Health Disparities and the American Indian: Dr. Donald Warne on the Way Forward

Health Disparities and the American Indian - Dr. Donald Warne on the Way
Forward

[Music begins ]

Female: Welcome to C onversations on H ealthcare with Mark Masselli and
Margaret Flinter , a weekly show where we speak to the top thought leaders in
health innovation, health policy, and the great minds who were shaping the
healthcare of th e future. This week , Mark and Margaret speak with Dr. Donald
Warne, A ssociate D ean of Diversity, Equity, and Inclusion at the University of
North Dakota School of Medicine and Health Sciences, a national thought leader
on American - Indian health and addres sing health disparities in underserved
populations. Lori Robertson also checks in, the managing editor of
FactCheck.org , looks at misstatements spoken about health policy in the public
domain, separating the fake from the facts . W e end with a bright idea that’s
improving health and wellbeing in everyday lives. If you have comments, please
e - mail us at [email protected] or find us on Facebook or Twitter , w e love
hearing from you . You can also find us on iTunes or S titcher. Please feel free to
leave a review for us there. Now stay tuned for our interview with Dr. Donald
Warne on Conversations on Healthcare.

[Music]

Mark Masselli: We ’re speaking today with Dr. Donald Warne, Associate Dean of
Diversity, Equity, a nd Inclusion a t the University of North Dakota School of
Medicine and Health Sciences . A primary care physician, he is also director of
INMED Indians Into Medicine. Previously he served as chair of the Department
of Public Health at North Dakota State Un iversity. He ’s also a senior fellow of
American - Indian Health Policy at the Robert Wood Johnson Foundation . He
earned his M . D . from Stanford University and a m aster ’ s in Public Health from
Harvard. Dr. Warne , welcome to Conversations on Healthcare.

Dr. Donald Warne : Thank you so much, happy to be here.

Mark Masselli: Yeah and as a primary care practitioner who comes from a long
line of traditional healers, your experience growing up in the reservation exposed
you to this time honor ed tradition of heal ing practices . A s you entered the
medical profession you are dishearten ed that so much of the disease burden you
faced was largely preventable . W onder if you could help our listeners
understand the prevalence of disease and poor health in American - Indian
populations and w hy they are so challenging to address ?

Dr. Donald Warne : Sure, a lot of our issues that we face in health status are
rooted in poverty and marginalization and less access to basic needs in life like
good education , good food and economic opportunities. W hen we look at this
from a historical perspective , o f course has been a long history of marginalization
and lo ss of land and los s of resources . O ne of the outcomes of that is less
access to services , less access to even simple things lik e healthy food . O ur
people are suffering from terrible disparities related to that including much higher

Health Disparities and the American Indian - Dr. Donald Warne on the Way
Forward

rates of type 2 diabetes , heart disease . We also tend to see higher rates of
cancer and other chronic diseases, but unfortunately it does not end the re. We
also have other high rate s of public health issues like even unintentional injuries
and accidents . We have very high rates of death s among our young people d ue
t o motor vehicle accidents, but also higher infant mortality rates , so kind of
across t he whole spectrum we’re dealing with dispar ities and m aternal and c hild
health , early child health, and then chronic diseases as people get older. O ne of
the outcomes is that our average age at death is much younger for American -
Indians . In North Dakota , the average age of death for American - Indians is
about 54 years , so just remarkably lo w lifespan.

Margaret Flinter: Well, Dr. Warne , I would like to try and put it into perspective
the American - Indian h ealth’s narrative. We have to look at the foundati ons of the
current state of disparity in native populations, populations whose numbers have
dwindled from a high of 25 million prior to the European migration down to just a
few million today . T hose native people who survived the genocide of the
American - Indian have carried it over these generations . Can you talk about the
importance of understanding the role of epi genetics and cultural trauma and the
impact that that has had on American - Indian health ?

Dr. Donald Warne: Sure, and actually just look ing a t the historical numbers of
indigenous peoples in the America and that doesn't really tell the whole story .
W hen we look at estimates of the indigenous population for North America and
South America it was in the 20 to 25 million range prior to contact wi th
Europeans, and of that number, it ’s estimated probably about 5 million lived in
what is now the United States in terms of -- s o historically , the r e we re probably
about 5 million American - Indians and Alaska natives and what is now the United
States . B y 1900 , that number wa s actually down to less than 200,000 , s o that
was almost a complete genocide . W hen we look at the numbers now with the
2010 census , there were about 5.2 million self - identif ied American - Indians and
Alaska natives in the census . O ur nu mbers have rebounded b ut huge impact in
terms of historical trauma and community wide trauma and lo s s of culture , and
lo ss of resource s, loss of people between initial contact in 1900 . T here is
emerging scientific evidence in the field of epi genetics t hat when populations
undergo significant toxic stress and traumas it can have intergenerational impact
on gene , expression and potentially direct impact on poor health outcomes .

Mark Masselli: I was taken by a longevity being in the mid 50s and it certainly
impacted by diabetes , depression and alcoholism . Y ou ’ve talked about the
Western medicine approach to this , which are to split these conditions apart and
then also split apart the medical side from the behavioral health . R eally you
come at it from a diff erent vantage point, looking at more holistically and also in
cultural context for the American - Indian population . I ’ m wonder ing if you could
tell us more about that and also tell us about your m edicine w heel approach a s
w e ll .

Health Disparities and the American Indian - Dr. Donald Warne on the Way
Forward

Dr. Donald Warne: Sure whe n I was working as a full - time primary care
physician i t was in Arizona and with one of the tribal population s that’s really
devastated by diabetes . S ome of our population s, half the adult have type 2
diabetes . I t really is r emarkable disparit y that we s ee right in Indian country , right
in the middle of this nation . W hat I see among many people with diabetes
whether they ’re American Indian or not is high rates of depression . It’s actually is
so prevalent I think we should be considering depression a com plication of
diabetes b ecause it ’s s o common . Now, n ot everyone with diabetes get
depression, but not everyone with diabetes gets kidney failure either , so I think
depression is common enough , i t really should be considered the comp lication .

In this nati on the most common self - medication for depression is alcohol intake .
W hat I see is lot of people with diabetes who a r e self - medicating the ir depression
with alcohol intake and the alcohol intake actually makes the blood sugar worse
and makes the depressio n worse, which leads to even more alcohol intake . I see
this vicious cycle of diabetes , depression and alcohol intake and it really is a
syndrome , I’ve seen it in hundreds of patients and in thousands of patient visits ,
We don't treat it systemically or holistically , we treat each individual condition
individually , and we tend to look at diabetes management and outpatient
depression management as a medical issue , but if someone has major
depression and alcohol dependence then we see that a s a behavioral h ealth
issue .

We essentially cut the patient in half and say that medical side will do its part , the
behavioral health side will do its part, but we do not really collectively address
this from a holistic perspective . That’s very contrary to what we would do
traditionally and w hat was I thought in traditional Lakota approaches to hel p with
it, we would never look at this in just individual parts , we look at the whole and
recognize it holistically. What’s happening here is there is certainly physical
illne ss, but there is also emotional, spiritual an imbalance that needs to be
addressed . I f we were to be intelligent as a health system w e would address it
from the perspective of how the patient is exp eriencing the disease process . I
think that’s one area w here traditiona l medicine has much to teach us i n modern
scientific medicine.

Margaret Flinter: Well, Dr. Warne I know that you were being considered by the
previous administration for the post of US Surgeon General and h ad you been
chosen you said you w ould have used that platform as a chance to highlight th e
underfunded and under resourced Indian H ealth S ervice . Talk with us about the
challenges with in the Indian Health Services and what solutions you envision to
address this significant gap in resourc es ?

Dr. Donald Warne: I n the United States people are not born with a legal right to
health services except American Indians. We are actually the only population
born with a legal right to health services and that ’s based on the many hundreds
of treatie s that were signed between tribal nations and the federal government .

Health Disparities and the American Indian - Dr. Donald Warne on the Way
Forward

E ssentially the tribes exchange d land and natural resources for various social
services like health , education and housing . T hat's why there is a Bureau of
Indian A ffairs , t hat's why t here's an Indian Health Service . T he land that is now
United States was not lo st in a war , it wa s actually exchanged to treaties and
treaties are the highest order of law in the land. W e have hundreds of treaties
between tribal nations and the federal go vernment and most of the treaties have
some sort of component of healthcare included some of the common language
was promise of all proper care and protection .

C ertainly as American - Indians we have not received all proper care and
protection . I n a very b asic way if you look at these treaties as contract s between
tribal nations and the US government , t h e US government is in breach of
contract because they have not held up their end of the bargain . Indian Health
Service for many , many decades now has been funded at about 40 to 50% of
actual need . W e have in adequate resources to provide all proper care and
protection as li ned out in our treaties . O ne of the programs that did help a lot is
Medicaid expansion under the Affordable Care Act . O f course , not ev ery state
expanded Medicaid , but if you look at access to health services comparing North
Dakota and South Dakota w here North Dakota we expanded Medicaid , South
Dakota we did not .

W e have much better access to health services and resources . I think India n
Health Service does its best with its limited resources to try to address things
holistically . Even their mission looks at the building emotional and spiritual health
to the highest level possible . T he challenge i s we just do n’t have the resources
to f ully invest in protecting health of American Indians and that really is the fault
of c ongress . T hey should be pointing the fingers at themselves for underfunding
this , the whole program for now for decades .

Mark Masselli: We ’ re speaking today with Dr. D onald Warne, Associate Dean of
Diversity, Equity, and Inclusion at the University of North Dakota School of
Medicine and Health Sciences. He ’s also director of INMED - Indians I nto
Medicine. Dr. Warne, we recently had North Dakota Governor , Doug Burgum , on
th e show talking about the state's effort to confront addiction , and you
participated in the governor's d ay of p revention and you said to get the solutions
to our addiction dilemma , you have to walk through truth . T ell us more about
some of the public health partnerships that are needed to help the American
Indian communities get the health they desperately need ?

Dr. Donald Warne: As a nation we need to come to terms with the American
h olocaust and that's exactly what it was . T he American - Indian popu lation was
almost completely wiped out because of deliberate effort to kill American - Indians .
T he challenge there is that we don't see a lot of us in our history books because
its unpleasant , but if we are ever going to get t o health equity , w h ere we can
actually raise health to appropri ate status for every population, we have to
content with the truth . I see a reluctance to do that because it makes people feel

Health Disparities and the American Indian - Dr. Donald Warne on the Way
Forward

bad , and the truth is there was deliberate attempt at genocide of American -
I n dians . People may have heard of Amherst Massachusetts or Amherst C ollege ,
that’s named after Lord Jeffery Amherst who is a colonial governor in the
colonies . H e i s the one who ordered the distribution of blankets from a smallpox
hospital to the n orth e astern tribes with th e purpose of killing them . Our f irst
document ed case of bioterrorism is our own colonial government , but that ’s not
taught in our history books , b ut that ’s a part of our truth . I think that if we don ’ t
understand the truth of history , w hat I see is th at people blame the victims . T hey
do not understand why we have s uch high rates of addiction or diabetes or
cancer and well from my perspective, if you want to get to equity, you have to
walk the truth e ven when it is unpleasant .

In terms of partnerships, w e do have to work with not just the federal
government , but also with our states, with Medicaid programs, with private sector
agencies . O ne of our challenges historically is that we are the minority of the
minority populations , and we are very underrepres ented in leadership positions
and in policy making positions. For American - Indians there ’s nobody in the
senate for example. W e have to have partnerships with non - Indian populations
to improve policy making and law making around access to health services , so
that’s something w e’re working on . T here ’s a lot of national and regional
agencies that are trying to improve this , but I think most people are unaware of
these issues and that ’s adding to the disparity.

Margaret Flinter: Wel l, Dr. Warne I really a ppreciate that you are tackling health
inequities with culturally relevant strategies. You are building a curriculum
around that at the North Dakota S chool of M edicine and H ealth S ciences . You
are encouraging through INMED American Indians to pursue care ers in the
health professions . Talk with us about your approach to training the next
generation of healthcare providers , h ealers in the American - Indian community
and , and wh at are you s eeing in terms of success ?

Dr. Donald Warne: Well, it ’ s a significan t challenge because we have to
recognize we have limited pool because of high rates of high school dropout , so
much of our work is also focused on building the pipeline of potential future
health leaders f rom our communities because if we have less high sc hool
graduates , we will have less college students and therefore less potential
medical student . A ctually right now we have our INMED Summer Institute going
on. We have currently 45 students from across the nation who are American -
Indian high school and middle school students here at University of North Dakota
for six weeks . W e expose d them to all kinds of opportunities and health career
they get to actually have a cohort of colleagues who are from similar background
and realize that they're not the only American - Indians who are interested in
health career.

There’s a lot of power in having c o horts of people or groups of people that are
trying to work toward a similar goal. I t wasn't until I was in college until I finally

Health Disparities and the American Indian - Dr. Donald Warne on the Way
Forward

met an American - Indian physician and the disparities and the shortages of
American - Indian health professionals are just tremendous , so that's really part of
my goal now is to try to reverse that . I n the United States , there are over 37,000
professors of medicine -- of th at number 10 are American Indian , 10 out of 37.
J ust the need for building role models and leaders with in academic health
institutions is just tremendous . We’re going do our part to try to reverse that.

Mark Masselli: W ell , i t seems like the populations has gr own. Ca n I as sume it ’ s
younger population ? How in other ways you ’re describing the successes to
young American - Indians w ho a re looking for careers , looking to role models like
yourself . W hat are you seeing that excites you about the population in terms of
accomp lishments that happened ?

Dr. Donald Warne: I mean in addition to high rates of death , and also of high
rates of birth , so the result is we have a very young population of American -
Indian s and Alaska native s . I am very encourage d about this current gener ation ,
there seems to be a re - awakening of cultural connect edn ess , but also this
younger generation wanting to do more for the ir communities, much more social
activism , much more inclusiveness . One other thing I find encouraging is that the
younger genera tion of millennial s here in the United States , I don't see the same
degree of racism , I see much more acceptance . I think th is current generation
that's now turning 18 is the most diverse generation that we've ever had . T his
generation moving forward fee ls like it's much more tolerant of others , so I feel
good about the future . W hat I'm hoping we can do is build upon that and
recognize that as American - Indians, but also as members of this nation working
toward building equity for all populations . I feel lot of that energy within our
young students right now, I believe that as the seventh generation of survivors
f rom Wounded Knee and other terrible outcomes , I see hope for the future in
their energy .

Margaret Flinter: You know, Dr. Warne, I wonder given the historical experience
of the separation of so many N ative American families from the ir children a s th ey
were sent to boarding schools and the like . A s you look at our current situation
at the border with the separation of parents and children, wh ethe r you have any
advice or comment for the country on the potential long term impact of that ?

Dr. Donald Warne: We know that adverse childhood experiences correlate to
poor health outcomes for adults . T he worst experiences are in childhood , the
worst of health status is as people get older and it's -- it's just remarkable to me
that we a re allowing this to happen . A gain , it’s an older generation of people who
dehumanize other s, and unfortunately in this country there ’s been a long history
of that . A gain , I don't think that the millennial generation is on - board with the
type of policy makers who would take children away from families , but we have
what we have right now so we all need to collectively recognize that this is
wrong. It ’s certainly that they tried to quote the bible, certainly not Christian. I t's

Health Disparities and the American Indian - Dr. Donald Warne on the Way
Forward

horrific circumstances and we are going to harm that entire generation of children
who are just simply seek ing safety .

Mark Masselli: We’ve been speaking today with Dr. Donald Warn e, A ssociate
D ean of D iversity , E quity , and I nclusion at the University of North Dakota S chool
of M edicine and H ealth S ciences . Y ou c an learn more about his work by going
to med.und.edu or you can follow him on twitter @ D onald W arne MD , Warne is
spelled W - A - R - N - E. Dr. Wa rne, thank you so much for your work, your
dedication to addressing health disparities and for joining us on Conversations o n
Healthcare today .

Dr. Donald Warne: I appreciate being a part of the c onversations .

[Music]

Mark Masselli: At Conversations o n Healthcare, we want our audience to be
truly to know when it comes to the facts about healthcare reform and policy. Lori
Robertson is an award winning journalist and managing editor of F act C heck.org,
a nonpartisan, nonprofit consumer advocate for voters that aim to reduce the
level of deception in US politics. Lori, what you have got for us this week ?

Lori Robertson: We saw a heated rhetoric on both sides of the aisle when house
republicans pursued a bill that would expand work requirements for the fo od
stamp program. Let’s look at th ese proposed changes which are part of the
foreign bill . In February, the most recent month for which we have figures, 40
million people received food stamp benefits. The GOP proposed work
requirements would cause 1.2 m illion , fewer people a month to access the
benefit by 2028 . U nder current SNAP rules , able - bodied adult between the ages
of 18 and 49 and without dependence are required to work at least 20 hours a
week or participate in a qualified job training or volunt eer program in order to be
eligible for more than three months of be nefits over a three - year period. The
proposed GOP law would raise the age of those subject to the work requirement
from 49 to 59 and extend the work requirements to adults with children a ge s 6
and older. The minimum work required would rise to 25 hours per week, 62% of
those who would lose benefits would be able - bodied adults caring for children 6
or older. A nother 2 7 % would be able - bodied adult between the age of 50 and 59
without depen dence. A nother proposed change in the bi ll would cut off SNAP
eligibility for those whose gross income exceeds 130% of poverty , instead of the
200% threshold for SNAP recipients in some state s, that would cause another
400,000 household s per year to lose eligibility . The bill failed in the h ouse in May
but the c ongress is expected to take up such legislation again . T hat’s my facts
check for this week, I am Lori Robertson, Managing Editor of FactCheck.org.

[Music]

Margaret Flinter: FactCheck.org is com mitted to factual accuracy from the

Health Disparities and the American Indian - Dr. Donald Warne on the Way
Forward

country’s major political players and is a project of the Annenberg Public Policy
Center at the University of Pennsylvania. If you’ve a fact that you would like
checked, e - mail us at www.chcradio.com , we’ll have FactCheck.org’s Lori
Robertson check it out for you here on Conversations on Healthcare.

[Music]

Margaret Flinter : Each week, Conversation highlights a bright idea about how to
make wellness a part of our communities an d everyday lives. According to
statistics from the Center for Disease Control and Prevention, N ative Americans
are 60% more likely to suffer from diabetes, obesity and a sedentary lifestyle, but
inspiring change in these cultures with conventional approac hes that ’s proven to
be challenge. A tribe in North Idaho may have found a workable solution right in
their own backyard . Leaders o n the Coeur d 'Alene R eservation have created a
fitness program called Powwow Sweat, an exercise program comprised of series
of their traditional dances performed to traditional drum and music.

[Music]

Shadeja : Hello, my friends and relatives m y name is Shade ja [PH 00:22:53 ] and
in this segment w e will be learning moments from the women ’ s traditional dance
category. A basic steps , one, two, three, four, five, six , seven, eight.

Margaret Flinter: LoVina Louie , the director of the tribes wellness center and
says the Powwow Sweat fitness program bring s an often underutilized
component of more broadly deployed wellness approach es , t he tribes own
cultural heritage . S he says it carries a lot of potential for ongoing motivation.

LoVina Louie : If you do not do it regularly, your calves will hurt, some say
[inaudible 00:23:27 ] for 25 minutes straight.

Margaret Flinter: The Coeur d 'Alene tribe has received a grant from the CDC to
not only develop and expand the Powwow Sweat exercise program, but also to
build a large communal organic garden incorporating community wide approach
to wellness. In the ensuing months since the program launch ed , a number of
participants like Ryan Ortivz [PH 00:23:49 ] have began to incorporate other
healthy habits such as quitting smoking and losing weight.

Male: I ’m aiming to lose 40 pounds by the end of the year .

[Music]

Margaret Flinter: The Powwo w Sweat workouts breakdown a half dozen
traditional dances into a series of repetitive moves design to build up endurance
overtime. A community based culturally relevant fitness program leading to
greater success.

Health Disparities and the American Indian - Dr. Donald Warne on the Way
Forward
[Music]
Female: Drop the Pringles and let’s jingle . One, two, three, four, step t urn .
Margaret Flinter: Now, that’s bright idea.
[Music]
Mark Masselli: You ’ve been listening Conversations on Healthcare. I am Mark
Masselli.
Margaret Flinter: I am Margaret Flinter.
Mark Masselli: Peac e and health.
Conversations on Healthcare i s recorded at WESU at Wesleyan University,
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