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On the Rez and Beyond

The New Physician April 2004
With limited Indian Health Service
funding available, American Indian and Alaska Native tribes find creative ways to care for their health.



More than a decade ago, Dr. David Yost was standing with thousands of other people transfixed on a girl dancing around a bonfire on the Fort Apache reservation in eastern Arizona. Clad in the traditional buckskin clothes of her tribe, she twirled and moved as part of her Sunrise Dance, a ceremony celebrating her passage into womanhood. “It’s a weeklong preparation…, and the week culminates with a very intensive weekend of ceremonies that involves a lot of activity, in terms of dancing, and there’s a lot of emotional and physical pressure,” Yost says.


The sight was quite awe inspiring, especially considering that only hours before Yost and his colleagues at the Whiteriver Reservation Service Unit, a U.S. Indian Health Service (IHS) hospital, were treating the girl for pneumonia with signs of sepsis. “We were sure—as we thought we were highly competent, trained physicians—her only hope was to go into an intensive care unit and abandon her ritual. But the elders intervened on her behalf, and said, no, this was necessary that she complete this ritual.”


So after several hours of receiving antibiotics and fluids, the girl was taken by ambulance to her ceremony, leaving Yost stunned. “She went from being stretcher bound and not even being able to sit up to within 24 hours she was up and dancing around a massive bonfire.


“It was just an amazing turnaround. We were left to wonder how much of this was our penicillin, and how much of it was the prayers and the intense spiritual support she got,” says Yost, who is not an American Indian but has spent most of his life on Indian reservations as the son of an IHS physician.


In some ways, miracles like this happen every day in the IHS, just not so dramatically. Part of the Department of Health and Human Services, the IHS is responsible for providing health care to federally recognized tribes of American Indians and Alaska Natives, as provided for in the unique relationship between the federal government and Indian tribes established in the U.S. Constitution and shaped by numerous treaties, laws, Supreme Court decisions and executive orders.


As a result, the IHS provides health services—either directly or indirectly—to more than 1.6 million American Indians and Alaska Natives belonging to more than 560 tribes in 35 states. To carry out this mission, the IHS provides technical assistance and training to tribes, coordinates health planning and resources of federal, state and local programs, and serves as the federal advocate for health services to American Indians. Furthermore, the IHS provides comprehensive health-care services, including preventive hospital and ambulatory care, and assists with the rehabilitative services and development of community sanitation facilities. This system consists of 49 hospitals, 236 health centers, 176 Alaska village clinics, 133 health stations, 33 residential treatment centers and 34 urban projects. The IHS employs approximately 921 physicians, 2,653 nurses, 326 dentists, 448 pharmacists, 353 engineers and 145 sanitarians. And in 2004, this is all financed with a $3.67 billion budget.


Those numbers may sound impressive, but the IHS spends an average of only $1,914 per patient. This amount is dwarfed by the $5,065 per capita health-care spending of the general U.S. population.


Despite the apparent lack of funds, the improvement of American Indian and Alaska Native health is widely recognized and attributed to the managed care provided through the IHS. Since 1973, the infant mortality rate has dropped by 54 percent, while the maternal mortality rate fell by 65 percent. And from 1940 to 1990, the life-expectancy gap between this minority population and whites decreased from more than 13 years to six years. Furthermore, the Centers for Disease Control and Prevention (CDC) found that the IHS has implemented a successful vaccination program with more than 90 percent of American Indian and Alaska Native children receiving all recommended vaccines, with the exception of the chicken pox vaccine and the fourth dose of the diphtheria-tetanus-whooping cough combination.


“Few bright spots exist in the shared history of the American Indians and the federal government…. A notable exception is the sustained campaign by a little-known agency, the Indian Health Service, to improve the health of this population,” wrote University of Washington professor Dr. Abraham B. Bergman in a 1999 issue of Milbank Quarterly, a public health and health-care policy journal. “Except for the intractable problems associated with the abuse of alcohol, the health status of American Indians raised to approximately the level attained by the rest of the U.S. population. This achievement is amazing when one considers the appalling poverty and harsh physical environment in which many Indians live.”


CHALLENGES REMAIN


But in apparent contradiction to these accolades, American Indians and Alaska Natives continue to have the poorest health of any minority population in the United States. According to an August 2003 report by the CDC and IHS, American Indians and Alaska Natives have higher rates of diabetes, bronchiolitis and injury than all other racial populations.


“Clinically, the rates of most leading cases of death for Indian people remain more than double the rates for the rest of America: For accidents, the rate for Indian people is 280 percent of the rate for the general U.S. population; for alcoholism, 770 percent; for diabetes, 420 percent; for homicide, 210 percent; and for suicide, 190 percent,” says IHS director Charles Grim, an Oklahoma dental surgeon and a member of the Cherokee Nation. “We have contributed to increasing the life span of Indian people from 58 years in 1955, when we transferred to the Department of Health, Education and Welfare, to 71 years today; but that is still six years lower than the rest of the population.”


In his annual State of the Indian Nations Address in February, Tex Hall, president of the National Congress of American Indians, called on President Bush and Congress to address these disparities. “In spite of the disproportionate health-care needs we face, today the per-capita expenditure for American Indian and Alaska Native medical services is less than one-third of the average annual expenditure for individual Medicaid assistance and is even less than our per capita health expenditure for federal prisoners.” Hall went on to request that Congress provide the IHS with a budget of $5.4 billion in 2005. The request was made a day after Bush proposed a $3.72 billion budget, a mere 1.4 percent increase over 2004.


Chris Walker, the senior director of health policy and planning for the Cherokee Nation, argues that not only is the IHS not receiving a significant budget increase, but the reality is that the agency’s funding is being cut. Besides not keeping up with inflation, Walker says the budget includes two previous spending mandates—a pay increase for personnel and a diabetes treatment program—which means that the general IHS 2005 budget is really decreased by $17 million.


While he applauds the salary increases and need to address the diabetes epidemic in the American Indian community, Walker says these required budget allocations come at the expense of other projects, rather than as true increases in funding. For example, Bush’s proposed budget calls for no increase in funding for maintenance and improvements or equipment, and a $52 million funding cut for facility construction.


“When you only have 2 percent increases year to year, and then an administration that says federal employees deserve a 3.1 percent increase in pay…. Where does that money come from? IHS has to totally eliminate programs or staff positions, or not deliver services…,” Walker says.


While the battle to increase IHS spending continues, life goes on at the reservation clinics and at the urban Indian health-care facilities around the country. And contrary to the perception of some, IHS administrators and physicians argue that fiscal restraints do not lead to substandard health care for their clients.


“I think the most common misconceptions about Indian health care and the Indian Health Service that I have encountered is that it is believed that the providers and the care delivered to Indian people is substandard. This could not be further from the truth,” says Dr. John Farris, a member of the Cherokee Nation and the clinical director of the W.W. Hastings Indian Hospital in Tahlequah, Oklahoma, the nation’s capital.


Farris and Yost both say they work with exemplary nurses and physicians—the far majority of whom are board certified in their specialties—and are able to provide most of the services available at a private clinic. Yost says that often when physicians or medical students visit the Whiteriver clinic, they will make a comment such as, “‘This looks like a real hospital.’ This is a real hospital, and this is high-level care, and people out here get high-quality care from outstanding physicians. This is an eye-opening experience for people sometimes…,” he says.


Not that the IHS facilities are unaffected by limited federal funds: It’s just not to the point where fundamental care is sacrificed. “There are certain things we would love to do that we just can’t do,” Yost says. At Whiteriver, such things as dentures, eyeglasses and wheelchairs are often considered nonessential in the overall budget picture. If there happens to be money left at the end of the fiscal year, then maybe those purchases can be made.


Also, in order to get the best deal on an MRI exam, Yost and his colleagues may send a patient to the Veterans Affairs (VA) hospital 350 miles away rather than to the closer private hospitals in Phoenix or Tucson because they have a deal with the VA that saves them thousands of dollars a year. “Sometimes we really have to sacrifice convenience,” he says.


Another sacrifice made by IHS physicians is in support staff. Yost says his physicians can be in their offices late into the night writing letters and completing paperwork because they simply don’t have enough office help. “I think there are a lot of things that if I was in private practice I would just ask one of my support staff to do, and I end up doing it myself,” says Dr. Marc Traeger, a Whiteriver clinician.


SELF-DETERMINED HEALTH CARE


Exactly how these budget shortfalls are dealt with varies greatly on the tribe and the reservation. The reason for this variety is the Indian Self-Determination and Education Assistance Act of 1976, which provides tribes with three health-care options: direct from the IHS, as was done historically; contract with the agency to provide services, which allows tribal governments more operational control; or compact with the IHS by taking over administrative, operational and financial control.


“Under self-determination, whether the IHS or a tribe provides health services for their members, standards and quality of care are maintained. And tribes have more flexibility in how they manage their resources and the IHS funds transferred to them and, as a result, sometimes can offer additional services,” Grim says. “Almost all of the 562 federally recognized tribes provide some level of contracted health services to their members, and approximately 52 percent of the IHS federal budget is transferred directly to tribes and urban Indian health programs.”


However, how much control a tribe exerts usually directly correlates to the size, wealth and geography of that nation. Wealthier tribes find it particularly beneficial to contract or compact with the IHS because they are able to supplement the agency’s services with their own. For example, wealthier tribes in Alaska have compacted with the IHS and now administer 99 percent of the agency’s funds in the state and supplement them in order to operate hospitals in Anchorage, Barrow, Bethel, Dillingham, Kotzebue, Nome and Sitka.


On a smaller scale, it’s similar to the system implemented by the Oneida Nation in Upstate New York. Supported by the nation’s revenue, the tribal government has established a fully functioning outpatient health service to treat more than 4,000 clients, about 1,000 Oneida and the rest from neighboring tribes and relocated American Indians. “We opened the doors in ’93, starting with a double-wide trailer set up. [Now,] we are averaging adding a dozen to 15 [new clients] a month,” says Mike Cook, the administrator for government programs and services for the Oneida Nation. However, rather than manage its own hospital, the nation supplements the IHS care with insurance for the Oneida, so they can use nearby hospitals for inpatient care.


In Oklahoma, the Cherokee Nation manages six outpatient clinics, an EMS service and a chemical dependency treatment facility. In taking over clinic services from the federal government in 1990, the nation essentially began paying the IHS for its employee pool, with employees either switching over to work directly for the tribe or remaining employed by the IHS and contracted out. “[We signed an agreement] where we take over a clinic or we take over a hospital, and we want the same management that is there, and we want the doctors that are there. And if those people choose to stay in the federal system, then we buy the federal system,” Walker says. And through self-management, he says the tribe has been able to double the number of clinics in the nation and provide services that better fit its members’ needs.


Despite these benefits, however, the Cherokee Nation continues to have its hospitals managed and operated by the IHS. Walker says the primary reason is the decision by Congress to not fully fund contract support costs, which are the administrative expenses required to take over and then run a hospital or any health-care system. According to the IHS, the contract support costs eligible to be paid for by the federal government include start-up costs, annually recurring direct costs and annually recalculated indirect costs.


“At Cherokee Nation, we basically run an $80 million program for the federal government. We operate eight clinics. We have 700 employees. [And] a part of that is…the administration [costs], like what the government would pay Boeing or General Dynamics to make a plane. Well, [the federal government] pays them 100 percent [of the administrative costs]. They pay us 66 percent,” Walker says.


The IHS says contract costs are funded at about 90 percent but acknowledges that congressional appropriation doesn’t meet the 100 percent legislated for by the Indian Self-Determination Act. “Every year for us, it’s $4 million negative. The federal government is not paying us. For the whole Indian health-care system, it’s $111 million,” Walker says. Whether these costs will be covered may be determined by the U.S. Supreme Court, which could hear Tommy G. Thompson v. Cherokee Nation of Oklahoma this year after the U.S. Federal Circuit Court of Appeals ruled in 2003 that the IHS is obligated to cover all contract costs. The suit, which seeks unpaid support costs from 1994, 1995 and 1996, names the defendant as the HHS secretary, which is currently Thompson.


On the rural Fort Apache reservation, where Yost practices, the contract costs aren’t a pressing issue. Being in a more remote area, the tribal government has only taken control of the EMS service, the mental health service, and the alcohol and drug rehabilitation program. The primary health-care services continue to be managed and operated by the IHS. “It is a major decision for a tribe to do, and it often reflects economic stability, their resources and the number of tribal members they have, and who they have who are interested in and qualified to run what are often very complex health systems.… In our region, which is eastern Arizona, a lot of tribes have chosen to run the program sort of piecemeal,” Yost says.


WHAT'S RIGHT FOR THE TRIBE


Regardless of what services each tribe decides to fully manage, self-determination has provided tribes with more say in their local health-care systems. And with more than 500 recognized tribes, each growing and changing at its own rate, the ability to control the public health system is crucial. “There are generalities in Indian health, but each nation is different, just like California and New York and other states are different,” Cook says.


The Oneida Nation, located 30 miles east of Syracuse, doesn’t look much different from the rest of Upstate New York, with tribe members commuting to jobs in nearby towns, working at private businesses on the reservation or at the nation’s casino, golf courses, newspaper, textile design company or retail shops. “We are in essence an urban center, making this area an attractive area for American Indians to reside,” Cook says.


Meanwhile, it’s quite a different scene in eastern Arizona. The Whiteriver Apache tribe relies heavily on the local timber industry, which has been devastated the last two years by forest fires that destroyed hundreds of thousands of acres. “It’s caused [the tribal government] to sort of reassess how things are going,” Yost says. To supplement the timber industry, the tribe is also supported by summer tourism and from the income of the tribe’s casino. However, unemployment and poverty remain high.


Yost says he has to consider outside factors when treating his patients. “A lot of the economic factors can really make health care challenging, and there are just some basic logistics [problems], too. Some of them don’t have telephones. Some of my patients don’t have electricity in their houses. Less than a fourth of them even have a car. So some of the things that other practices take for granted, like the simple thing of telling a patient to come back the next day and be checked again, that could be very daunting for a person who doesn’t have a car or doesn’t have a phone,” he says.


However, Yost points out that that doesn’t mean the Fort Apache reservation—or any other for that matter—is out of touch with modern society. “When I was growing up on the Navajo reservation, television was a special thing that you got only one fuzzy channel out in rural Arizona. Now, our kids are connected as anywhere,” he says. At the reservation’s high school, students walk around with cell phones just as they do everywhere else. And the availability of satellite TV and the Internet has made medical information—not to mention superfluous pharmaceutical advertising—available to his patients, just like it is to people in Phoenix.


The end result for IHS physicians is a peculiar mix of problems, where one patient doesn’t have electricity in his home, while the next wants to know why he can’t get the most recent drug he saw advertised on TV.


LISTENING TO TRADITION


Another consideration for IHS physicians is the role of the tribe’s traditions in modern medicine. In many ways, it’s not that different from any other practice, in that communication is vital to understanding patients and their needs. “In our practice, we really have a wide variety of patients, from the very traditional and following a traditional Apache belief—and you have to be very cognizant and respectful of that—and we have others who have very openly told [us] that they are not traditional at all,” Yost says.


Traeger says the importance of local traditions has heavily influenced the way a physician will communicate with a patient. “As far as patient education, I have to make sure I am not going to offend them or say something that is culturally insensitive…. When we start talking about death, that’s not something that’s culturally acceptable because sometimes it’s perceived as wishing death on someone, even though all we are trying to do is plan for the future.”


The role of medicine men also continues to be an important factor in treating Apaches. Yost says Whiteriver physicians try to maintain good relationships with local medicine men and work with them to treat patients, but notes that many of his patients won’t tell him they’re seeing medicine men, as they’re afraid he’d be insulted. “People don’t come in with a big sticker on their chest saying, ‘I’m traditional and follow such and such.’ We have to learn to ask patients in respectful ways.”


Of course, asking a patient what he wants or feels is not unique to caring for American Indians and Alaska Natives. And Grim says there is a lot that U.S. medicine can learn from the IHS, especially about the role of the community in managing its own health. “[What can be learned from IHS is] that local involvement at the community level helps make health programs more effective. Public health models can help empower communities to identify their own health problems as well as actively involve them in developing the solutions,” Grim says.
Scott T. Shepherd is an associate editor with The New Physician. Direct comments about this article to tnp@amsa.org.