(Hilary Godwin) Dr. Warne is Associate Dean for Diversity, Equity and Inclusion at the School of Medicine and Health Services
Health, sorry Health Sciences at the University of North Dakota and also
directs both the Indians Into Medicine Program there and their MPH program. His
research examines the impacts of historical trauma and adverse childhood
experiences or ACEs on health and in his talk today Donald will examine historical and cultural factors that have had an impact on the health of American Indian
families and identify potential solutions towards achieving greater
health equity. With that I'm gonna turn it over to Don so we have plenty of time
to hear from him and thank you. [Applause] (Donald) Hau philámayaye mitakuye pi. Hello, Thank you and Welcome to all my relations here today I'm very happy and honored to be a
part of these discussions and I'm so happy to see academic institutions
focusing on the whole idea of promoting equity and making sure that all
populations can live in a healthy way so as was mentioned I'll talk about the
impact of unresolved trauma on American Indian health equity and I'll give you a
little bit of my own background as well I'm Oglala Lakota originally from a small town called Kyle South Dakota but my people
are known as the Oyate and you may have heard of Sioux Indians right we've
all heard that term Sioux Indian S I O U X. We never called ourselves Sioux Indians
actually we called ourselves tje Oyate and the Lakota were further west and
in what is now western South Dakota and North Dakota. The Dakota were to the east
including the western part of what is now Minnesota and the Nakota were over to the south. So the reason it was called the Dakota Territory and the
reason it's North Dakota is that colonization came from the East so they
encountered the Dakotas that's why it's North Dakota.
if colonization had come from the West to be North Lakota so I bet UNL instead
of UND that's really the reason. So you've heard the term Sioux Indian
before right? Sioux is actually a shortening of an Ojibwe word that means
snake or enemy. Snake in the grass actually what it means and the reason we
were called this if the French settlers did not like us so they used that term
to call us snakes in the grass or enemies so any time you use the word
Sioux Indian you're actually saying snake. You're saying enemies. It's
actually a derogatory pejorative term so I don't call myself Sioux indians i'm Lakota that's that's who I am and again we did have our people also in what is
now western Minnesota those that's where the Dakota people were located. So the
Dakotas still have four small reservations in Minnesota, upper Sioux lower Sioux, Prairie Island and Shakopee and those are relatively small communities
and I'll talk a little bit more about this in terms of history and how that
leads to unresolved trauma but there was a war in 1862 called the Dakota War
which pushed most of the Dakotas now west of what is known as the Red River
of the north and that's the river that separates North Dakota and Minnesota. So
where I work currently is in Grand Forks North Dakota. So Grand Forks is called
Grand Forks because it's a confluence of two rivers the Red River heading west
I'm sorry the Red Lake River heading west and the Red River heading north. So
where those two rivers meet is actually in many ways a sacred place you could at
one point in time take a canoe from Red Lake all the way to Lake Winnipeg and
this whole region the Red River Valley was a gathering point for the Oyate,
Lakota, Dakota and Nakota so where I work now really is my peoples homeland and I
get asked all the time why is it that you work in North Dakota you know it's a
cold place it's a not a very populous place but I'm there because it's my
homeland it's where my people are from. So you've sure you've heard the word
Minnesota right how many people know what Minnesota means? okay one,
Derrick, actually my friend over there he knows what Minnesota means so
Minnesota actually comes from two Dakota words "mni" is water so you may have
heard of you know during the Dakota access pipeline issues Mni Wičoni
water is sacred or water is life. So mni is water and shota means like smokey
or cloudy so shota or mni shota is literally when the smoke rises off the water so
this is a mni shota so that whole region with all of the
lakes and other types of waterways was known as the land of the mni shota or
short Minnesota right that's what we call it now
so that's Minnesota so you've probably also heard the word Minneapolis right so
that's actually from two words as well but in this case it's Dakota Greek so
Dakota mni and Greek poleis means City right so it's water city in Dakota Greek
so every time you say Minneapolis pat yourself on the back you're being
bilingual in Dakota and Greek. So that's the area where I work and where I'm from
originally is Kyle,South Dakota on the Pine Ridge Reservation and I always like to
ask how many people have been to Kyle South Dakota? Wow that's like six more
than usual that's actually you'll have to let me know how it is how you wound up
actually visiting Kyle South Dakota. The original name is phežúta ȟaká which
means medicine route and it's an area where we still have a lot of our
traditional healers and medicine men and it's also an area where we still collect
a lot of our traditional herbal medicines. there's an area between Kyle
and Allen South Dakota South Dakota called Yellow Bear Canyon and we still harvest a lot of our healing herbs and roots
from from this region but it's not called Kyle South Dakota it's where I'm
from and it's a very small town there's a three-way stop sign that's about as
big as it is and and we have a lot of poverty where I'm from but it's very
rich culturally we still have a lot of strong strength in our connection to
tradition so this is a picture of the Little Wound School, Little Wound named
after Chief Little Wound who is one of my ancestors and there's kindergarten
through high school at this school and it serves kind of the greater Kyle
region I'd like to say there's a greater Kyle metropolitan area. One of our big
challenges though is that less than half the kids who start kindergarten actually
graduate from high school so our dropout rates are over 50%
and this is true in many of our reservation communities so if we have
more than half of our kids not even finishing high school then the question
is where is the next generation of doctors going to come from the next
generation of nurses or public health professionals or teachers or attorneys
or business people so we have to recognize that educational outcomes have
a tremendous impact on public health and we know that in public health and when
we develop educational programs to improve outcomes for grade school middle
school and high school in many ways that is a public health intervention. So we
have all kinds of challenges related to poverty and challenges related to
education it's also a food desert now. This is the the cafe in Kyle I was here
just a couple weeks a couple months ago and the cafe has closed down so
hopefully something will reopen that provides healthier foods but I think
what they learn here is that you can bread and deep-fry just about anything
and serve it for lunch. So the foods that are available are things that can be
stored for long periods of time and the reason it's a food desert is that
there's no local access to a supermarket the closest supermarket to Kyle is in
Rapid City South Dakota and that's 90 miles away so imagine doing a hundred
and eighty mile round-trip every time you wanted to go to a supermarket then
add on top of that poverty, limited transportation, bad weather so what would
you do how do you actually get access to healthy food under those circumstances
so right across the street from the cafe is the gas station and the gas station
doubles as a grocery store. So it's they have a convenience market there and you
can imagine the type of food that's available right it's things that are in
cans or bags or frozen there is a small section for fruits and vegetables we'll
put fruits and vegetables in terms of fresh we'll put that into quotes not not
a lot of healthy choices and in public health in addition to the idea of a food
desert there's also the concept of a poverty tax and it's not a real tax per
se where the government takes a percentage of
but people who live in these communities pay more money for fruits and vegetables
than people who live in a city or a suburb because of the cost of
transporting perishable goods to these remote communities so you could want to
eat healthy foods but have limited access and it costs more money so we're
doing all kinds of things from a policy perspective and from our structural
perspective to keep people sick so What's the outcome if we don't have
access to healthy food choices the schools are impoverished, so most of the
kids are depending on the schools for breakfast and lunch and they don't get
healthy food in those settings either. Did a site visit at one of the schools
not in my home community but another reservation and the most popular
breakfast item was the giant cinnamon rolls with the white caked on sugar and
kids would eat two or three at a time because they're hungry and this is also
the population of children in the U.S. that has the highest risk for type 2
diabetes in the world so we keep making things worse based on where we invest
our resources and we promote inequity based on current policies so one of the
outcomes of that is just terrible health disparities. Here's a picture of one of
my uncle's and he has a leg amputation. Why is his leg amputated? Poorly
controlled diabetes isn't it remarkable that we just know that now leg
amputation diabetes if you ask that question forty years ago people might
say oh it must be a combat veteran right but now diabetes has become so rampant
across multiple populations that we're accustomed to seeing the outcomes of
poorly controlled diabetes like amputations like heart attacks like
dialysis right kidney failure in many of our reservations the newest nicest
building on the reservation is the dialysis center how obscene is that you
know we're investing once we have organ failure or significant complications of
the disease so there's another program in my community where they will build a
ramp for people who are in a wheelchair so you can see there's a wooden
so he can get into his home and it's wonderful if you're in a wheelchair need
to get into your house at least our services that will build you a ramp but
wouldn't it make more sense to invest in healthy food in the first place we don't
do that so once you have diabetes and your leg is cut off then we'll invest in
your needs but not before that so what are we telling our children we're
telling them that we're not going to invest in their health
the only time we will invest in their health is when they have an amputation
we'll build them a ramp or if you have kidney failure guess what you
automatically get Medicare right so kidney failure is one of the automatic
qualifiers for Medicare so we invest in the challenges after they've occurred we
don't invest nearly enough in primary prevention and addressing the problems
on the front end so where I'm from there's a lot of rich history and
culture but we never had a written language so we don't have written
textbooks that we can draw upon for understanding our history but we do
understand history and life lessons through stories and there's a story of
three sisters walking along a river and as they're walking along the river they
see babies and young children in the water struggling to stay afloat
so the first sister jumps in and says this is an emergency it's a crisis we
need to get the babies out of the water right now we probably all know people
like this right the second sister thinks about that and says no we need to teach
the babies how to swim so they can survive while they are in the water and
the third sister keeps walking upstream and the other to get angry angry with
her and say where are you going why aren't you helping us and she says I'm
going to find out who's putting these babies in the water and I'm going to
stop them that's public health that's literally working further
upstream so when I look at public health I recognize that it's consistent with
traditional medicine principles from a cultural perspective that we should be
looking at things in a much more comprehensive way so do we need that
first sister who's taking care of the crisis well absolutely we need emergency
room physicians we need ICU physicians we need hospitalists do we need that
second sister who can help with chronic disease management up
patient care primary care of course we do but we also need that third sister
walking upstream we need effort put into preventing the issues from occurring in
the first place so I put a lot of time thinking and about the the overlap of
modern health inequities and traditional cultural approaches and when I think
about our challenges I also have to recognize that we have a lot of
diversity in American Indian populations this is a map of the Indian Health
Service areas for those who don't know Indian Health Service is the federal
agency that provides health services to American Indians and Alaska Natives it's
divided into twelve areas or regions and where I'm from in the Great Plains we
tend to have some of the worst health outcomes in the nation actually the
average age at death for men from Pine Ridge my home reservation is now down to
48 average age of death for women it's a little bit better at 54 so 48 years for
men from my community I'm 52 so I guess I've reached my longevity right it's all
gravy from here right but it shouldn't be that way and unfortunately tend to
see some of the worst health outcomes in the the Northern Plains the Billings
area of IHS Great Plains and Bemidji areas and for those who are from Alaska
I apologize that no Alaska's not off the coast of California but this is the best so this is a map showing the states that
have at least 3% American Indian or Alaska native population so this is
population by concentration in each state and there's now only seven states
that have at least 3% American Indian or Alaska Native
so Alaska Montana North Dakota South Dakota Arizona New Mexico and Oklahoma
so we see huge just sectors of the United States in which there's very few
American Indians and especially the East Coast very few American Indians left now
why is that is that because historically Indians didn't like the East Coast too
much traffic well there's a reason for this for the
the pattern of population in the US and it has a direct impact on equity so
right now we have 35 states that have federally recognized tribes so there's
15 states that do not so what that means is that of those 15 states 30% of the US
Senate has no tribes in their constituencies do they care about our
issues if you're from a state that doesn't have a tribe would you advocate
for IHS why would you is that gonna get you any votes so we have a lot of built
in inequity because of our distribution of population and when we look at this
map we have to recognize that the only reason we're concentrated in the West is
that colonization started in the east if colonization had come from the other
direction the the map would be reversed so this is a part of the discussion that
is difficult thinking about the historical context of American Indian
population and what's happened over time and what does that really mean for
long-term and intergenerational health impact well if we look at our 48 states
of course at the time of contact the entire region was Indian country so when
I see this map I'd like to say let's talk about Indian country right the
entire the entirety of the United States is indigenous but of course we've seen
tremendous changes over time the 13 colonies were terrible for the
northeastern tribes so there was a time when the population was was filled with
indigenous peoples and what is now the northeastern United States but through
colonization through warfare and in many cases the intentional spread of disease
many of those populations were wiped out you may have heard of Amherst
Massachusetts and Amherst College named after Lord Jeffery Amherst who was a
colonial governor and I'm sure some of you know this story but Amherst is very
famous he is the one who ordered the distribution of blankets from a smallpox
Hospital to the northeastern tribe with the purpose of killing them so our
first documented case of bioterrorism is our own colonial government we don't
frame it that way it's very uncomfortable to think about and to talk
about but that is a part of United States history
first documented case of widespread bio terrors of the intentional spread of
smallpox to kill indigenous peoples and the outcome is was hardly anyone left in
the northeast because of that effort so it can actually Google Amherst and
smallpox I like how the word Google is a verb right and you'll find the letters
that he wrote in his own pen and I know it's very hard to read here but it is
translated and this is this is what he said you will do well to try to
inoculate the Indians by means of blankets as well as to try every other
method that can serve to extirpate or get rid of this ex herbal or horrible
race extirpate this exurban race I should be very glad your scheme for
hunting them down by dogs could take effect yeah you can find that a few if
you look for it so one of our challenges when we're trying to promote equity is
that we also need to understand the truth and I don't tell these stories and
talk about these things to make anyone feel bad that's not the point
that's not the intent the reason we have to understand these things is that if we
are ever going to get to equity we have to walk through truth even when it's
unpleasant even when it makes us uncomfortable
because it is the truth this is the truth of our history and if we're going
to get to the truth of the solutions we better have a common understanding of
the reality that our people face so this is also in many ways kind of a slap in
the face to indigenous peoples we honor this bioterrorist by naming a city after
him naming a university after him Amherst College he was a mass murderer
there's no two ways about that intentionally killed many many thousands
of indigenous peoples I wish that was taught in our history books
it's not taught I think because it paints us in a bad light right we look
we look bad as a nation where we have this as part of our history
but we need to be honest we need to tell the truth even when it's uncomfortable
so in the southeast a lot of the tribes are not there anymore either
and that wasn't due primarily to things like smallpox you may have heard of the
Trail of Tears that's actually named after but it's called the Indian Removal
Act of 1930 so there was a law Indian Removal Act which was originally
advocated for by Thomas Jefferson is to forcibly remove tribes from the
southeast to somewhere in the middle of the country so the Indian Removal Act or
Trail of Tears led to the removal of tribes from their homelands in the
southeast to what is now Oklahoma so the 40 or so tribes in Oklahoma only for
them or from Oklahoma the rest of them were removed from
another location and in that process some of the tribal members refused to
leave so they stayed in their homelands why some well some did get removed so
that's why we have these dynamics now where we have Cherokees in North
Carolina and Cherokees in Oklahoma Seminoles in Florida Seminoles in
Oklahoma Choctaws in Mississippi Choctaws in Oklahoma you get the point
so Oklahoma was set aside as Indian Territory that was to be where the
removed tribes could then stake out claims and create their own reservations
so there was a date set aside in the early 1830s for this process to occur so
for those who are college sports fans what's the mascot for University of
Oklahoma Sooners how many people know what a sooner is a handful of people do
very good most people don't so a sooner actually reflects this timeframe there
was the date set aside for the tribes to claim the land and the non-indians who
got there sooner took it so a sooner is a land thief it probably wouldn't
agender as much school pride to say the University Oklahoma land thieves
but that's what a sooner is so that's why before their football games they'll
take out a covered wagon onto the football field sooner schooner you know
sooner pride sooner culture but actually what that is is the thieves of the land
does land ownership in modern America correlate with wealth or poverty
absolutely so when we think about this this is
actually part of the roots of ongoing poverty was that our land was stolen
actually isn't that remarkable and think about all of the wealth that's been
generated out of Oklahoma just from oil alone you know that was stolen it's a
it's documented it's well known well understood but not taught in our history
books for some reason right we don't like to acknowledge the things that make
us look bad as a nation but there are real people who were impacted in a very
real and meaningful way and we see the ongoing intergenerational challenges the
discovery of gold was not good for the California tribes during this timeframe
after 18-49 with the discovery of gold and going on over the next 20 years or
so there were a lot of Indian Wars you may have heard of that term up before
and there was a timeframe where it was actually legal to kill American Indians
for a bounty you may or may not have known that that occurred in California
it also occurred in Minnesota so the Dakota war of 1862 is what pushed the
Dakotas West from their homelands in Minnesota to what is now North Dakota
and South Dakota so during this timeframe
there was a it was legal to kill American Indians you can see here Sioux
scalp $25 so you could trade in a Sioux scalp for $25 bounty that was a lot of
money in those days so that's why even in museums you'll see scalps of American
Indians that were from this time frame perfectly legal to do in in US history
so used to show this image and a few years ago someone sent me a newspaper
clipping from the following year 1863 from Winona Minnesota says the state
reward for dead Indians has been increased to 200 dollars for every
Redskin sent to purgatory this sum is more than the dead bodies of
all the Indians east of the Red River are worth yeah we probably don't know
much about this in our history books right and again I don't tell this story
to make people feel bad that's not the point
but we need to get to a point in this country where we acknowledge the truth
this is the part this is part of our truth as a nation and it's why the
American Indian population is spread so thin and why there entire sections of
the u.s. in which there are no American Indians left there are policy basis for
this and incredible inequities that allowed for this dynamic to occur so
this is a map from the US Census website and it shows the concentration of
American Indian population by county so you can see there's entire sections of
the US which are essentially no American Indians left but again concentrated in
those seven states with Alaska Montana North Dakota South Dakota Arizona New
Mexico and Oklahoma but that's why there's also so many American Indians in
Oklahoma because of removal and the reason that we're concentrated in the
West is because the eastern tribes absorb the brunt of colonization so
that's why our populations are distributed in the manner that they are
so when we look at the numbers we estimate that in North America and South
America there were probably about 20 million indigenous peoples living in the
Americas and of that number probably about five million living in what is now
the United States at 1492 by 1900 there were less than 200,000 American Indians
left from over five million to less than 200,000 it was almost a complete
genocide many of the tribes were completely wiped out
so so we have to acknowledge that this is a tremendous impact in many ways this
is the American Holocaust sometimes people get uncomfortable talking about
in these these terms but that's exactly what this is our people were almost
completely eliminated from existence so the good news is by the 2010 census
there were five point two million self-identified American Indians and
Alaska Natives but when you have this pattern of loss loss of life loss of
population loss of land loss of culture loss of resources does that have a
health impact and can that health impact be passed on from one generation to the
next so when we think about unresolved trauma
in American Indian populations we have to recognize that part of that
unresolved trauma is the long-term impacts of genocide and historical
trauma so there are a lot of people have been studying historical trauma in
various populations and what we see is that when some populations suffer
significant traumas like what I'm describing here we do see
intergenerational impact on health status and future generations so how do
we draw that line between history and current health disparities so this is
from a publication I did several years ago with one of my colleagues in North
Dakota and we have to recognize that there's multiple components to this we
also have a unique history with boarding schools I'm sure many of you are
familiar with the idea of boarding schools in the US and they were called
residential schools in Canada and what would happen during the boarding school
era is that children were taken from their homes on reservations and in some
cases put into boarding schools many thousands of miles away my own mother is
a survivor of boarding schools she's now 80 years old but still doesn't
like to talk about her experiences in boarding schools and we have really a
lot of documented examples of terrible things that did occur
at these boarding schools another challenge that we face just looking
along this this lifeline high rates of stress during pregnancy we unfortunately
have a lot of unplanned pregnancies a lot of young people who are
self-medicating unresolved trauma and wind up getting pregnant and then those
children are great risk when there's a great deal of stress during pregnancy so
in terms of boarding schools it's a picture of the Carlisle Indian School in
Carlisle Pennsylvania and each of these boarding schools has a large graveyard
right next to it and we know that we have a lot of excess death of children
who attended boarding schools and we don't know why we know that there were
outbreaks of things like tuberculosis but that doesn't answer the question as
to why did we have such an extent of excess death. We probably will never know
why so many American Indian children died when they were at boarding school
but I look at this... you know each of those headstones represents an American
Indian child between age six and 12 you know and of course it's its history you
know this has happened in the previous century in the 1900s when I look at this
someone loved each one of those children as much as I loved mine as much as you
love yours and they were taken away to Carlisle Pennsylvania died a thousand
miles from home before we had good transportation. So they just stay there.
They're just buried in Pennsylvania not in their homelands. When I was there I was able to take some pictures of some of the headstones you know there's an Alvan who's Lakota
they say Sioux here, died in 1881. I had an uncle Alvan so I think about these
things and one of the other heartbreaking components of this is they
have a whole row of headstones that says unknown they don't even know the name of
the child who died just unknown lost to history the soul just lost
history not even acknowledged not even remembered does that make some of us
feel bad does it cause anger does it cause
depression is there a biopsychosocial response when we understand these types
of components of our history and the fact that the modern society doesn't
even care enough to talk about it in our history books so not only are we
suffering through the traumas the whole history is not even acknowledged by
modern society that's harmful to just ignore and not acknowledge some of these
challenges so how does this pass from one generation to the next there's been
some fascinating studies that are looking at potential reasons why some of
the negative health consequences can occur from one generation to the next
and I'm sure many of you are familiar with epigenetics and what we find is
that when people live under very stressful circumstances if there's toxic
stress that can actually have an impact on gene expression it changes our DNA
when there's toxic stress so we see different patterns like methylation of
some of the the DNA or where the the DNA divides during meiosis and mitosis
there's the telomere where we see division of the DNA so the the telomere
as we get older shortens and what we see people who are living under toxic
stressful conditions it shortens the telomere and that might explain some
premature aging related to stress so this all has to be worked out from a
research perspective but I I really believe that epigenetics will provide a
scientific platform for us to better understand historical trauma how it gets
passed from one generation to the next there's been some really good studies in
recent years looking at Holocaust survivors from Nazi Germany and the
descendants of Holocaust survivors have worse health status than matched
controls who are direct descendants of the Holocaust so
there's something happening in subsequent generations based on these
types of outcomes so that's one stressor right this historical trauma and related
to boarding schools there's other types of stressors that are really prevalent
in impoverished populations related to poor nutrition now
we haven't identified all of the mechanisms yet but we do know there's an
epigenetic impact of poor nutrition that does occur and the WIC programs of women infants and children I'm sure many of you are familiar with that it's through
the USDA, it's a food program for impoverished moms and babies and when I was working as a full-time primary care provider many years ago the WIC program
was basically a baby formula distribution program you know they're
just basically handing out baby formula they've done a much better job in recent
years to promote breastfeeding and we know that as a population formula-fed
babies grow up to have higher rates of diabetes than breastfed babies and it
makes sense because you know breast milk is healthy its natural is what our
creator gave us to to sustain our children and you know the whole idea of
baby formula is really interesting isn't it does that sound appealing to anyone no come on over we'll have a glass of
formula you know it's called formula for a reason right there's chemicals and
head basically so unfortunately because of high rates
of poverty we have entire generations of American Indians who have higher
percentages of formula-feeding because of WIC that's a policy based
intervention that led to higher rates of baby formula feeding for entire
generations of indigenous peoples here in the US so how many people have heard
of the commodity food program out of the USA quite a few good within what's
called the commodity food program there's what's called the food
distribution program on Indian reservations FDPIR so that's where
commodity cheese comes from you know government cheese literally is from this
and I grew up eating commodity foods you know so there's sugar, flour
it used to be lard that there distribute then they changed it to
vegetable shortening which is probably worse anyway then they also had grape
juice but I think with just sugar water with purple food coloring I just
remember as a kid everyone had that like that kool-aid smile you know the stain a
purple stain on their face from drinking kool-aid or the commodity grape juice
when we think about those foods they're just incredibly unhealthy and when we
think about traditional foods like right now if you go to a powwow or you go to
an event what's a traditional American Indian
food that's always served? Fry bread. Did we ever fry dough historically? No. So fry
bread is not a traditional American Indian food it's actually people doing
the best that they can with their commodities so the roots of fry bread
are not cultural the roots of fry bread are in the USDA so people say they want
to say it's a traditional say that's fine its traditional USDA food it's not
traditional American Indian food and you can see the Elder in this picture on the
right she's using commodity flour and commodity shortening to make fry bread
but now it's been acculturated so every time I go home for a ceremony or for a
feast there's an expectation that there will be fry bread why? Because its
traditional. Well, no it's not. So part of our truth as tribes as community leaders
we have to acknowledge that we're participating in colonization now we've
taken it over we've owned it that's ours no it doesn't have to be and it
shouldn't be I I really believe there's epigenetic impact of toxic food when we
look at corn syrup and you know probably the biggest false advertisement and
nutritional history is a whole idea of enriched flour
there's nothing enriched about it right it's all the nutrients taken out and all
that's left behind is the starch and that's how we make our fry bread just a
picture of some of the commodity foods that these kind of spam like meat
products and it can I'm not sure exactly what that was powdered eggs powdered
milk grape juice on the right here this is a big
container of pure corn syrup now for those of you who noted nutrition you
know corn syrup is basically a toxin and if you look on the label it says use in
your baby formula it says use on your pancakes and we wonder why we have such high rates of diabetes people always seem surprised when I show these
pictures but this is true this is what we grew up with you know this is this
was normalized in American Indian populations and we're seeing the health
inequities today right so these are remarkable pieces of history for us I'm
sure many of you have heard of adverse childhood experiences the ACE study and
we know that the more adversity someone experiences in childhood the worse their
health status is as adults and we we know that when we see adversity in
childhood it can create disruptions in neurological development it can have
impact on behavior and social development then ultimately high risk
health behaviors and early death and some of the outcomes of adverse
childhood experiences include higher rates of obesity diabetes depression
suicide even higher rates of sexually transmitted infections higher rates of
health risk behaviors like smoking and addiction and then life potential lower
graduation rates lower employment so when I look at the outcome of adverse
childhood experiences it looks like the exact same list of American Indian
health and social disparities there's something linking together unresolved
trauma and the health inequities that we see today so does the trauma and when we
turn 18 we've got through the ACE timeframe and our adults well we have
adult we have adverse adulthood experiences as well not as well
described I think in the literature but when we have toxic stress ongoing
marginalization and quite frankly in many of our communities a lot of racism
that American Indians still face those toxic stressful
circumstances are not good for our health and then the other question is
where are the traditional parenting skills built-in when you have entire
generations of future parents taken to boarding school what have they learned
about parenting when I was growing up my uncle's who are medicine men and
traditional healers there tell us about the old ways of parenting and it wasn't
the idea of a nuclear family and it's an odd term - nuclear family that's what we
think about but in the old way it was a responsibility one generation to raise
the next generation so aunts and uncles participated in raising the nieces and
nephews so I would be just as responsible for my nephew as I am for my
son and what a healthy way to raise families that social support that's
built in we don't focus on that even we look at access to health information you
know you have to be a mother or father and an uncle you don't count or when I
have a student who needs to go to a funeral during medical school for their
empty well according to our guidelines at the medical school that doesn't count
you don't get an excuse for an aunt if it's your mom yes so we have built in
cultural incompetence to see in terms of you and how we define families and we've
seen a lot of disruption in our families as a result just real quick on the
disparities I mentioned the terrible numbers were men from Pine Ridge in
North Dakota statewide the average age at death is seventy-seven point four
years for the white population in North Dakota and you can see 56 point six
years for American Indians in North Dakota so in many ways this is
third-world health conditions and I like to remind my colleagues in public health
academics we do not have to cross an ocean to find third-world health
conditions it's right here let's stop ignoring it and let's take it on let's
let's lean into this and do something about it our disparities and chronic
disease of course much higher with diabetes and in many parts of the
country cancer but higher rates of alcohol related deaths accidents
suicides what's tragic about our suicide rates in the Dakota
it's more than double for American Indians but it happens at a much younger
age we see a spike of suicide in the teen years and early adulthood so not
only is the rate twice as high the years of potential life lost or even worse
because of early suicide so why is all of this happening. One of the studies
that I participated in I was a co- principal investigator for what was
called the South Dakota Health Survey and in this study we basically cut and
pasted from other surveys validated questions a lot of berthe's questions we
also screened for mental health conditions and not self-report but
actual screening so phq-2 for depression GAD - for generalized anxiety disorder
audit C for alcohol use disorder and we included the ACE study as well so the
outcomes were really tremendous when we when we look at the outcomes for mental
health screening each grouping of bars the the far right light blue bars or
reservation populations and for depression anxiety and post-traumatic
stress significantly higher levels of positive screening for the mental health
conditions for the reservation-based populations then when we look at our ace
scores significantly worse adverse childhood experience scores for the
American Indian population in South Dakota as compared to the rest of the
state we had some people who responded to the survey who had a scores of 10
maybe they had experienced every one of the defined adverse childhood
experiences not surprisingly each of the individual scores was significantly
higher measures of abuse neglect and household dysfunction so didn't want to
be too data heavy but just know that our preliminary data from many states shows
that the adverse childhood experiences scores are much higher for American
Indians and not surprisingly we have some terrible health outcomes so we have
a lot of challenges ahead of us poverty unresolved trauma ongoing
marginalization and really in many ways inattention and neglect of our issues
and the the not surprising outcomes with disparities
and health education income and worsening inequity and suffering and
death so we need to address equity in a much more comprehensive way we can't
think of this in our silos of medicine silos of Public Health silos of
behavioral health and and even social services we have to look at it more
comprehensively so I'm sure many of you have seen this image or something
similar in the past I like this this way of envisioning the difference between
equality and equity and equality it's a one one size fits all right broad
brushstrokes everyone gets the exact same Medicaid plan for example assuming
that one package of services will meet the needs of every individual and each
diverse population so on the Left that's equality everyone gets the same services
whether you need it or not the guy on the Left didn't need it it's serving the
guy in the middle okay but the one on the right is still underserved so the
idea of equity is to raise everyone's health status to an equivalent level on
par with each other so we're not just looking at the package
of services but what are the actual needs of the individuals and the
communities so I'd shown this image for years and a couple of years ago someone
sent me a slide that I think is just brilliant and the question is why is
that fence there in the first place right so rather than just think about
the package of services to overcome the fence let's knock down the fence right
what are the systemic barriers leading to health inequity and how can we be
interdisciplinary and intelligent enough to knock those things now and I've put
forth that's really the role of academic public health to work collaboratively
across multiple disciplines and address things we need those packages of
services you know we need to think in terms of equity but we also have to look
at systemic barriers and what can we do collectively to to get rid of those
barriers in terms of next steps in just in the last couple minutes you have some
good news I always hate to be the bearer of just nothing but bad news you know so
at UND we are starting a new indigenous health
mph program this fall available hundred-percent online so if you want to
master public health in indigenous health that's what we have available
through und and then starting next fall follow 2020 a PhD in indigenous health
the only one like it in the world and it's it's really a shame it's taken this
long to do this when I think about the impact of colonization worldwide we see
the same pattern of health disparities whether you're American Indian Alaska
Native First Nations in Canada Maori in New Zealand Pacific Islander Aboriginal
Australian we see the same patterns of outcomes based on colonization
there's an entire arena of health policy health programming and socially and
culturally acceptable ways to address this so we're planning to do that so
just very briefly the course work will include principles of indigenous health
identifying the indigenous populations worldwide and they are they are
everywhere applied biostatistics and epidemiology using datasets that include
indigenous data so it's not just theoretical but how do we actually look
at the data for indigenous peoples it is methods heavy but we need our own
researchers leading these efforts so quantitative qualitative mixed methods
community-based participatory research frameworks as well as tribally driven
frameworks and as indigenous peoples we've been doing research for thousands
of years we just had different terminology for it
so indigenous research methods as a part of this in terms of program evaluation
you also have a Health Policy courses then for program evaluation we need to
build our evidence base of indigenous specific programs so we need to evaluate
programs but do it in a culturally appropriate way so in evaluation of
public health programs but also indigenous evaluation frameworks and
then finally indigenous leadership frameworks so for those who might be
interested or know students who went to a deeper dive into indigenous health
we're starting that at UND in Lakota we have a lot of values that
we look at as being very important and one of them is fortitude and in
fortitude we don't have a word that translates directly into that but we
have a couple of ways that we say it one is a Tata energy which means to stand in
the wind to face the way to face the challenge and we learned this from our
animal brothers and sisters and when you see in the plains and there's blizzards
and there's you ever heard of Buffalo it's the the bulls are standing facing
the wind protecting everybody you know and that's what we need we need to be
courageous enough to face the challenge to face the truth even when it makes us
uncomfortable even when it's unpleasant but that's the only way we will get
toward equity and then think about the health of children I was like to end
with this saying from her sister tribe the Blackfeet a child is sacred and when
that child comes into the home the family must welcome it and if the child
is happy and feels the want he will come into this world very very strong and not
to know this is to know nothing and not to know this is to know nothing
we have to treat our children as the sacred beings that they really are but
we need the positive frameworks we need the positive community environments the
social and ecological environments in which to live in a healthy way again and
I also have selfish reasons for this I actually have four children here's a
picture of two of them what if in the time of their grandchildren we don't
have to have this discussion anymore would that be a beautiful vision for all
of us to consider. Thank you all very much. [Applause] So if there's any questions or comments
yeah. (Stephen Bezruchka)Thank you very much for that eloquent and moving presentation you
talked about federally recognized tribes at one point. The Duwamish and other
tribes here are not federally recognized what's the advantage to a tribe to be so
recognized? (Donald) Yeah it's a great question so there's a lot of tribes in the US and
really throughout North America and some of some of the tribes have
what's called federal recognition where the federal government recognizes them
as a tribe and the advantage to that is then access to programs to Indian Health
Service through Bureau of Indian Affairs and other related programming there's
even scholarships for example they're linked to being an enrolled member of a
federally recognized tribe but you're right we have a lot of state recognized
tribes that are not federally recognized and they don't have access to some of
those same services here's one of the challenges though because agencies like
IHS are terribly underfunded so if you are one of the 573 federally recognized
tribes are you incentivized to letting more tribes be recognized now from from
an altruistic perspective sure but it doesn't mean that our budgets going to
go up so the more tribes that get recognized the less resources per tribe
if the budget doesn't increase so the best way to divide and conquer is to
limit resources and it's still happening today because of exactly those issues (Audience member) Earlier you you were talking about how there's not that much representation from from indigenous or Native
communities in the U.S. in our legislative areas right you've probably
been to a lot of them what is the main resistance to it, is it really that people
just don't give a shit or they really like it's not in the front of their head
like knowing all these disparities? (Donald) I think there's multiple factors at play one just to acknowledge in this last election I'm sure many of you know the very first American Indian women
were elected to Congress or two of them let's give them a hand. [Applause] Yeah Deb Halland from New Mexico and
Charisse Davids from Kansas both American Indian women elected to
Congress but isn't that remarkable talk until 2018 for an American Indian woman
to actually get elected to Congress so so I see hope for the future with some
of those outcomes but if you are a legislator from a place where there are
no tribes you have no motivation to vote for more funding for the for Indian
Health Service for example because it's not going to benefit any of your
constituents so if we look at representative government the challenge
with that is when you have a very small minority population we are the minority
of the minority populations we are not well represented and even in
other parts of the country that are represented appropriately in Congress
they don't have us in their constituency so there's that piece of it just the the
logistics and dynamics of representation the other piece of it quite honestly
there are representatives from states that have tribes that are still not
supportive and it's really unfortunate we just happen to have several states
that are ultra conservative that don't want to vote for more funding for health
care and that's where a lot of the tribes are if you look at Oklahoma North
Dakota South Dakota Montana you even Arizona New Mexico are changing a
little bit but we just happen to have concentrations of population in states
that quite frankly don't care about our outcomes on the balance you know we I
I've worked with South Dakota legislators that were advocating for
different types of programs to integrate with the state and one of the
legislators is about 10 years ago now he actually said to me well why is there an
Indian Health Service there's not a Norwegian health service just know no
understanding of history and the trust responsibility that the u.s. government
has and no understanding of treaties and this is a lawmaker in South Dakota you
know so not only is there a challenge with lack of understanding of the truth
there's actually I think in many ways semi intentional ignorance on behalf of
some of our elected officials so we have a huge challenge politically so if that
tells us as American Indians Alaska Natives we can't solve this alone
we need collaborators we need partners and advocacy so we need all of you we
need people who are American Indian and non-indian to actually work with us
collaboratively to fix some of these policy challenges that are leading to
ongoing inequity so I guess that's a very long answer but for some people
it's that they don't understand it don't care or purposefully vote against our
needs. (Audience Member) I work at Chief Seattle Club here in Seattle where we serve Native people
experiencing homelessness and we've worked really hard in the past but
especially the last couple months on the point in time count the homeless census
so to speak on getting them to include native people experiencing homelessness
or native people in general and there's been a lot of backlash on that and
there's been a lot of resistance to include native people and just people of
color in general so uh you know clearly we can all see from an outside
perspective how racist data systems affect public health but is there just
sort of your native public health perspective do you do you have any
public health wisdom on how those things correlate to each other
racist data systems and public health? (Donald) Yeah so the the the data systems are very challenging and just how do we define the population
so for example census is self-reported IHS data is just for users of IHS so I'm
American India but I don't use IHS because I have insurance so I'm not in
that data set you know then there's also tribally enrolled data sets so I'm an
enrolled tribal member and I'm also self identified in the census but I'm not in
the IHS data so how we look at the data is very challenging and that's part of
why we need applied biostatistics and applied epidemiology for indigenous
populations because our participation in those data sets very significantly
purpose is a wonderful survey tool the behavioral risk factor surveillance
system but American Indian participation is incredibly low so we can't use
purpose data and assume that we're actually answering questions about
American Indians so we haven't found the right solution but we do have tribal
epidemiology centers and urban Indian epidemiology centers that are trying to
address this and Abigail Echo-Hawk in the back over runs one of those here
right here in Seattle so yeah one last question. (Audience Member) I was wondering if you would be willing to share kind of the time and the effort it took for you to, for there
to be thecreation of the MPH and the PhD programs that focus on indigenous health
and you know what kind of support did you need from peers, students, faculty
institution, policy level and what kind of challenges did you experience? (Donald) Okay so
to develop the programs the time frames? so I've been thinking about this for a
long time because I used to be the executive director the Great Plains
tribal Chairman's Health Board and in truth I was really disappointed with the
lack of knowledge of mph graduates about indigenous health or American Indian
Health and I was very fortunate I went to Harvard to get my mph and I was
impressed with how much my professors they could talk about Southeast Asia
they could talk about sub-saharan Africa they knew nothing of what was going on
in Indian country and I think that's a pervasive problem across Public Health
academics is lack of understanding of Indian Health so I didn't think about
this for years and when I was asked to apply for the directorship of the the
mph program at North Dakota State University this is now eight years ago
it was with the caveat that I I'll do this but I want to start an American
Indian Public Health Program so I did have support
to do that and then now at UND for the doctorate it just happens to be at a
time frame of their wanting to expand doctorate opportunities and MD PhD dual
degree opportunities so I've been very fortunate to find support to move in
that direction but I haven't found that support in in every public health arena
I think there are just certain pockets that recognize that this is a need and I
would say this University this College of Public Health here does recognize a
need to move in this direction so in my own experience it really depends on
where you're located but if you have the right leadership these things can move
forward and they are moving forward at UND. (Hilary) all right thank you please join me in thanking Don [Applause] and please join us downstairs in the
lobby for a reception and feel free to come up and chat more
