Date post: | 17-Jan-2018 |
Category: |
Documents |
Upload: | justina-harrington |
View: | 218 times |
Download: | 0 times |
1
2015 AMSUS MeetingThe Society of Federal Health Professionals
2 Dec 2015 – San Antonio, TX
RADM Dawn Wyllie, MD, MPHChief Medical Officer/Deputy Director
Bemidji Area IHS
“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
10
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
Robert Mc Swain
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 Management15
CALIFORNIA
TUCSON
BEMIDJI
NASHVILLE
ALBUQUERQUE
NAVAJO
ALASKAAK
TN NC
MS AL SC
LA
FL
PA
NY
ME
MACT
RI
**
NVUT
AZ
BILLINGSMT
WY*
OKLAHOMACITY
KS
OKTX **
IN
MN
MI
WI*
CA
*
*
CO
NM
Note:Texas is administeredby Nashville, Oklahoma City,and Albuquerque.
*Area Office
WA
OR
ID
*PORTLAND
PHOENIX
*
ND
SD
NE IA
*
ABERDEEN
Indian Health Service Area Offices
Hospitals Health Centers Urban Programs
16
A Rural Health Care System in 35 States
IHS DemographicsWho 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
18
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 20
Health DisparitiesCardiac Disease
All Races AI/AN Asian / Pacific Islander Black White0.0
50.0
100.0
150.0
200.0
250.0
300.0
171.3
121.4
92.7
212.0
169.8168.7
199.2
76.8
257.2
162.3
Age-Adjusted Deaths due to Diseases of the Heart (ICD-10 I00-I09,I11,I13,I20-I51; per 100,000)
2011-2013
United States Bemidji Area
Health DisparitiesCerebrovascular Disease
All Races AI/AN Asian / Pacific Islander Black White0.0
10.0
20.0
30.0
40.0
50.0
60.0
37.0
25.6
30.6
49.7
35.736.1
31.4
36.2
49.3
34.9
Age-Adjusted Deaths due to Cerebrovascular diseases (ICD-10 I60-I69; per 100,000)
2011-2013
United States Bemidji Area
Health DisparitiesCancer
All Races AI/AN Asian / Pacific Islander Black White0.0
50.0
100.0
150.0
200.0
250.0
166.2
110.4103.3
193.8
166.3168.6185.5
103.2
210.2
166.2
Age-Adjusted Deaths due to Malignant Neoplasm (ICD-10 C00-C97; per 100,000)
2011-2013
United States Bemidji Area
Health DisparitiesDiabetes
All Races AI/AN Asian / Pacific Islander Black White0.0
10.0
20.0
30.0
40.0
50.0
60.0
21.3
35.8
15.8
38.9
19.521.2
54.0
21.1
36.4
19.8
Age-Adjusted Deaths due to Diabetes Mellitus (ICD-10 E10-E14; per 100,000)
2011-2013
United States Bemidji Area
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 Employment2006
7%11%
8% 6%
16%
5%
0%5%
10%15%20%
U.S. All Races U.S. White U.S. AI/ AN
% teens who are highschool dropouts% teens not attendingschool and not working
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 ConsiderationsReligion/Spirituality
• Presiding religious/spiritual official• Ceremony (may be a blending Christianity &
Traditional Spirituality)• American Indian Symbols - the use & practice of:
– Tobacco * Cedar– Eagle Feathers * Sacred Pipe– Medicine Bag * Smudging– Sweat Lodge * 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 ConsiderationsTraditional 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 • 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 CreditIf 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/trends2014/
• 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 ServiceChief Medical Officer/Deputy Area DirectorBemidji Area Indian Health Service522 Minnesota Ave, NWBemidji, MN 56601Email: [email protected]