COVID-19 and American Indians: Dr. Donald Warne on the Devastating Toll of the Pandemic on Native American Populations

Dr. Donald Warne

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Female : Welcome to Conversations on Health Care with Mark Masselli and
Margaret Flinter , a show where we speak to the top thought leaders
in health innovation , health policy , care delivery and the great minds
who are shaping the health care of the future. This week Mark and
Margaret speak with Dr. Donald Warne, Director of Indians Into
Medicine at the University of North Dakota School of Medicine and
Health Sciences. A finalist for Surgeon General under President
Obama, Dr. War ne looks at the deep i nequities impacting outcomes
for American - Indian populations by COVID - 19 . The impact of
centuries of cultural trauma on nation ’ s native peoples and the need
to address gaps in the Indian Health Service, which Congress is treaty
bound to do.

Lori Robertson also checks in , the Managing Editor of FactCheck.org
she look s 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 well being in everyday lives. If you have
comments please e - mail us at [email protected] or find us on
Facebook , Twitter , or wherever you listen to p odcast . Y ou can also
hear us by asking Alexa to play the program . Now stay tuned for an
interview with Dr. Donald Warne here on Conversations on Health
Care .

Mark Masselli : We're speaking today with Dr. Donald Warne Director of Indians Into
Medicine or INMED at the University of North Dakota School of
Medicine and Health Sciences, a family physician. He's also D irector of
the Public Health Program and Associate Dean of Diversity, Equity and
Inclusion at the UMD School of Medicine.

Margaret Flinter: Dr. Warne is descended from a long line of traditional healers and
medicine men of the Oglala Lakota Sioux tri bes. He earned his MD
from Stanford University School of Medicine and his m aster's in Public
Health from Harvard. He was a finalist for US Surgeon General under
President Obama and was a senior fellow in American - Indian Health
Policy at the Robert Wood Joh nson Foundation. He's won numerous
awards and distinctions for his important work. Dr. War ne, welcome
back to Conversations on Health Care.

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

Mark Masselli : Yeah, it's great . T he COVID - 19 pandemic has claimed now 130,000
lives in the country . The cases are accelerating, particularly across the
south in the Midwest . F rom the beginning th e coronavirus is claiming
more lives of people of color, especially native communities at a much
higher rate than the non - native population . I’m wonder ing if you
could help our listeners understand the toll the pandemic has had on
American - Indians and Alaskan Native communities as well .

Dr. Donald Warne

Dr. Donald Warne: Yeah, so one of the challenges when you have something like a
pandem ic or a public health crisis is that the populations that have
less public health infrastructure are at much greater risk for bad
outcomes . We know that many of our tribal communities , American -
Indian , Alaskan Native communities are very impoverished . As a
result, don't have the same type of public health infrastructure that
we'll see in cities or suburbs, for example . Quite often th e
marginalized populations , impoverished populations also have less
infrastructure in terms of being able to mount a public he alth
response to a crisis.

When we think about public health infrastructure, we need to have a
good public health workforce , so p eople who are well trained, they
also need to have facilities that -- buildings and equipment, laboratory
capability, those typ es of things , and t hen also very good information
systems . We're seeing some of the challenges in coordinating data in
the middle of trying to respond to the pandemic . I think the public
health infrastructure, kind of in terms of the muscular system, which
is the people , t he skeletal system which is the buildings and
equipment , and the nervous system which is essentially the
information systems . U nfortunately, across the board our
infrastructure is just not as good . That has a direct impact on
responding to a public health crisis.

W e see that in many comm unities of color many impoverished
communities and particularly in rural populations, it's even more
magnified. T here's all kinds of challenges that put American - Indians
and other marginalized populations at greater risk for things like
COVID - 19. In addition to that, we have higher rates of chronic
diseases like heart disease, lung disease, and diabetes . All of those
chronic disease put people at higher risk for hospitalization and higher
risk for death from COVID - 19. It's kind of the perfect storm of lack of
infrastructure, meeting a population with significant health
disparities.

Margaret Flinter: Well, Dr. Warne , we know that the people are strong, but the social
determinants really seem to all grow in the wrong direction . We've
certainly seen this as you say, in rural and urban areas with different
populations, but I'm not sure people realize just what a heavy burden
th at more than five million American - Indians bear in all of this around
challenges with jus t access to food, to housing, to economic security .
Du ring this time of the pandemic, also basic utilities like electricity and
running water become really important. Maybe just talk a little bit for
our listeners about how all of these come together as ki nd of deeply
entrenched challenges that have impacted health outcomes in the
American - Indian communities.

Dr. Donald Warne: Yeah, so when we think about social determinants of health, we know

Dr. Donald Warne

that impoverished populations have shorter life expectancy and a
higher disease burden . Unfortunately for American - Indian s we have
among the highest rates of poverty in the nation. When you have
poverty, you also tend to have less access to healthy food. We also
have a lot of food deserts , and a food desert is essentia lly a
community that does not have a local supermarket. Where I'm from
in Kyle, South Dakota, we do have a convenience store, but the
closest supermarket is actually 90 miles away. Just imagine having to
do a 180 - mile round trip every time you wanted to go to the
supermarket , and then so on top of that poverty, less access to
transportation. I would not be surprised if inadequate nutrition also
places people at much greater risk for bad outcomes from COVID - 19.

In addition, whe re we have poverty we tend to h ave overcrowded
housing . We see that in a lot of our tribal communities , so we could
have multiple generations living together . W hen you are facing a
pandemic, if somebody has been exposed, you need to be able to
quarantine. It's almost impossible to quara ntine when you have
overcrowded housing . Then when someone is diagnosed as positive
with COVID - 19, they need to isolate , so how do you isolate when
housing is overcrowded? It’s all of those social factors and the social
context in which populations live th at puts them potentially at much
greater risk for bad outcomes.

Mark Masselli : Dr. Warne as you say, the crisis of health disparity in American - Indian
population can be put on the shoulders of Congress, and its failure to
fulfill its obligations laid out i n the treaties with tribes who exchange d
millions of acres of land for future guarantee of housing and health
care. I'm wondering if you could help our listeners understand what
was promised, and what was not delivered in terms of funding for the
Indian He alth Services . How did that bring us to today?

Dr. Donald Warne: It's a little known fact that American - Indian s are the only population
that is born with the legal right to health services . That's based on the
treaties which are signed between the tribal n ations and the federal
government. I know that if another nation were to violate a treaty,
the federal government would not be very happy about that. Well,
the federal government has been in breach of contract or violation of
treaty with tribal nations for hundreds of years. Those treaties
guarantee various types of social services including housing,
education and health care. That's why we have a B I A a Bureau of
Indian Affairs. That's why we have an IHS Indian Health Service . B ut
the Indian Health Service has been terribly underfunded since its
inception. The Indian Health Service doesn't have the resources to
adequately provide care that we might expect i f we go to a veteran's
health facility, or if we're on Medicare or Medicaid, or even if we're a
federal employee, we would expect a certain minimum quality of care
and access to services . We don't get that in Indian Health Service.

Dr. Donald Warne

If we think about populations that have a legal right to health
services, American - Indian s are not getting equal protection und er law,
because we don't have the political clout within our populations to
change that. To have political clout, you need to either have money or
votes, and we tend not to have very much of either . We need
advocates to recognize that this really is a trav esty that the US
government has been underfunding Indian Health Service for decades
and people are dying as a result, bad policy kills people, and Congress
shares a lot of the blame.

Margaret Flinter: Well, Dr. Warne , I understand the CDC has issued additi onal funding
to Indian Health Service s to address pandemic related challenges , but
I'm sure you're looking not just at the immediate situation, but a little
longer term . Perhaps there's an opportunity to remedy some of the
shortfalls within the care delive ry system itself . What are your
thoughts about how some of these new resources might help make a
meaningful impact and maybe not just now in response to the crisis,
but creating a better infrastructure for care delivery going forward?

Dr. Donald Warne: Wel l, I'm hoping that if there is a silver lining with the pandemic that
will shine a bright light on the disparities, I think that there's just a
lack of awareness , generally speaking , of the American - Indian right to
health care, but also the underfunding of the Indian Health Service
and how that leads to bad outcomes. I'm hoping that we can create
more awareness of these challenges and develop more advocates to
help us build the infrastructure and re sources that we need to have a
high quality health and publ ic health system.

In terms of the resources, they've been very helpful in terms of doing
things like setting up incident command centers and th e kind of
emergency response. Using resources to train more contact tracers ,
those resources c ould be used to tra in and hire people from all
communities, including tr ibal communities to work in those settings.
A one time infusion of resources to respond to a pandemic does not
address the infrastructure problem. We need a longer term
investment . We need Congress basic ally to take the responsibilit y
seriously and live up to their legal obligations to fully fund American -
Indian health programs.

Mark Masselli : We're speaking today with Dr. Donald Warne , Director of Indians I nto
Medicine INMED at the University of North Da kota School of Medicine
and Health Sciences . He is also the Director of the Public Health
Program and Associate Dean of Diversity, Equity and Inclusion at UN D
School of Medicine. Dr. Warne , you were just saying that there was a
silver lining in the pandemi c and telemedicine seems to be one of
those things that all of a sudden opened up. The regulatory relief was
given by CMS and various states did it . I think on the whole it's been a
transition that many safety net providers have a move towards . I

Dr. Donald Warne

think pat ients have welcomed it , but the reality is there's a digital
divide in our country that not everyone can have access to broadband
activity. I'm wondering if you could share with us your thoughts on
telehealth , its potential for reaching out to those rural American -
Indian and Alaska n ative communities for both primary and
behavioral health care . What do you see the opportunities are and
what are still the hurdles that we need to overcome?

Dr. Donald Warne: Well, ironically, just earlier today, I was on a tel econference call with
the Governor of North Dakota and several other stakeholders . We
were talking exactly about this issue , t hat there is an opportunity
because of more waivers and less regulation around telemedicine, we
could potentially expand its utili zation . In a state like North Dakota,
where we have a lot of rural communities , telemedicine really is the
future. We're not going to have a circumstance in the near future
anyway, where we have adequate numbers of physicians and
hospitals and intensive ca re units and cardiologists and pulmonologist
and all those services in every rural population , just simply not
possible.

One simple technology is telemedicine and it is true , there is a digital
divide. Some populations have better access to internet than o thers.
If you need high speed internet or ability for high definition video that
certainly is a challenge in many of our populations, including tribal
populations . B ut in true for much of telehealth and telemedicine, we
do not need high definition imagery. There's a lot of good evidence
particularly in behavioral health that psychiatry telecounseling is very
effective. It really is just a matter of util izing it and evaluating the
outcomes because my sense is that for much of the work that needs
to be done, we just need to connect with people .

When I think about opportunities under telebehavioral health, we still
have an opioid crisis in the US and particularly in tribal populations as
well. It's not getting a lot of attention now understandably because of
th e pandemic , but I could envision a future in which we have more
access to things like medication assisted treatment through
telemedicine and hopefully save lives. I think again, another silver
lining might be increased access to telemedicine , telehealth pr ograms
for al l populations, including the trav elers.

Margaret Flinter: Well, Dr. Warne , we have followed your program and your work
Indians I nto Medicine or INM ED at the University of North Dakota
School of Medicine and Health Sciences as a way to prepare
American - Indian students for careers in medicine and public health . I
think you're up to , what, 250 graduates of the medical school at this
point which is a wonderful achievement . Certainly for every student
of the health professions or training in the hea lth professions over
these last several months, this is a generational challenge to them,

Dr. Donald Warne

watching and learning and practicing how we respond in a pandemic .
Maybe share with our listeners a little bit more about INMED and how
you've been inspiring young pe ople to think about careers in medicine
and public health and also, maybe give us a little bit of insight into
how your trainees and students have responded and then
environment to both learn and serve during this pandemic?

Dr. Donald Warne: Yes certainly , and for clarification, actually IN MED has been around
since 1973. The new programs that we've launched at U N D since I
joined faculty there are the Indigenous Health Master Public Health
program and the Indigenous Health PhD. Those are brand new
programs. In terms of medicine, we have anywhere from six to eight
American - Indian medical students per year , that actually places us at
th
the 100 percentile of medical schools nationally in terms of the
percentage of American - Indian and Alaska n ative medical studen ts .
I’m very proud of that. We have a terrible shortage of physicians in
rural communities, but particularly tribal communities.

As American - Indian s, we're somewhere between 1 and 2% of the
overall US population. We're only about 0.2% of physicians. We hav e
a terrible under representation in the physician workforce. I think that
one of the things that students are cognizant of is that they know the
schools that are Indian friendly, and those that might not be . In
addition to that we have quite a few indigen ous health professors. I
think probably the best way to recruit and retain and inspires
students who are American - Indian is to have American - Indian faculty
members and most medical schools don't have that . When we look at
full professors of medicine around the nation t here's nearly 40,000
professors of medicine . Of that number there's only around 30 who
are American - Indian. We're just terribly underrepresented in those
sectors.

It's a big challenge for other schools as well in terms of where we're
going to hire and retain American - Indian faculty who can then help
with recruiting students. We're trying to build that pathway from
elementary school all the way through residency programs. We have a
s ummer Institute, where we bring about 40 to 50 students per yea r to
spend the summer with us on campus . They take courses in
chemistry, biology, physics, math, health and communications , w e
keep them very busy. We know that they're very engaged and
enjoying it because more than half that cohort always applies to
reent er the summer i nstitute the following year. We're trying to really
build that pathway from grade school into medical s chool.

One of our big challenges, though, is that we just don't have enough
resources. Again, we're funded through Indian Health Service . Indian
Health Service itself is underfunded. We haven't had an increase in
our funding in 12 years. As the cost per student goes up the numbers

Dr. Donald Warne

of students that we can engage each year goes down . It's just
heartbreaking we have to turn so many of them away simply because
we don't have the resources to support all of them .

Mark Masselli : You know, Dr. Warne , I want to sort of pull the thread on sort of a
vision that you have, and, we're looking at pandemic that will be with
us for a while . B ut there's also, I think, a right time sort of inflection
point for opportunities . I'm wondering if you could share with us how
you envision a new kind of health system . You talked a little bit about
sort of the availability of mental health services, but also maybe some
m ore substance on what does it mean to be under funded at I H S?
What's your sort of bold vision in addition to funding but how these
dollars should be used?

Dr. Donald Warne: Yeah. Just in terms of the underfunding, Medicare is funded at about
$12,000 per be neficiary per year . IHS is funded at about $5,000 per
person per year , so l ess than half of what was received in Medicare .
Ev en the Bureau of Prisons gets more money per person for health
care. Think about that. Federal prisoners get access to more resourc es
for health care than American - Indian children. It really is remarkable
to me that , one, that this is well known, generally speaking , it should
be. It's a huge challenge, and we're looking at under funding . I've
heard a lot of people say that the Indian Health Service is broken. I
don't see it as a broken system. I see it as a starved system. It's never
been fully resourced.

The corollary that I’d like d to use , if you have a car that needs a full
tank of gas to get to its destination, but every day you on ly put a half
a tank of gas in there , you can blame the driver, you can blame the
car, you can blame the road , but in truth, you should blame the
people who were responsible for filling it up , and that's Congress.
Congress has been underfunding it every ye ar, and is been more than
happy to complain about it and bring the IHS director t o testify before
the s enate and say all kinds of things about how they're inept . B ut in
truth, Congress has the blame here. They a re the ones who are
responsible for filling t he tank of gas , and they've never done it. They
need to be held to account .

I'm hoping we're living in a timeframe where awareness of inequities
is growing , a wareness of racism is growing . W hat we have here is
institutional racism where American - Indian s ar e getting substandard
health care in the wealthiest nation in the world in which they were
the first occupants. What I would envision in the future, but things
that we could do not just an Indian country, but across the board, we
really should have more ho ming community based services. It
shouldn't just be hospital based health care, we should have wellness
programs . We should have more community health workers . We
should all be invested in keeping each other healthy , but we just have

Dr. Donald Warne

a system in which the payers pay for treating disease . The health
system makes money by treating disease. We need a better system
and it’s we’re incentivized to keep people healthy not to just simply
treat diseases after they occur.

Margaret Flinter: We’ve been speaking today w ith Dr. Donald Warne, the Director of
Indians I nto Medicine or IN M ED . He's also the Director of the Public
Health Program an Associate Dean of Diversity, Equity and Inclusion at
the University of North Dakota School of Medicine and Health
Sciences. You can learn more about his important work by going to
med.und.edu/ indiansintomedicine or follow him on twitter
@ d onaldwarnemd. Dr. Warne we want to thank you for your
incredible contribution to addressing health inequity for advancing
public strategies for unde r served communities and for taking the
time to join us again on Conversations on Health Care .

Dr. Donald Warne: Thank you for having me.

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Mark Masselli: At Conversations on Health Care, we want our audience to be truly in
the know when it comes to the facts about health care reform and
policy. Lori Robertson is an award winning journalist and Managing
Editor of FactCheck.org, a nonpartisan, nonprofit consumer advocate
for voters that aim to reduce the level of deception in US politics. Lori,
what ha ve you got for us this week?

Lori Robertson: Noting that the United States accounts for about one quarter of
global COVID - 19 cases and deaths. House Speaker Nancy Pelosi said
the US has , “ T he worst record of any country in the world. While the
US has the m ost confirmed cases and deaths by a wide margin , i t does
not have the most in either category on a per capita basis. ” Pelosi
emphasized the US share of coronavirus related cases and deaths,
“ We are 4% of the world's population. We are 25% of the cases and
the deaths 25% , we have the worst record of any country in the
world .” Pelosi got the percentages right , but where the US ranks in
dealing with the pandemic depends on how one looks at the
numbers.
th
As of June 28 , the day Pelosi made her claim, nine other nations
including Chile and Peru had more confirmed cases per capita. Eight
other nations including the UK, Italy and France had more confirmed
deaths per capita . The US case fatality rate was 5%. That's not the
lowest rate in the world, but it's lower th an the rate in dozens of
other countries. Pelosi ’ s claim reminded us of President Donald
Trump's claims that the US leads the world in testing for COVID - 19
simply based on the sheer number of tests performed. In Trump's
case, we also pointed out that the U S wasn't the leader in test per
capita . Pelosi no doubt has a point about the large number of

Dr. Donald Warne

confirmed cases and deaths in the US. It is no way our in tention to
minimize the seriousness of the situation . That's my fact check for this
week. I'm Lori Robert son, Managing Editor of FactCheck.org.

Margaret Flinter: F act C heck.org is committed to factual accuracy from the country's
major political players and is a project of the Annenberg Public Policy
Center at the University of Pennsylvania. If you have a fact that you'd
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 Health Care.

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Margaret Flinter: Each week C onversations highlights a bright idea about how to make
wellness a part of our communities and everyday lives. According to
statistics from the Centers for Disease Control and Prevention , Native
Americans are 60% more likely to suffer from diabetes, obesity and a
sedentary lifes tyle, but inspiring change in these cultures with
conventional approaches , that's proven to be a challenge. A tribe in
northern Idaho may have found a workable solution right in their own
backyard. Leaders on the Coeur d'Alene R eservation have created a
fi tness program called Powwow Sweat an exercise program
comprised of a series of their traditional dances performed to
traditional drumming music.

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Shedaezha : [ Native American’s language ] Hello my friends and relatives , my name
is Shedaezha and in thi s segment we will be learning movements from
the women's traditional dance Category . A basic steps 1 , 2 , 3 , 4 , 5 , 6,
7, 8 .

Margaret Flinter: L oVina Louie is the Director of the Tribes Wellness Center and says
the Powwow Sweat fitness program brings an oft en underutilized
component of more broadly deployed wellness approaches the tribes
own cultural heritage . She says it carries a lot of potential for ongoing
motivation.

LoVina Louie : If you don't do it regularly, your calves will hurt . It sounds like jump
roping for 25 minutes straight.

Male : Far more attractive than doing jogging or the bicycle because it also
relates to my culture and my people.

Margaret Flinter: That was Louis speaking to local reporter Emily Schwing [PH] . The
Coeur d'Alene tribe has rec eived 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 a community
wide approach to wellness. In the ensuing months since the program
launched, a number o f participants like Ryan O ’ Tevez Ortivez have

Dr. Donald Warne
begun to incorporate other healthy habits such as quitting smoking
and eliminating soda .
Ryan Ortivez : I’m aiming to lose 40 pounds by the end of the year.
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Margaret Flinter: The Powwow Sweat workouts br eakdown a half dozen traditional
dances into a series of repetitive moves designed to build up
endurance over time, as well as preparing the tribal members to
partake in the summer's upcoming Powwow , a community based
culturally relevant fitness program th at incorporates cultural
traditions into the process of achieving health and wellness goals.
Shedaezha : Drop the P ringles and let's jingle . 1, 2, 3, 4 --
Margaret Flinter: Now that's a bright idea.
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Mark Masselli: You've been listening to Conversat ions on Health Care. I'm Mark
Masselli.
Margaret Flinter: And I'm Margaret Flinter.
Mark Masselli: Peace and Health.
Female : Conversations on Health Care is recorded at WESU at Wesleyan
University, streaming live at www.chcradio.com , iTunes, or wherever
you listen to podcasts. If you have comments, please e - mail us at
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