COVID-19 reveals deficiencies in IHS funding

GRAND FORKS, N.D. — I am an enrolled member of the Oglala Lakota tribe from the Pine Ridge Reservation in South Dakota. I am fortunate to have grown up in a family with strong connections to culture, and I come from a long line of traditional healers.

Currently, I serve as the Associate Dean for Diversity, Equity and Inclusion as well as the Director of the Public Health program and the Director of Indians into Medicine, a program that creates much-needed pathways for Indigenous students to enter careers in the health professions. At the University of North Dakota, we also offer a specialized PhD in Indigenous Health.

Like other communities of color, American Indians have been hit hard by COVID-19, with several tribes seeing case rates between 2,200 and 12,850 per 100,000 — higher than the rates of any U.S. state. Risk factors include poverty, overcrowding, intergenerational homes and high rates of preexisting conditions like diabetes and lung disease, but our communities have long grappled with lack of basic public health infrastructure.

American Indians and Alaskan Natives (AI/ANs) are the only population in the U.S. that is born with a legal right to health services. That is based on hundreds of treaties signed between tribal nations and the federal government, which include language such as “promise of all proper care and protection” in exchange for land and natural resources. The treaties are contracts, and the federal government has never lived up to its treaty obligations — so they are essentially in breach of contract. The Indian Health Service is not “free health care.” It should be considered the largest prepaid health plan in history, because of everything we gave up for basic social services like housing, education and health care. That is why agencies like the Bureau of Indian Affairs (BIA) and Indian Health Service (IHS) exist. The treaties are the basis for services provision to AI/ANs.

When considering public health infrastructure, you need to have a well-trained workforce; you need to have good information systems; and you need to have good equipment and buildings. In most tribal communities, we do not have adequate infrastructure, because public health in AI/AN populations has been under-resourced relative to other communities. Our ability to investigate outbreaks and conduct surveillance in a public health crisis is really diminished because of policy decisions from Congress to never fully fund IHS.

In public health, we try to prevent disease, and in medicine we treat disease. Because of the longstanding, intergenerational underfunding, most of the resources are expended for medical care, with very little left for health promotion and disease prevention programs in Indian Country. We typically do not have healthy food programs. On the other end of the health spectrum, when it comes to higher levels of care and people are very sick from COVID-19, quite often they need Intensive Care Unit admission, and they also need ventilators. But we typically do not have those services on reservations either.

It is going to require a generation of good policy to make up for generations of bad policy, but among the most important things is for Congress to fully fund IHS. As Tribal nations, we are not asking for anything unusual; all we are asking for is the federal government to live up to its treaty obligations. The United States is one of the first nations to point the finger at human rights abuses around the globe, but those countries can easily put the finger back at us for the way we have treated Indigenous people.

One thing that COVID-19 has done is shine a bright light on public health and policy inadequacies. Some basic things that we take for granted if we live in a city or suburb are just not available in tribal communities: connectivity and communication systems, cellphone access, high speed internet access. Those basic services are not always available, particularly in the more impoverished and rural communities. Also, it is impossible to quarantine or isolate people when you do not have adequate housing.

Another challenge is to promote culturally relevant health programs. If you look at the data regarding health education and health professional programs, people tend to work with communities that they are familiar with. It is much more likely that someone from a reservation will go back to work there than to expect someone who is not from the reservation to go work in that community. So we must build our own workforce. We need pathways programs from grade school all the way through medical school, and that is part of what we do at UND. We have a Summer Institute. It was virtual this year because of the pandemic, but usually we have 50 middle and high school kids from American Indian communities all over the country come to spend six weeks with us on campus. They take courses in biology, chemistry, physics, math, communications and health, and we do fun things and have cultural events on nights and weekends.

We nurture and develop a lot of our future health professionals in those pathways programs, but the challenge again is that it is underfunded, and we cannot support all the kids who want to participate. To me, that is a travesty. This year we had well over 100 applications for 48 spots, and we should not be turning anyone away, but those are the circumstances we are in. So, workforce development is hindered by Congress not adequately funding IHS.

In terms of the relationship between tribes and other public health authorities, in some areas of the IHS, there is a very good relationship with the states, and in other areas there is an adversarial relationship. Collaboration and cooperation across public health agencies has a huge impact on the quality of communication and access to resources. We have a long way to go to improve tribal public health systems, and COVID-19 has highlighted the systemic deficiencies. At UND, we are doing our part in training the next generation of public health professionals, and I hope other universities will improve their focus on the health needs of Indigenous people.

Donald Warne, MD, MPH is the Associate Dean of Diversity, Equity and Inclusion as well as the Director of the Indians Into Medicine (INMED) and Master of Public Health Programs, and Professor of Family and Community Medicine at the School of Medicine and Health Sciences at the University of North Dakota. He also serves as the Senior Policy Advisor to the Great Plains Tribal Chairmen’s Health Board in Rapid City, S.D. Dr. Warne is a member of the Oglala Lakota tribe from Pine Ridge, S.D., and comes from a long line of traditional healers and medicine men.

He received his MD from Stanford University School of Medicine and his MPH from Harvard School of Public Health. His work experience includes: several years as a primary care physician with the Gila River Health Care Corporation in Arizona; Staff Clinician with the National Institutes of Health; Indian Legal Program Faculty with the Sandra Day O’Connor College of Law at Arizona State University; Health Policy Research Director for Inter Tribal Council of Arizona; Executive Director of the Great Plains Tribal Chairmen’s Health Board; and Chair of the Department of Public Health at North Dakota State University.