IHER Seminar Series: Dr. Donald Warne, MD, MPH presents: ‘Impact of Unresolved Trauma on American Indian Health Equity’
Good afternoon everyone uh thank you for joining the iher Health Equity seminar series uh my name is Uta katri I am faculty um within the department of emergency medicine as well as at iher um and I’m so excited that you’re all joining us uh for this exciting lecture
Today um it is my great honor and privilege to introduce our speaker Dr Donald War Dr Donald War joined the John’s Hopkins Center for indigenous indigenous Health as co-director on September 1st 2022 he is an acclaimed position and one of the world’s preminent preeminent scholars in indigenous health health education
Policy and Equity as well as a member of the olala Lakota tribe from Pine Ridge South Dakota Dr Warren will also serve as is John’s Hopkins University’s new Provost fellow for indigenous Health policy Warren comes from a long line of traditional healers and medicine men and is a celebrated researcher of chronic Health
Inequities he is also an educational leader who created the first indigenous Health Focus masters of Public Health and PHD programs in the US or Canada at North Dakota State University and the University of North Dakota respectively waren prev prly served at the University of North Dakota as professor of family and Community
Medicine and Associate dean of diversity equity and inclusion as well as director of the Indians into medicine and public health programs at the University of North Dakota school of medicine and Health Sciences Dr Warren’s career is informed by Rich Work and life experiences he served the Puma Indian
Population in Arizona as a primary care physician and later worked as a sta St clinician at the NIH he has also served as a health policy research director at the intertribal Council of Arizona executive director of the Great Plains tribal Chairman’s Health Board and a faculty member at the Indian legal
Program of the Sandra de o Conor College of Law at Arizona State University Dr Warren has received many awards recognizing his research accomplishments educational leadership and service work including the American Public Health Association Helen Rodriguez triz award for social justice and the Explorers Club 50 people changing the world Dr Warren received a
Bachelor of Science degree from Arizona State University doctor of medicine degree from Stanford University School of Medicine and a master of public health degree from the Harvard School of Public Health we are really excited to welcome Dr Warren today um please uh keep in mind that we do have a option to
Submit your questions and we’ll hopefully get to as many as we can at the end of his presentation thank you drks well thank you so much Dr Katy really appreciate the kind introduction and good to see uh so many people here as well as people online as well so very
Happy and honored to be a part of these important discussions and I really appreciate the work that’s coming out of the relatively new uh Institute for health equity research right here at uh Mount siai there’s it’s exciting to see the work that moving forward and I really appreciate the opportunity to
Make sure that indigenous voices are at the table and part of the discussions as we move forward toward promoting Health Equity so today we’ll look at the impact of unresolved trauma on American Indian Health Equity and I’ll try to leave it enough time at the end in case there’s
Any questions we could have some potentially through uh the chat on Zoom uh but also certainly here in the room if there’s any any questions so what we’ll talk about is uh initially terminology we hear the terms American Indian and Native American use interchangeably but they actually do have different legal definitions we’ll
Go over that we’ll look at a brief history of policy uh colonization and marginalization and how that has had an impact on health inequities for indigenous peoples and we’ll look at some contemporary challenges as well as potential Solutions and identifying a path forward so I’d like to start these
Discussions with a terminology and the racial designation is American Indian and Alaskan native so if we think of the United States of course we have the lower 48 states plus Alaska and Hawaii and when we think about North America so it’s 49 states for the US and North America the racial designation is
American Indian and Alaskan native and at the federal level it’s actually the Office of Management and budget that determines the races and ethnicities why it’s om I have no idea I I’ve never been able to understand exactly why it’s Office of Management and budget that determines that but there’s several
Races and one ethnicity that’s for formly acknowledged by the federal government the ethnicity is Hispanic so you’re either Hispanic or non-hispanic and then there’s other racial designations so that’s why you’ll hear the term non-hispanic white for example so there’s white there’s black or African-American Asian uh American and
Pacific Islander and then for the indigenous North American population it’s American Indian and Alaskan native and the reason it’s Alaskan native is that not all indigenous people to Alaska are American Indian culturally or linguistically so a large group of uh indigenous alaskans the athabascan tribal groups are American Indian from a
Linguistic and cultural perspective there are athabascans even in the southwest so Navajo and Apache tribes are actually athabascan linguistic groups so atab Baskin are all across North America but if you go north from there and look at the inup or Inuit populations they are not indigenous just
In North America they’re also in Siberia across North America and also Greenland so they are not American Indian but they are Alaskan native so if you call them American Indian they actually get offended because that’s not their cultural group so that’s why it’s American Indian and Alaskan native um
And thinking about this even further one thing that’s unique about experience of tribal members in the US is that we do have Tribal sovereignty and being an enrolled Tribal member is actually a political designation so much like we can be the a citizen of the United
States or the resident of a state we can also be citizens of our tribal Nation so for many of us we have triy citizenship citizens of the US citizens of our tribe and residents of our states so as a result we’re eligible for things like Medicare as US citizens Medicaid as
State residents but also Indian Health Service as tribal members so we have a unique status as enrolled tribal members from a political perspective one thing to keep in mind is that the Indian Health Service user population uh does not Encompass All American Indians and Alaskan natives so there’s about 2
Million people who use IHS and in the last census there were 9.7 million self-identified American Indians and Alaskan natives so it’s a little over 20% of American Indians Alaskan natives use IHS but we’ll often see IHS data used as representing All American Indians and it doesn’t so for example
I’m not in the IHS database you have to have an active chart within the last three years to be included in the database and I lived in places where there were no IHS facilities and I have private insurance so why would I go to IHS I can actually go to the private
Sector so we have to be careful and cognizant of the fact that IHS data does not represent All American Indians in Alaska data it’s probably the best database we have but it’s not all inclusive it’s actually a minority of American Indians and Alaskan natives so we’ve also heard the term
Native American right and we hear that used interchangeably with American Indian but if you are in Hawaii are are you an American you bet right so in 1978 there was actually the Native American programs act that defined Native Americans as American Indians and Alaskan natives but also native
Hawaiians and Indigenous people to other US territories so American Sim legally are Native Americans the Chamorro indigenous people of Guam are Native Americans so I try to be cognizant of that fact if we’re using the terminology we should use it correctly so it’s fascinating just even looking at the
Origin of those terms terms so why is it that I’m an Indian anybody have any ideas why I’m called Indian or why there’s an Indian Health Service anybody know people usually don’t know but actually it’s because of Columbus he thought he was in India believe it or
Not so that’s why we have the West Indies that’s why we have American Indians is because Columbus was lost at sea therefore I’m an Indian isn’t that remarkable so we have an Indian Health Service a Bureau of Indian Affairs because Columbus genuinely thought he was in India um but why are we we
Americans where does the word American come from does anybody know any thoughts yes CER from Italy yeah do you remember his name or no Amero vuchi yeah Amero vuchi very good so Amero verspui basically named North America and South America after himself isn’t that remarkable so so we
Have to be cognizant of the terminology of the history so every time we say American Indian we’re actually paying homage to Two Italians right right Americo basuchi and Columbus you know every time we say American Indian so a lot of us don’t like that terminology just because the
History is not really accurate so many of us use the term indigenous and Indigenous peoples are the original inhabitants of various parts of the earth and it just happens to be the indigenous people of the 49 states of the US in North America are the American Indian and Alaskan native population so
It’s really remarkable on the census I have to check a box it says American Indian and Alaskan native even though I’m not Alaskan native I’m American Indian so I try to be cognizant of the terminology that we are using so when we think about the history of colonization
And some of the commonalities across indigenous populations particularly those who are colonized by Great Britain we see a common outcome and they had a common playbook for lack of a better term and that included of course taking of land and enslaving local indigenous peoples but also putting indigenous peoples into boarding schools or
Residential schools we saw that same pattern in the US in Canada as well as Australia and New Zealand and it’s really remarkable when we look at the history of colonization we see common health outcomes so we have the same Health disparity patterns for indigenous peoples all over the world as a result
Of colonization and when you think about it we have loss of land loss of territory loss of economies loss of language loss of culture loss of traditional food systems so of course there’s going to be a health impact based on all of that loss and here in the Northeast just think
About some of the terminology that we use to describe where we are for example New York right so paying homage to Great Britain and colonizers every time you say New York or the whole idea of New England how offensive from an indigenous perspective right New England New Jersey
New York and we use these terms all the time without even thinking about them from an indigenous perspective that’s paying homage and uh actually paying respect to the colonizers so that’s something to think about you know what is the original terminology we should know these things based on where we live
So we can see there’s a huge impact of colonization on land and resources and certainly on access to things like traditional food systems and not surprisingly we see terrible Health disparities so there’s been a lot of recent uh research done in recent years looking at the impact of emotional and
Psychological trauma and we know that when there’s traumatic events in a person’s life that can have a long-term impact on their health it could be onetime events uh accidents or injuries diagnosis with a chronic disease these type of traumatic events can have emotional and psychological impact we
Can also see toxic stress or ongoing Relentless stress having a huge impact on the health of our our populations so when we’re under toxic stress we see stress hormones so elevations and things like cortisol and epinephrine and all of the uh physiological impact of those elevated stress hormones and things that
Cause toxic stress can be things like living in poverty living in marginalized communities living within racism and unfortunately we still see racism in the United States and that does have an impact on population Health there’s also been a lot of work in recent years looking at childhood trauma and particularly adverse childhood
Experiences and we know that the more adversity someone faces during childhood the worse their health status is as an adult and one of the areas that we’re moving forward in terms of our research through John’s Hopkins and other indigenous focused areas of academics is the impact of historical trauma and
Colonization as a stressor and an an area of unresolved trauma that’s having an impact on health even today so we’ll talk a little bit about that but in very basic terms if you lose culture language is taken away food systems are taken away and you become dependent on uh
Unhealthy Lifestyles and uh dependent on programs that are providing unhealthy food for example of course that’s going to have a health impact so when we think about ourselves in a holistic manner this is a medicine wheel and it shows four components of who we are as human beings spiritual mental physical and
Emotional and we can have trauma in any of those Arenas right we can have physical trauma have level one Trauma Centers for physical injuries and as in mentioned there’s been a lot of work looking at psychological and emotional trauma and I would say for American Indians and other indigenous peoples
There’s also spiritual trauma that deep rooted spiritual connectedness to place loss of access to Sacred sites and even having our traditional religions made illegal so for those who might be interested in looking it up you can Google the code of Indian offenses yes Google is a verb right so we can Google
Things now but the code of Indian offenses in 1883 made our religion and our ceremonial practices illegal punishable by withholding food or imprisonment isn’t that remarkable so it was the law of the United States to say specifically things like the Sundance were against the law the work of what they said was
So-called medicine man is illegal so we had our our religious practices made illegal so many tribes unfortunately lost that historical connectivity to traditional ceremony and religious practice and that was in place for almost 100 years it took until 1978 when we had the American Indian Religious Freedom Act to reverse the
Code of Indian offenses but we had 95 years in which our ceremonial practices were against the law out of show of hands how many people knew that you know very a few people did that’s outstanding but most people don’t know that part of our history but it’s an
Important part of our history we have to acknowledge that there were policy-based decisions and laws that led to disparities and inequities so let’s just look at the lower 48 states and what we now call American Indian populations as the indigenous peoples here the uh 13 colonies were devastating to the
Northeastern tribes and I’m sure many people are familiar with Amherst Massachusetts right an Amherst College UMass Amherst named after Lord Jeffrey Amherst and he was very well known in Indian country because he is the Colonial governmental leader who ordered the distribution of blankets from a small poox hospital to the regional
Tribes with the purpose of killing them so our first documented case of biot terrorism is our own colonial government but it’s not taught in those terms most people are not even aware of this and there’s nothing you can google google Amherst and small pox and you can
Actually find the letters that he wrote and this is actually in his pen I know it’s a little bit difficult to read it’s incursive uh but what he says here he’s writing this to one of the colonial army uh leaders 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 extrap or get rid of this exorable or horrible race extrae this exorable race I should be very glad your scheme for hunting them down by dogs could take effect Jeffrey
Amherst so what do we do now now we honor him we name a city after him we name colleges after him he was a murderer he was a biot terrorist and this is part of the the fabric of Contemporary American life which is so frustrating in that we don’t know basic
History about our terminology about our words about where people come from and I talk about these things not to make anyone feel bad no one here is responsible for what happened at that point in time but I talk about these things because it’s the truth and if
We’re ever going to get to equity we have to walk through truth even when it’s difficult even when it makes us feel uncomfortable so please don’t feel bad about the things I’m talking about that’s not the point but we just need to understand the truth there are reasons
Why we see the inequities that we do today and there’s a unique history of indigenous Americans that most people are not aware of and we have to be aware of that history to develop appropriate and meaningful interventions to promote Equity among indigenous peoples in 1830 there was a law called
The Indian Removal Act so the law Indian Removal so for those who like to push back against the idea of systemic racism when you’re saying you’re going to remove Indians that’s pretty racist from my perspective right and the purpose of Indian Removal was to remove the American Indian population from
Primarily the southeast to what is now Oklahoma so more colloquially it’s known as the Trail of Tears you may have heard of that so tribes in the Southeast were removed and placed into the Oklahoma territory and there’s a very interesting Dynamic that occurred many of the tribal members refused to be removed they
Wanted to stay in their homelands whereas others were removed so now we have this interesting Dynamic where we have seols in Florida and seols in Oklahoma Cherokees in North Carolina Cherokees in Oklahoma chakas in Mississippi chakas in Oklahoma so you get the idea of the 38 ferally recognized tribes in Oklahoma only four
Of them are actually from Oklahoma the rest that were removed from other parts of the country so think about that loss of access to traditional sites ceremonial sites sacred sites loss of access to traditional food systems and then being placed into a new territory um and then being dependent on the
Federal government for things like food so going further uh through history the discovery of gold was devastating for the California tribes there was actually a point in time where there was a bounty you could actually kill American Indians for a bounty to make way for the gold rush and during this
Time frame we saw tremendous loss of life and uh the first governor of California was Peter Hardman Bernett and he said in his State of the State address in 1851 that a war of extermination will continue to be waged between the races until the Indian race becomes extinct
Must be expected while we cannot anticipate this result but with painful regret the inevitable Destiny of the race is beyond the power or wisdom of man to avert so it’s something that is just going to happen we can’t do anything about it that Indians will become extinct in California that was
Basically what the governor was saying at that point in time so it’s estimated that about 100,000 American Indians died during the first uh just a couple years of the Gold Rush isn’t that remarkable so the population was just absolutely devastated by 1873 only about 30,000 indigenous people remained in California
And many of those tribes are very very small in terms of numbers or some of them are completely wiped out during that time frame so that’s just a few examples of uh history as it relates to indigenous peoples of what we now call the United States so in my work recently
I’ve spent a lot more time and energy focusing on the impact of unresolved trauma and chronic disease disparities so my research really is focusing more on historical trauma and epigenetics and other other factors that lead to chronic disease disparities so when we look along that Continuum one of the other
Considerations is that we had boarding school systems in the United States and the boarding schools were forced removal of American Indian children to be placed in boarding schools and the way that the families were compelled is that they were removed from their homelands put on reservations had no access to
Traditional food systems and became depend on the federal government for food so what the families were told was either give up your children or we will withhold your rations so give up your children or starve isn’t that remarkable and one of the results of that was thousands and thousands of American
Indian Alaskan native children being removed from their homes and put into boarding schools so this is a picture from the Carlile Indian School in carile Pennsylvania and I have four kids and I’ve seen lots of class pictures and usually when I see a class picture I see
Smiling I see Joy I see laughter I don’t see any of that in this picture I see fear I see anger I see sadness and all those beautiful little faces that look like my kids you know these these young innocent children were put into these circumstances where they faced all kinds
Of abuse well documented physical abuse sexual abuse emotional abuse neglect entire generation of indigenous people and that was federal policy toward American Indians and the goal was to get rid of the culture and that was part of the the British colonizing Playbook that then became the US policy is to do
Things like boarding schools and we saw that like I had mentioned in other English-speaking indigenous populations Canada Australia New Zealand had very similar stories it’s a famous set of pictures of a Navajo young man and on the left upon uh enrolling at Carlile and then 3 years later and this was
Shown as a success story say look the the Indian is no longer there right they took the culture away and that was seen as a success story when it comes to the boarding schools this is a picture of the the graveyard that’s right next to the Carlile Indian School and uh when you
Look at these boarding schools there’s well over a hundred of them most of them have huge graveyards right next to them and the reason is we had excess death at the boarding schools and we don’t know why so many American Indian kids died at boarding school we know that there were
Outbreaks of things like tuberculosis and influenza and small poox but we don’t know why there was so much excess death it wasn’t all infectious disease we probably never will know why but I look at that and each of those headstones represents an American Indian Child between age six and 12 generally
Speaking thousands of miles away from home taken out of their home put into boarding school and they died and were buried away from homelands and when I think about this also what is the impact then on the survivors what if you’re a child and you see so many of your friends and
Playmates and classmates dying at such an unnaturally High rate does that have an impact on you well absolutely and what did these entire Generations then learn about parenting right was it’s all corporal punishment almost like a military style model uh of parenting and it completely changed the cultural Dynamics related to
That unfortunately and this is not ancient history my mother is a survivor of boarding schools you know she went to Pine Ridge boarding school um back in the 1940s so part of my work in recent years is also looking at epigenetics and uh just real briefly with epigenetics um we
Can see changes to DNA when there is um toxic stress and the changes to DNA at least in some studies that we’ve been able to do shows that uh those changes can potentially pass from one generation to the next okay so what would you like to hear
Again so just thinking of this in terms of epigenetics um uh I really believe that epigenetics will provide a scientific platform from which to better understand intergenerational trauma because we can see in some animal models in particular where the epigenetic changes pass from one generation to the
Next and uh we’ve done some preliminary studies that are really compelling and what’s fascinating one of our studies we looked at a traditional food called chokeberry and we published this so you can look this up too but we uh did pre-tests of measures of inflammation and epigenetics and one of the epigenetic
Changes that can occur from toxic stress is methylation of the DNA so actually a methyl group or a carbon group attaching to a nucleotide where it doesn’t belong and we uh tested first in cell culture then we actually did a clinical trial with chokeberry juice and we found
Demethylation of interlan six Gene this is really remarkable stuff so nutritional epigenetics that can actually be treated with traditional foods and the chokeberry has actually been described as a medicinal food for thousands of years so in addition to identifying the the causes and Associated uh signs related to
Disparities we also need to study the interventions and things that could work to reverse some of these challenges that we’re facing and that’s what we’re working on now another challenge uh we have high stress circumstances in many of our communities and a lot of stress during
Pregnancy is not good we know that uh toxic stress during pregnancy has a negative impact on the mother as well as the baby and then historically um with changes to Food Systems we had access to very unhealthy food excuse me so the wick program women infants and children in recent years
They’ve done a much better job of promoting breastfeeding but when I was working as a full-time clinician in the 1990s the reservations where I worked the wick programs were basically baby formula distribution centers just handing up baby formula and we know that as a population formula fed babies grow
Up to have higher rates of things like diabetes than breastfed babies but because of Wick we wound up seeing higher rates of formula feeding um in American Indian populations as opposed to breastfeeding so they have done a much better job in recent years to try to improve
Outcomes so another food program is the fdpir food distribution program on Indian reservations and that’s also known as the commodity food program and the commodity food program is a food distribution program that was largely very unhealthy foods that were distributed Ed to the tribal communities so now when we think of traditional
American Indian food a lot of people think of fried bread right Indian fry bread well we never fried dough that’s actually not an indigenous food it’s people doing the best that they can but their Commodities so if you want to call it traditional food it’s traditional USDA food not traditional American Indian
Food right so you see the child on the left with a big fry bread and on the right you can see the Elder using commodity shortening and commodity flour to make fry bread now think about these engineered Foods so shortening is hydrogenated just super saturated vegetable oil vegetable oil should be
Liquid at room temperature but by hydrogenating it and saturating it with hydrogen uh you actually can make it room temperature that can last for years on a shelf but it’s also very unhealthy it’s a type of fat that can can clog arteries and cause heart attacks and so
We see those disparities and then enriched flour I think the word enrich is probably the biggest nutritional uh misnomer in history because it’s basically all the nutrition taken out of the Grain and all that’s left behind is the starch so very unhealthy form of carbohydrate a very unhealthy form of
Fat and we call it fry bread so when I go back home for ceremonies or for feasts I always point that out you know this really isn’t our traditional food and then of course my family members get mad at me because they love their FR
Bread you know but but part of our truth is that we’ve acculturated we’ve adopted these unhealthy principles into our modern culture we have to be cognizant of that we have to be aware of that and we have to be courageous enough to address it even when it’s uncomfortable
But but that’s not our traditional food and it’s killing people it’s poison here’s a picture of some other commodity Foods they had some sort of spam like meat products with beef and pork uh commodity cheese the big bricks of government cheese on the right that’s a container of pure corn syrup corn syrup
Is another engineered food that is ultra sweet and it’s in so many of our Foods now but if you look closely this is coming from the USDA Our Own federal government it says use and baby formula so think about that we’re replacing all of this Rich wonderful traditional food and even breast milk
With these engineered foods and replacing with really unhealthy things like formula and corn syrup and now we wonder well why are there such high rates of diabetes and it’s amazing to me how many researchers say oh it must be genetic there’s not a gene to answer this right
We did not have high rates of diabetes prior to the introduction of these Foods prior to the impact of colonization so trying to identify a gene is a waste of time and energy and and so what if you found a gene then what then what do you
Do I think it’s much more important to be more proactive and pragmatic we know what caused this so let’s reverse that but we don’t see the same types of rationale in NIH and we’ve worked for many years trying to improve ni priorities and and what they’re focusing
On and this is one area where I think we need much more work and so it even says on the label here use on pancakes and French toast you know but just remarkable and this is federal policy linking to health disparities so kind of going through that timeline we also see adverse
Childhood experiences and I’m sure many people are aware of the ace study that was originally done in the 1990s and it showed a strong correlation between adverse childhood experiences and poor health outcomes as adults and uh Aces have long-term impact on many factors including General Health
So we see higher rates of obesity heart disease diabetes and some forms of cancer when we have higher adverse childhood experiences scores or Ace scores we also see higher rates of mental health challenges High rates of depression anxiety post-traumatic stress and suicidality we also see impact on life
Potential so uh higher drop out rates higher rates of poverty higher rates of unemployment that are correlated to adverse childhood experiences and when you look at the outcomes of high Ace scores it’s basically the same list of disparities that we see in American Indian and Alaskan native
Populations so I’m very proud of my friends at the CDC particularly at the national Center for injury prevention uh the the ace pyramid used to have Aces or adverse childhood experiences at the base of the pyramid and there’s now much more recognition that generational embodiment and historical trauma has an impact on those
Local communities and can change the local context and create social conditions in which families are at greater risk for adverse childhood experiences but with Aces and that stress during childhood it disrupts neurological development has an impact on social and behavioral development adoption of high-risk Health behaviors and early onset of disease disability
And death so we see strong correlations between adversity and childhood and poor health outcomes and early death we’re about to publish these data uh this is specifically from North Dakota and we wanted to look at the decade prior to the pandemic so this is 2009 to 2019 the
Red bars are the American Indian population and the blue bars are the white population in North Dakota and you can see between age zero and one that’s infant mortality you can see how much higher that red bar is than the blue bar infant mortality rates are significantly
Higher for American Indians and you can see it looks like two completely different populations right the peak in the 50s or the American Indian and the peak closer to 80s for the the white population in terms of the age at death um for the populations so another way to
Look at the data this is really remarkable in North Dakota the median age at death for American Indian men is 55 median age of death 55 for American Indian Indian men for white women it’s 85 30e difference for the white female population in North Dakota it’s a Blue
Zone it’s a very healthy longevity state but for American Indian men death at age 55 is the median so I’m 57 so I guess it’s all gravy from here right I’ve hit my median longevity but it shouldn’t be that way and the vast majority of premature death is preventable the vast
Majority so that’s why we need more programming like Health equity research how do we promote Equity we need to put resources into things that make sense not identifying a gene but actually do something about reversing the impact of colonization and doing something about food systems and doing something about promoting cultural connectedness and
Ceremony and reversing some of the terrible impacts of what has happened over the years so the adversity does not end at age 18 right we still see adverse adulthood experiences and toxic stress and we know that living under under toxic stressful circumstances is not good for health uh even for our adult
Population so we have to have a much more holistic perspective on trauma obviously there can be physical trauma but we can also see psychological and emotional trauma and I hope you can also see that there’s a spiritual trauma when we look at loss of land loss of language
Loss of culture loss of ceremony even when our religious practices have been made illegal we have to be able to reverse that and again one size does not fit all so we have to have unique contextual programming for indigenous peoples and that’s part of the work that
Needs to happen moving forward we’ve uh been a part of and also observed some preliminary studies that are really compelling the power of prayer and the power of connectedness on wellbe is really compelling and I think that’s an arena that needs to be further studied CBT is cognitive behavioral therapy and
There’s a whole Arena of indigenous mindfulness traditional uh perspectives on prayer and gratitude and what we see and this the studies again are very compelling when we’re concentrating on things that make us angry it raises our blood pressure raises our blood sugar raises our cortisol raises our epinephrine but we’re when we’re mindful
Of things that we’re grateful for it reverses all of that to such a degree that if it was in the form of a pill it would be standard practice but because it’s cognitive behavioral therapy it’s alternative medicine right mindfulness is that alternative medicine but it’s effective and I think that as a health
System as a society we should be smarter than that just because it’s not found in the pharmacy does not mean it’s ineffective right so there’s all kinds of culturally relevant interventions that we can use we know that exercise and physical activity is good not just for physical health it’s a great
Intervention for depression as well and we see all kinds of benefits also social connectedness um and counseling but particularly that social connection is so vitally important for well-being and during the pandemic I wish we had never used the term social distancing right six feet is a physical distance not a
Social distance and what we wound up seeing is much more social isolation in recent years what have we seen higher rates of suicide higher rates of Overdose higher rates of addiction because of social isolation linked to the pandemic and we know that social connectedness is vitally important and
All of these interventions can be designed in a culturally relevant way so for some uh considerations and just being respectful of indigenous populations and contributions to science um uh the whole Arena of oral rehydration solution or Pedialite was actually developed working with tribes in the southwest that was the origin
Actually of the center for indigenous Health was the work of Johns Hopkins Physicians developing Pedialite and saving lives from preventing dehydration many viruses uh uh many vaccines for viruses and and bacteria IA were developed with collaboration among American Indian populations as well and many of our tribes were just instrumental in developing covid-19
Vaccinations as well so we’ve participated in research historically when it can be done in a culturally appropriate and respectful manner also diabetes management the DPP or diabetes prevention program that engaged a lot of tribal communities across the country and we learned a lot about diabetes management by working with tribal
Nations so we’ve made significant contributions to many fields of science we also have uh indigenous healing systems and Indigenous healing methodologies and acetal salicylic acid is aspirin anybody know where that comes from where’s aspirin come from Willow exactly willow bark very good so uh willow bark tea was a a medicinal um
Intervention we used for many thousands of years we’ve used Willow and now we call it aspirin right so I often I’m asked what hospitals in the US are incorporating traditional American Indian medicine effectively and my answer is every single one of them because when you rule out myocardial
Infarction the first thing you do is give them asper so every time you’re in the ER and you do that you’re giving them willow bark tea you know you can thank the American Indian population because that’s our medicine it was our medicine until Bayer discovered it right
Now it’s modern medicine but that’s just one example of many examples of Botanical medicine also the entire field of osteopathic medicine at still considered the father of Osteopathic Medicine grew up in Missouri and he learned osteopathic medicine from the shauni and Oto Indians it’s traditional indigenous medicine and co-opted quite
Frankly and now it now kind of build as some sort of European intervention but it’s not it’s indigenous medicine and there’s just many many examples of this so we see all kinds of dis parities in health outcomes and certainly uh educational outcomes and one of our big challenges is the one size fits-all
Approach and I’m so pleased to be here at a Health Equity uh Research Institute U because we recognize that one size does not fit all right and I’m sure you’ve seen this image or similar images where in the U field where we have equality everyone gets the same intervention everyone gets the same
Medicaid plan whether or not it’s effective everyone gets the same curriculum whe whether or not it’s effective that’s equality everyone gets the same thing whether or not it works so you can see in this example the guy on the left did not need that box to
Stand on it’s serving the one in the middle pretty well but the guy in the right is still underserved so through an equity lens we recognize that one size does not fit all and sometimes we need to do unique interventions for Unique populations so part of that for example
With indigenous peoples is to understand history why is it that we have these disparities and even more importantly what do we need to do to overcome those disparities so I’d been showing this image for years and and describing it this way and a few years ago someone
Sent me an image that I think is just brilliant and the the question is why is that fence there in the first place right is it the package of services to overcome the barrier or do we need to get rid of the barrier and what are some
Of the barriers that we face if we think about this we don’t have nearly enough providers who are indigenous we don’t have any medical school Deans who are American Indian in the United States zero Medical School Deans who are American Indian same with public health we don’t have any American Indian public
Health school Deans this is 2024 and that’s just ridiculous we need better representation so we need to recognize that indigenous health is an academic discipline while I was at UND as was mentioned we started the the world’s first indigenous Health PhD program and in the first four cohorts we’ve
Matriculated 60 students in into the indigenous Health PhD program of that number 55 of the students are indigenous and the others are outstanding allies who have had Direct experience working with indigenous populations but they’re going to change the world and we’re going to keep admitting more and training them well in uh research
Methodologies but also indigenous methodologies public health program evaluation but also indigenous evaluation Frameworks American Indian and Indigenous Health policy and Leadership uh skills so really well trained in academics so we need to recognize indigenous Health as an academic discipline we also need to recognize indigenous medicine as a
Clinical science longterm I would love to see indigenous medicine as a graduate medical education opportunity we have so much that we’re already doing that’s indigenous medicine but it hasn’t been framed from that perspective and there’s so much more that we could do and much research that needs to be done to show
Uh from a scientific perspective that these are valid interventions and then we also need an American Indian or indigenous school of medicine and Health Sciences and there’s a model to do this if we look at the network of the historically black colleges and universities within that Network there’s actually five medical schools five
Medical schools based at HBCU this is a map of the tribal colleges and universities and this is a map of the tribal medical schools zero right could we fix this could we think big dream big so what many of us are working on now is an indigenous school of medicine and the
Idea of medicine being much bigger than just medications right the idea of medicine is a healing system as a healing force that incorporates the medicine wheel spirituality mental health emotional health physical health and recognizing that there’s so much that we could do to promote wellbeing through an indigenous lens and I I bring
This up a lot and people tend to laugh but my question is what if medical school was a healing experience rather than a traumatic one I know what my medical training was like it certainly was not healing and I think about my colleagues that go through the torture of medical school the now
There’s a cap on hours but when I went through training there was no cap on hours during residency programs and I see the majority of my colleagues end their training and then released into society as being traumatized scientists with no training in things like trauma-informed
Care why do we do that and expecting the existing system to change is not working and I think we have enough empirical evidence to show that the current system doesn’t work so perhaps we need our own school so we need multiple Health Sciences we need both the undergraduate
Medical education or medical school as well as graduate medical education or um residency programs and why not develop a fellowship in indigenous medicine wouldn’t that be wonderful wouldn’t it be fantastic and wouldn’t that promote healing in many of our communities and this is something that could be done more naturopathic approaches we need
More nurses and therapist occupational therapy Physical Therapy speech therapy Public Health Allied Sciences Clinical Psychology we need the whole gamut of providers um that we could develop through an indigenous school of medicine so where could this be located we we need to have a city that’s large enough
To have access to Medical Specialties so for clinical training you need medical special Specialists so has to be a big enough City ideally no current medical school and what I’ve observed is when there’s a new medical school there’s push back from the existing ones because we’re competing for clinical training
Sites basically and ideally a significant number of American Indian and Alaskan native patients so some current places that we’ve thought about are like Rapid City South Dakota Flagstaff Arizona Santa Fe New Mexico Anchorage Alaska so we’re in the process now for in 2024 we’ll be doing a feasibility study for indigenous school of
Medicine so we need allopathic medicine we need people who are going to an accredited medical school and passing boards obviously but there’s other things that we can incorporate landbased healing the whole idea that strong spiritual connectedness to place is a healing opportunity that we’re not actively pursuing in most medical
Schools we need to incorporate ceremony and language and not just to learn how to provide ceremonies to patients we should be promoting that within our medical students and what I would Envision is having self- assessments of Wellness of medical students upon entering and then self assessment of Wellness upon graduating and it should
Improve and what if we had entire cohorts of healers Physicians and other providers who actually were healed themselves by the time they were seeing patients full-time wouldn’t that be beautiful and shouldn’t that be our goal but are we doing that now and I think about my own training and I say this a
Lot but I had to memorize the CB cycle four times right so undergraduate biochemistry in the MCAT Medical School biochemistry and step one AB boards never used it once as about as clinically useless as information can possibly be I’m an old physician I can just say the truth right it’s useless
But I didn’t get training in trauma informed care and what’s more important to be a good physician memorizing enzymes or learning how to do trauma-informed care so we’ll just fix it but we have to do it within our own system I believe we also have to incorporate traditional indigenous
Medicine not just in the US you know we didn’t draw the line between US and Canada and we have so many englishspeaking indigenous peoples now we can work collaboratively why not learn systems of healing from Hawaii or from Australia or New Zealand we need to um also have uh
Healers on faculty so medicine men medicine women traditional healers on faculty with us and another component of this is we don’t need to follow a Time bound curriculum it should be Competency Based curriculum and I’ve asked a lot of people in medical education what’s magical about four
Years and no one can give me a good answer other than well that’s the way we’ve always done it well the way way we’ve always done it has led to these disparities so that’s not good enough and it should be Competency Based not time bound and if it takes someone three
Years wonderful if it takes someone seven years who cares and I think about the training of traditional healers it might take four years it might take 10 years ultimately that’s not relevant what’s relevant is that they’re effective healers upon graduation so we can change these things if we choose to
But that’s the direction we need to go this is a picture of the oate health center it’s a new tribal facility in Rapid City South Dakota have very good friends here and family members on the board and um I know I see this and I see an indigenous school of medicine and why
Not just one of the campuses of many focusing on a healthy way of learning to be healers so I always like to end the discussions with a quote from Black Elk and he was a Lota traditional healer from the late 1800s and he met with a writer named
John neart in the early 1900s and they wrote the book called Black Elk speaks and it’s my favorite quote from him of course it was not I who cured it was the power from the outer world and the visions and ceremonies had only made me like a hole through which the power
Could come to the two-leggeds if I thought that I was doing it myself the hole would close up and no power could come through and what he’s talking about is humility and the fact that we need to maintain humility and it probably won’t surprise you but the the core value at Stanford
Medical School was not humility believe it or not but in my own experience when I see people losing their humility they lose their effectiveness in medicine if you lose your humility you lose your ability to Be an Effective healer in education if you lose your humility you
Lose your ability to teach in law enforcement if you lose your humility you lose your ability to promote Justice and that’s a basic core value of Who We Are s Lota and other indigenous populations so in my own experience as a clinician every time I walked into that
Exam room I would think what an honor that this person would allow me to be a part of their healing process in education every single student what an honor that they have allowed me to be a part of their educational process and for today looking at iher and the
Wonderful work that you’re doing here and building here I do feel deeply honored to be a part of these these important discussions and I’ll go ahead and end it there so thank you all very much so I’ll go and um see if there’s questions should we start in the room
First any questions or comments Lots online okay people want some time to think of a question in the room and I think we have um five more minutes on the webinar um the first question was really related to the and if you could please repeat it in case
They can’t hear me online but um if you um around the terminology so the question was how does the term First Nations used in Canada tie to the discussion on terminology yeah very good uh so the terminology discussion in in Canada First Nations is typically used although that’s evolved over time they
Used to say Aboriginal also in in Canada um so First Nations is the term that’s more widely accepted but now they’re even using the term indigenous more frequently but basically the indigenous peoples of what is now Canada historically were called First Nations so that’s a a unique term just across that invisible
Line between US and Canada that was drawn by the colonizers yeah I’ll keep going I like um this question um there are no medical schools for indigenous medicine because that would not allow corporations to make money so where would the funding come from for schools research if not the
Corporations that also have B Investments and farma yeah so great question so where would the money come from from the um for the indigenous School of Medicine especially if we’re not engaging particular um corporations and um this is something that could be endowed by multiple sources you know
Just like we have uh you know the Joe rich guy professor of medicine why not have a tribal named professor of medicine there are some tribes that have resources you could have a tribal chair of Medicine and are named after for particular tribes there’s also other types of fundraising opportunities grant
Opportunities um for graduate medical education there’s opportunities even through CMS and medical education so we would take advantage of all the federal sources we could but you know what’s really interesting is that there’s a lot of international interest in this as well and we would have um philanthropic opportunities above and beyond what’s
Typically used here you had a philanthropist here for the Mount Si right in the medical school so perhaps that’s these are things that we can consider as well yes I don’t it’s not a clear question yet but I’m I’m really curious hearing about this about how tribal the influence of tribal leaders
And it’s their relationship to what you’re proposing and how that could work um and also what some the variability um across tribes in terms of approaches to to Med yeah very good question so the role of tribal leaders but also the variability of traditional medicine systems in different regions so uh
Absolutely they we ideally would not have this base in just one tribal Community we would not want tribal politics to actually derail the whole opportunity so it has to have a separate governance system and there’s a model for that through ahac the American Indian higher education Consortium where
We could have more of a national consort around governance for a medical school and then absolutely we see a lot of diversity of traditional medicines across tribes and regions so we would want to incorporate uh all of that and recognize that some tribes are very open to sharing their traditional systems and
Others are not and that’s okay so I think any indigenous population that wants to have a a training module to benefit our students and future patients we would welcome that even if they’re from the outside the US I think indigenous medicine is much bigger than what we now call American Indian Alaskan
Native yeah go ahead for this wonderful thought just say what you represent oh well I’m I’m John rip I’m the dean for wellbeing and resilience great but actually I had a question about some work that I did a decade ago um we had a wonderful partnership with chesa chicken
College in North Dakota and uh in helping us start uh sort of a summer pipeline program um we sent students from here out there uh it it was a beautiful partnership and and the president of the college was very clear the goal was to train a local doctor um
And I don’t think we ever were able to accomplish that in many ways I think our people got a lot more by learning so much of this and coming back and bringing that with them learning the truth yeah what are your thought I mean you’re talking about an indigenous
School of Medicine um but you know how do how do we how do you sort of start earlier so you can get those folks really connect you know this kind of pipeline yeah very good and and I know the program you’re talking about so I know Cynthia Lindquist is the president
Of chunes CH is the the um tribal College it’s at the Spirit Lake reservation in North Dakota it’s really close to where I worked at University of North Dakota actually in Grand Forks um so absolutely the the other consideration usually when I see medical schools wanting to increase American
Indian enrollment they say okay where are the Indians with high MCAT sores you know that’s not where you start it’s got to be way Upstream from there so this is a longterm intervention this is intergenerational so we need to have better early childhood education we need
To have uh much more influence at the primary school and high school levels and have culturally relevant Premed programs and there’s a lot of University that want to partner on that and there’s certainly a network of tribal colleges that would be good to do that I think
We’ve learned a lot about uh remote education through the pandemic that’s maybe a silver lining is that we don’t have to have all the faculty all in every single location so we can centralize a lot of that effort so absolutely we have to build that pathway toward medicine and other Health
Sciences has to start very early but this is the long game I me it took generations to cause the inequities is going to take generations to fix it so it’s not going to happen in my lifetime but my goal would be that the the students we train now the Ripple effects
I’ll have across Generations will make it happen but excellent question no yes thank you for inspiring us um when we I heard think about partnership with folks like you as you represent um but that we don’t have a lot of skills specifically in indigenous health or indigenous Health res research I’m
Interested your view of what a role could be is a role more we should be focusing on Eng populations in New York state is it um we come and serve because you have questions is it that we find questions in common across different populations what is what is
Your vision of people who have some skills but not skills working with the population and can we be of service and how well a couple things um depends if you’re having more of a national Focus or Regional Focus or or mainly New York so it kind of depends on on what the the
Focus is but particularly with tribes here for example in the state of New York you know one of the things that I’ve done where I’ve worked is recognize that the tribes and the communities have their own priorities and I don’t assume that I know what they are so we’re
Actually doing a huge research project right now in the Great Plains called the Great Plains initiative where we’re working with tribes and communities to develop communitybased research priorities so an inventory of tribal research priorities so I might have my assumptions and they might be right but
We don’t know that for sure so there’s a whole process of things like key informant interviews and focus groups and and actually working in a a real meaningful way with the communities to determine what are their priorities so I don’t know that it needs to be designed
Here in this building if anything hiring indigenous faculty and research assistants who can go out into the communities and collect those data and determine what is their priority what are their priorities how would they even Define equity through a cultural lens you know so it doesn’t have to be all
Centralized in terms of priorities for research education and programming that I I would gather input from the the regional communities yeah and cultivate Champions within those communities as well I think I don’t know the only strong VOR I know we have ISO those look at hiring an indigenous Health Equity faculty
Line that would be we would love to have you help us recruit second person okay be happy to help recruit yes we have lots of uh upcoming uh PhD graduates as well so absolutely other questions there are more questions online I do think we’re
At the end of the webinar hour um so we will thank all of our um participants and listeners online and we’ll continue the conversation the right thanks very much