Yvette Roubideaux of the Indian Health Service: NewPublicHealth Q&A
NewPublicHealth spoke with Yvette Roubideaux, MD, MPH, director of the Indian Health Service (IHS) and a member of the Rosebud Sioux tribe, about innovative efforts to improve the health of Native Americans.
NewPublicHealth: What is significant to you about the observance of Native American Heritage Month?
Dr. Roubideaux: Each year it’s a celebration of the richness and the strength of Native American cultures. It’s a great opportunity to be reminded of the great cultures and traditions of American Indians and Alaska Natives and how that relates to overall health and well-being.
NPH: For 2012, what are some of the key projects and issues that are on the front burner with regard to Native American health in the U.S.?
Dr. Roubideaux: Well certainly one of the biggest issues relates to the disparities that this population experiences compared to the U.S. general population and the significant burden of disease that’s causing lots of illness for the population, including chronic diseases and obesity. Trying to narrow that gap in disparities, trying to improve access to care are major efforts of what we’re doing with the Indian Health Service. For example, the mortality rates on diabetes are almost three times the U.S. population rates. We know that obesity is higher in American Indians and American Indian children. We know that, for example, alcohol-related mortality is almost six times greater in American Indians and Alaska Natives.
NPH: In what ways might Native Americans approach health and well-being differently than other Americans?
Dr. Roubideaux: Well, I think that there’s a general understanding among American Indian and Alaska Natives that the culture and their traditions promote health, and so a lot of the prevention efforts and community-based health initiatives are really starting to focus more on what we can learn from our traditions. How can we learn to be healthy and live in balance and seek wellness? It comes from the fact that for American Indians and Alaska Natives, there’s a recognition that over a hundred years ago we didn’t have the illnesses that we have now, we didn’t have diabetes, we didn’t have obesity, and so they must have been doing something right and what can we take from the lessons of our ancestors and our traditions to be healthier. And, of course, it’s eating healthy and making healthy food choices, more physical activityand living a life in balance—in balance in general and in balance with nature.
Many programs are focused on returning to traditional ways. Some of those are reintroducing gardening and growing traditional plants and some are returning to traditional games and physical activity that the tribes did. Some tribes, they were runners, and so they’re doing more runs, and lacrosse is a traditional Native game and they’re reviving that for the kids. Many tribes are looking at their past to find answers to the health problems that are plaguing them today. Healthy eating practices of Indian people included eating very lean meats, berries and greens—foods from nature. And they had to have enough food for the whole group so they didn’t over-indulge and had to prepare for famines, and so they were very cautious about what they ate.
NPH: How can accreditation benefit tribal public health departments and the communities they serve? What are some of the greatest opportunities and challenges that accreditation presents?
Dr. Roubideaux: Well, I think that there’s been a lot of positive reaction to the development of public health accreditation because many tribes have their own health departments, their own health programs, and really welcome the opportunity to understand what they need to do to provide quality public health services and would love to be able to achieve that recognition of accreditation. I think that there are many tribes who are doing an excellent job of addressing health in their communities but there’s really no way to recognize them, and so public health accreditation provides a standard towards which they can achieve and then a way that they can show their community that they are providing quality health services to their health departments.
I think that the barriers to accreditation really relate to resources and time and staff availability. The resources for public health are usually quite limited and there’s usually one person doing multiple jobs and trying to find the time to meet the standards and to invest in the resources. To meet some of the standards will be a challenge for some tribes, but I do know that there are tribes that are very excited about the new accreditation.
NPH: And what are some of the innovations from the Indian Health Service that might help improve the health status of American Indians?
Dr. Roubideaux: We are trying to educate people on the recognition that health relates to the entire community. It’s not just not going to be solved in the clinic. Health issues are impacted by all sorts of social determinants of health, and what we’re trying to do more is partner with tribes to get tribes involved in making decisions that will improve the health of their communities with resources that they have and making sure that we have a more community-based approach to what we do.
When I was a practicing physician I could treat the patient with diabetes, but once they left the clinic, they were going back to cultural celebrations with fatty foods and were in communities where they couldn’t go walking because the roads weren’t safe and there wasn’t any place to go exercise, and so I think a lot of the approaches now are looking at ways to incorporate health and address the health issues in the schools and in better housing and safer communities. It’s not about the Indian Health Service thinking in the western medical model that we know all the answers. It’s more about partnering with tribes and working together on health issues and having recognition that both the community and the health system have a role.
Our other innovations stem from some of our programs. Our special diabetes program for Indians is a community-based grant program where over 400 diabetes treatment and prevention programs have been developed and many of them incorporate traditional approaches and community-based approaches to prevention, especially trying to start with young people.
We have an initiative to reduce obesity in our youth, and we’re promoting breastfeeding as a natural way of providing nutrition for a child that has been shown in research to reduce rates of childhood obesity.
Access to healthy food part relates to many of the programs that tribes actually run. Tribal communities are sovereign nations. They have control over, for example, if grocery stores are open on their reservation or whether there are convenience stores or there’s fast food, and so tribes can control the types of foods that are in their community and there have been tribes that have worked with IHS to make sure that there’s access to healthy fruits and vegetables in communities. I remember when I worked in Arizona in the early 1990s, you could hardly find any fresh vegetables in the local grocery store, but now when you go to that same community, they do have a fresh food section and that’s why working with the tribes has been great because they can create that access by who they allow to be the vendors for food in their communities.
We’re promoting gardening in communities so that people can learn how to grow their own food and how to prepare it. And cooking classes have become popular in our diabetes programs because Indian people may not have grown up knowing how to cook certain types of vegetables and dishes that are healthier, and so providing education about healthy ways to cook, even healthier ways to make fried bread if you’re going to make it--don’t use lard, use a healthier oil, and don’t make them as big. .
And tribes are recognizing the barriers in their communities to being physically active. Some tribes have been using funding from the special diabetes programs to build wellness centers and where people can exercise in a safe place. They’re making the roads safer, building walking paths. The Chickasaw Nation actually built a new medical center and they put a walking path around the hospital so that people could exercise while they’re visiting family or waiting.
NPH: What advice do you have for philanthropies, government organizations and businesses who want to reach out to Indian Country but don't know where to start?
Dr. Roubideaux: Of the 565 tribes, there are over 300 different cultures represented in those tribes, and even within tribes individuals vary in how they relate to that culture. Either they may be more traditional or more acculturated, or so the barriers that can happen in taking care of people in the healthcare system are that there could be a lot of room for misunderstanding. You know, it ranges from not recognizing that an elder speaks very little English and speaks their traditional language and doesn’t understand why they’re supposed to take the medicine to understanding some of the fears that people have and things they don’t like to talk about and being sensitive to that. It's also key to understand that some patients may be seeing their traditional healers and medicine men for their healthcare and may not tell the doctor and so there might end up being confusion or even harm related to the different treatments that may be occurring.
A person with diabetes may want to do a sweat lodge or a fast and it’s important that the doctor is able to counsel the patient on how to regulate their insulin and their medications. And then there’s just a general misunderstanding and mistrust that can occur when a provider doesn’t understand the unique needs of a patient. And if you work in a facility that serves multiple tribes it’s very difficult to try to adapt to all of that.
I think the one framework that I think helps the most that I’ve seen is the concept of cultural humility, not cultural competence, you know, acting like you can learn it all and be competent or cultural sensitivity, implying that you’re sensitive. I think the concept of cultural humility really resonates with me related to the American Indian and Alaska Native population because it basically starts with a healthcare provider admitting that they don’t know what each patient’s background is, what their beliefs are, what their traditions are, what their issues are and approaching each patient as an individual and not making any assumptions. And I think that really is a framework that helps when you serve a lot of very diverse cultures—always learn from the patient.