encompasses nearly 30,000 square miles, an area the size of Vermont and New Hampshire combined. Patients who live in rural parts of Riverside and San Bernardino counties must travel long distances for health care. Those who live near the Colorado River and in cities such as Needles and Blythe, which lie along the Arizona border, sometimes must travel several hours for specialty care.

“If you think about that vast expanse with an urban corner, it makes all the sense in the world to have all forms of telehealth,” said Mario Gutierrez, executive director of the Center for Connected Health Policy. “Telehealth has always been thought of as a rural tool.”

Indian Health is the largest tribally owned health care system in the state and one of the largest in the West, aside from the Navajo Nation and some tribally owned systems in the Northwest, said Bill Thomsen, chief operations officer. There are more than 50 health systems serving Indians in California, he said.

The health system exclusively serves Indians belonging to nine tribes in the Inland Empire and their eligible dependents. The health care system has seven health centers and 14,000 patients, Thomsen said.

In recent months, Indian Health has rolled out a telehealth project, which is initially focusing on endocrinology to combat high rates of diabetes among tribe members. In San Bernardino County, for example, 13% of American Indian adults suffer from diabetes, and nearly 80% are overweight or obese, according to Healthy San Bernardino County.

“Native Americans are the largest diabetic population in the world,” said Karen Davis, Riverside-San Bernardino County Indian Health’s clinical services director.

Overall, Indians face a scarcity of health care resources and unusually high rates of asthma, diabetes and heart disease. American Indians are 177% more likely to die from diabetes, according to Native American Aid.

Pulmonology, cardiology, gerontology and dermatology will be addressed in the project’s subsequent phases.

The project focuses on specialty care because 45% of the Indian health system’s patients don’t have health insurance, restricting their access to certain medical services, Davis said.

“The value that we have seen is increased access to care, which ultimately affects outcomes,” she said.

Gutierrez said that because of the region’s shortage of specialists, the endocrinology project can have a big impact because it is crucial to diagnose diabetes early and control it, he said.

“The earlier you intervene, the more likely you are to avoid debilitating effects — loss of limbs, eyesight, all those complications that can be prevented,” he said.

‘A Model for the Rest of the State’

Steven Viramontes, clinical applications and telemedicine coordinator for California through the federal Indian Health Service, said implementing telemedicine in rural areas is a “no brainer.” It addresses cultural considerations in providing medical care to American Indians and improves access for patients who would otherwise not be able to receive certain specialized medical and psychiatric services.

“They are taking this on in a stepwise fashion,” he said of the health system’s telehealth project. “And I think that can serve as a model for the rest of the state.”

Davis said cultural awareness is a particularly important component of the project. Patients prefer receiving care through the Indian Health system, rather than seeking specialized care outside of the system, she said. She added that building trust with patients is important.

“We want people who can interact with the patient in an appropriate and sensitive way,” she said.

Diabetes treatment must address cultural influences, such as diet and lifestyle, and providing treatment through a tribal health system ensures much better compliance and understanding among patients, Gutierrez said.

“It’s not just diagnostics,” he said. “It’s education.”

Coordination of Care

Davis said one of the reasons she has become such a proponent of telehealth has to do with improved efficiencies and savings through better coordinated care.

The health system is expanding its pilot project to include more clinics and specialists. The initial project linked three clinics with an endocrinologist who works for a separate Indian health system in Santa Barbara. Through the project, a primary care doctor or nurse and a patient can video conference with a specialist.

Primary care doctors can learn from the specialists by observing how they interact with certain health issues, and when they encounter a similar case, they can handle it more effectively, she said. The health system has found that costs drop because continuity of care is improved and duplication of services and tests is avoided, she said.

In addition to remote locations in the region, another challenge for the health system has been the Inland Empire’s shortage of primary care doctors and specialists, Davis said. Telehealth helps the health system circumvent that problem.

Gutierrez said this type of coordination of care is in step with the medical home model of care. Medical records can be kept in one place, and the primary care provider retains a full record of coordination with the specialist, he said.

Support Growing

While the implementation of telehealth has lagged for financial, regulatory and technological reasons, support for telehealth has been gaining momentum in recent months. Congressional backing for financial provisions for telehealth appears to be growing. In April, a number of senators expressed support for expanding telehealth. Also, an unprecedented number of telemedicine bills are awaiting action.

While California has not led the nation in telehealth implementation, it has remained in the middle of the pack. The American Telemedicine Association gave the state an overall “B” grade for its telehealth delivery and an “F” for its Medicaid coverage of telehealth rehabilitation and home health services, according to a report released May 4.

In California, one obstacle has been access to high-speed broadband in rural areas, Gutierrez said. Another has been cost. A lot of health centers don’t have the money to invest in technology and training, he said. However, he expects that health care reform will drive the adoption of telehealth as health systems move away from the fee-for-service model.

Viramontes sees telehealth as the future. He believes it can benefit Indian health systems across the state. Not only is telehealth a useful tool in rural areas, but it also brings people together to share skills and knowledge, he said.

“We see an opportunity here,” Viramontes said. “This is where we are headed.”

OKC Tribal Epidemiology Center Offers Public Conference On Native American Health Concerns

By SUSAN SHANNON

8:54 PM FRI MARCH 28, 2014

Photo Credit Susan Shannon

Photo Credit Susan Shannon

A two day conference allows a newly created organization to demonstrate its work and research on various health-related issues facing Native Americans in the United States. The sixth annual Tribal Epidemiology Center Public Health Conference’s theme isWhere We Have Been, Where We Are, And Where We Are Going.

Where We Have Been

In the mid 1990’s, Native American tribes saw the need to write their own health stories and maintain their own data banks on health statistics. Funding from the Indian Health Service helped to create the first two epidemiology pilot centers, or EPI Centers.

In 2004, the Oklahoma City area received similar funding to create what is one of twelve centers currently serving the United States’ indigenous population.

Where We Are Now

Tyler Snyder is the epidemiologist at the Tribal Epidemiology Center in Oklahoma City. Snyder says this center is not just about a traditional view of epidemiology.

“What we do here, instead of doing just disease outbreak and surveillance, we provide EPI services in the form of helping people develop surveys, implement the surveys, doing analysis and we also provide training, like tobacco cessation training, intervention training, and training on a number of other health issues,” said Snyder.

“We also provide some community health profiling,” Snyder said. “We look at data from the national level, state level and also some locally collected data and put those together to form a picture for a tribe so we can say ‘here’s what your tribe’s health looks like right now.’

Dr. Tom Anderson (Cherokee), is the director of the so-called EPI Center in Oklahoma City. Anderson said part of the Affordable Care Act reauthorizes the Indian Health Care Improvement Act, and sets some specific goals.

“Tribal epidemiology centers are to be considered as public health authorities for the area tribes,” Anderson said. “The EPI centers were to carry out seven specific functions including disease surveillance, data collections, evaluation of delivery systems, assist tribes in identifying highest priority health status, recommendations for targeting services, and so on.”

Where We Are Going

Patricia Yarholar (Sac and Fox) is the public health coordinator at The Tribal Epidemiology Center. Yarholar sees the conference as a way to implement some of those directives. The two day conference will hold several behavioral workshops and suicide prevention workshops imbued with native sensibilities.

“We also have the health policy track, we’re going to be having a workshop on incorporating taking culture into policy. Making tribal health programs and employees work with American Indians so it will be culturally appropriate information,” Yarholar said.

“A workshop on accreditation for public health as well as another one on the tribal public health institute is very new and I think a lot of people will be very interested in what this workshop has to share with us,” Yarholar said.

“What it does is reach out to tribes and provides market analysis, organizational and financial analysis in working with Native American tribes,” Yarholar said. “An assessment to determine needs and the potential role that the tribal health public institute has in order to go along the line of organizational structure, and operating costs can be done.”

The AARP will be holding a round table on transportation.

“This relates to a lot of the health disparities people experience because they don’t have transportation to go to appointments or maybe to go to different areas to pick up medication or to pick up proper foods,” Yarholar said.

Other workshops will go over the Affordable Health Care Act, the Health Insurance Marketplace, diabetes in Cherokee children and diabetes in the Kickapoo tribe.

Keynote speakers include Michael Bird(Santa Domingo/San Juan Pueblo), the first Native American to serve as president of the American Public Health Association, and Dr. Jessica Rickerts(Prairie Band Potawatomi), the first female Native American dentist. Rickerts will present a workshop on the dental health of American Indian/Alaska Native Veterans

The 6th Annual Tribal Epidemiology Center Public Health Conference takes place April 29 & 30 in the Fire Lake Grand Casino in Shawnee and is free and open to the public.

A Deadline Whizzes By and Indian Health Money Is Left Behind

Monday was a key deadline for the Affordable Care Act. In order to begin insurance coverage on January 1, 2014, people were supposed to sign up by December 23, 2013, for that shiny new policy.

(On Monday the White House announced the deadline is extended a stay. That’s a good thing for people trying to navigate the web site at the last minute.)

How many American Indians and Alaska Natives signed up for this new program? Who knows? But you’d think that something this important would have so much information posted about it that it would almost be annoying. There should be posters, flyers, signup fairs, reminders and banners. This should be a big deal.

Instead this deadline whizzed by, hardly making a sound in Indian country.

But this is why the deadline – and health insurance matters. From this point forward every American Indian and Alaska Native who signs up for some form of insurance, through a tribe or an employer, via Medicaid, or through these new Marketplace Exchanges, adds real money to the Indian health system.

How much funding? Healthcare reform expert Ed Fox estimates the total could exceed $2 billion. But what makes that $2 billion even more important is that it does not need to be appropriated by Congress.

Most of that funding stream will come from the expansion of Medicaid, the primary mechanism for expanding coverage under the Affordable Care Act. This is a particularly thorny problem for Indian country because only about half of the states with significant American Indian and Alaska Native populations have expanded Medicaid. That’s why it so important for Indian country to keep pressing for this critical funding source.

But even without the Medicaid expansion, many in Indian country are eligible for special considerations through the Marketplace exchanges. Most people won’t have to pay out-of-pocket costs like deductibles, copayments, and coinsurance depending on income. And American Indians and Alaska Natives have a sort of permanent open enrollment period, so the signup can occur anytime.

But, as Dr. Fox writes, “Unfortunately, fewer than 10 percent of those American Indians/Alaska Natives eligible for subsidies will purchase qualified health plans, even fewer American Indians/Alaska Natives likely if they currently receive services at an IHS-funded health program.”

So the problem remains that as long as one-in-three (non-elderly) American Indians and Alaska Natives are uninsured, there will not be enough money to pay for quality healthcare.

But the Affordable Care Act is an alternative. This is the deal: The Indian health system has never been fully funded. And that is not likely to change in our lifetime. No Congress or president in the history of this country has ever presented a budget that meets the health care needs of Indian country.

But the Affordable Care Act opens up a new way of tapping money, exchanging complexity and paperwork for more money that does not have to go through Congress. Money that can go directly and automatically into the Indian health system. According to the Kaiser Family Foundation, nine in ten American Indians and Alaska Natives qualify for some sort of assistance to get coverage.

The Affordable Care Act’s potential revenue stream is particularly important right now because the appropriations process in Congress is so completely broken.

But. Wait! American Indians and Alaska Natives have a treaty right to health care. There is no need to do anything, right?

Then I was re-reading my tribe’s treaty with the United States, the Fort Bridger Treaty of 1868. Article 10 says: “The United States hereby agrees to furnish annually to the Indians the physician, teachers, carpenter, miller, engineer, farmer, and blacksmith, as herein contemplated, and that such appropriations shall be made, from time to time, on the estimates of the Secretary of the Interior, as will be sufficient to employ such persons.”

And there is that word: “appropriations.” The process that Congress uses to spend money; a framework that has never even once considered full funding for Indian health.

I hear from many folks who say this is all too much. Let’s repeal the law and start over. Ok, then what? Repealing the law is not going to change the dismal funding of the Indian health system. Congress cannot even agree on regular spending, let alone something like that. But for all the complications, for all the confusion about web sites and paperwork, the Affordable Care Act opens up a check book with a couple billion dollars. We can watch deadlines whiz by. Or, we can say, there it is. Take it.

Mark Trahant is the 20th Atwood Chair at the University of Alaska Anchorage. He is a journalist, speaker and Twitter poet and is a member of The Shoshone-Bannock Tribes. Join the discussion about austerity. Comment on Facebook at: www.facebook.com/TrahantReports.

 

Read more at http://indiancountrytodaymedianetwork.com/2013/12/23/deadline-whizzes-and-indian-health-money-left-behind-152843