Seperate and Unequal

Imagine, this in America "the Land of Plenty"...

--ryan



Indian health care: Separate, unequal
Federal care spending low, death rates high for tribes

Maxine Gould, a Navajo, and her one-month-old son, Isiah, listen
while a public health nurse advises her on child care. The health
system has decreased infant mortality but problems remain.

By Judy Nichols
The Arizona Republic
April 14, 2002

Native Americans are dying at shocking rates. Of alcoholism,
tuberculosis and diabetes. From accidents, suicide and homicide. At
rates up to seven times higher than other Americans.

In Arizona, the average age at death for Whites is 72, compared with
55 for Native Americans. That's younger than for residents of
Bangladesh.

The federal government, which promised in treaties to provide health
care for Native Americans, spends less than half as much per tribal
member as it does for programs covering other Americans. Private
health plans spend more than twice as much per person.

"If this were happening in any other part of America, there would be
Senate hearings, commissions," said Sergio Maldonado Sr., an Arapaho
who is a program coordinator in the American Indian Studies program
at Arizona State University.

"They would be asking, 'Why are these people dying? Is it the water?
The air? Anthrax? But because it's Arapaho, Sioux, the border towns
around reservations, no one blinks an eye."

Maldonado said the lack of health care and differences in life span
are a sign of continuing discrimination.

The leading causes of death for Native Americans are heart disease
and cancer, the same as for other populations. But while those rates
are closer to the norm, they are increasing as other populations are
seeing improvements.

Native Americans die in accidents at more than three times the rate
of other Americans, a fact so discouraging that federal officials
say facetiously they wish for more disease.

"We'd love to have higher cancer rates," said Alan Dellapenna,
deputy director of the Indian Health Service Office of Environmental
Health and Engineering in Rockville, Md. "That would mean young
people were living long enough to develop those kinds of diseases."


Promise made

In the early 1800s, the push for westward expansion resulted in war
between the United States and many Native American tribes. Treaties,
which stripped Native Americans of more than 400 million acres of
ancestral lands, promised health care, as well as peace.

"When people say, 'You get free health care,' I say, 'Bear sweat,' "
Maldonado said. "There's no 'Free.' Blood was spilled."

Today, the Indian Health Service, part of the U.S. Department of
Health and Human Services, provides care for about 1.5 million
Native Americans, living on or near reservations, some of the most
remote and impoverished parts of the country.

But it has never been fully funded.

This year's budget is $3.2 billion. But according to a study
conducted by a group of tribal and Indian health leaders, more than
$7 billion annually would be needed to provide care similar to that
other Americans receive. And $15 billion would be needed to add and
improve facilities to make the system equal.

The Indian Health Service spends about $1,920 per person annually.
That compares with more than $4,390 that private insurance budgets
for most Americans' health plans, or the federal government's $3,859
for Medicaid, $5,600 for Medicare and more than $5,700 that veterans
receive.

"Health care for Native people has never been a high priority
nationally," said U.S. Sen. Ben Nighthorse Campbell, R-Colo., a
Cheyenne chief and the only Native American in the Senate.
Campbell, a member of the Senate Committee on Indian Affairs, said
most Americans feel a moral debt of gratitude to veterans, but do
not understand the "unique legal, moral and historic relationship
with Indian tribes."

Funding also has suffered because of the evolving misconception of
the "rich Indian," the mistaken belief that Native Americans were
raking in money first from land and oil, and now, from casinos,
Campbell said.

"These headline-grabbing myths lead policymakers to conclude that
most Native Americans do not need federal assistance for health
care," Campbell said. "Of course, the opposite is true. The vast
majority of Native Americans remain mired in poor economic
conditions and continue to suffer from significant health problems."
Sen. Tom Daschle, D-S.D., whose state has some of the highest death
rates for Native Americans, is so concerned that he plans to request
an additional $4.4 billion for the Indian Health Service this year.
"While Congress debates how to allocate trillions of dollars,
medical treatment for American Indians and Alaska Natives is being
rationed," said Daschle, who called the situation inexcusable.
Dr. Craig Vanderwagen, chief medical officer for the health service,
acknowledges that the system is seriously flawed.

"We don't feel good about the number of patients who need care who
are rejected because their problem is not life-threatening," said
Vanderwagen, based in Rockville, Md. "It's rationing. We hold them
off until they're sick enough to meet our criteria. That's not a
good way to practice medicine. It's not the way providers like to
practice. And if I were an Indian tribal leader, I'd be frustrated."
But there is little or no support from others in Congress, said Dr.
Stephen Kunitz, a professor of community and preventive medicine at
the University of Rochester School of Medicine who worked for IHS
and has studied it for many years.

"Virtually no one has an interest in funding it except the Indians
themselves," Kunitz said.

The bulge was small at first. Just a bump, really. Sticking out near
Felipe Robles' backbone. But it grew. It grew until it was the size
of his fist. Until he had to struggle to get out of bed. Until he
couldn't stand without his carved rattlesnake-head cane.
At first, doctors thought it was cancer. They were wrong.
The disease lodged in his spine, gnawing away at his vertebra, was
something you expect to see in someone's lungs: tuberculosis.
The rate of TB in Native Americans is more than five times greater
than for other Americans.

"I got it three years ago, when I was in jail," said Robles, 46, a
Pima. "I was stuck in a cell for three days with a guy who was
coughing a lot. I finally asked him what was wrong and he told me he
had TB. I called the guards and they pulled me out of there, but I
guess it was too late."

When the lump appeared, Robles went to a clinic in Guadalupe, but
was turned away because he had no insurance. Eventually, he ended up at the Phoenix Indian Medical Center, where his name is on a growing list of patients who are closely monitored, watched each time they take their medication, for one year. Any less, and the TB might not
die, might spread to someone else.

Robles can't work any more and may need surgery to stabilize his
spine.

"I'm scared," Robles said. 'I'm afraid a slight move in the wrong
direction and I'll be paralyzed from the waist down."

For now, he spends his days reading the Bible at the Phoenix halfway
house where he lives.

"I'm not proud of my past," said Robles, who has been in prison for
drug charges. "But I'm born-again now. I'm trying to do the right
thing."

The first health care for Native Americans, provided by the U.S.
Army, was designed to protect Whites from uncontrolled epidemics of
smallpox, measles, diphtheria and malaria. The diseases, brought by
Whites, devastated the Native populations, which never had been
exposed, and threatened to boomerang into the ranks of the military
and the settlers.

Eventually, health care was taken over by the Bureau of Indian
Affairs, then moved to the U.S. Department of Health, Education and
Welfare, now Health and Human Services.


Model of efficiency

The blueprint for the Indian Health Service is seen as a model of
efficiency, studied by countries around the world. It offers cradle-
to-grave care and one-stop shopping at its hospitals, where medical,
dental, podiatry, psychiatry, optometry and even pharmacy services
are available. And its public health arm builds water and sewer
systems on far-flung reservations.

Through efforts to reduce infectious disease, increase immunizations
and improve water system, the service greatly upgraded Native
American health in the 1950s and '60s, significantly reducing infant
mortality rates and deaths from gastrointestinal diseases.
The system has been less successful dealing with behavioral health
problems like alcoholism, drug abuse and obesity.

Native Americans have the worst diabetes rates in the world, nearly
four times greater than other Americans, and the worst alcoholism
rates in the country, more than seven times greater.

"When you're dealing with these conditions - consuming food,
alcohol, tobacco - you're dealing with people's beliefs, values and
behaviors," said Kunitz, of the University of Rochester. "It's very
hard for the health system to address these as effectively as they
could address the contaminated water supply."

Some Native Americans say they must do more for themselves, eat
right, exercise more, restore balance, all teachings of their elders.
"We have a moral imperative to take care of ourselves," said
Maldonado, of ASU. "We can't point all the fingers at the Indian
Health Service."

Inequalities exist in the system, sometimes for logical reasons,
sometimes because of politics. For example, in Alaska, where it
costs more to deliver care to remote Native villages accessible only
by plane, IHS spends more than $6,080 per person annually for health
care. But in the Kayenta area of the Navajo Nation, it spends only
$766 per person.

The limited funding, isolated locations and lack of support staff
all make it difficult to recruit and retain doctors, nurses,
dentists, pharmacists and other health professionals.
Many in the system call the pay abysmal, offering examples like
ophthalmologists, who make $100,000 at IHS, but can make twice that
in private practice. And there are high vacancy rates - 17 percent
for nurses at Phoenix Indian Medical Center.

"The people who are here are not here for the money," said Dr. Ken
Steward, head of the Emergency Department at the Gallup Indian
Medical Center. "They're hardworking, conscientious. Money is a
secondary consideration."

The tight budget also forces the system to focus on primary care.
Patients needing specialists, for things like heart operations, hand
surgery and neurology, must be referred to doctors and hospitals in
the private sector. The service has limited funds for
this "contract" care, however, and the money runs out each year.
So the service often guarantees payment only for people who may die.
Others must pay for the care themselves, or qualify for Medicare,
Medicaid or other private insurance.

Lita Piffero quit worrying about her dignity long ago.
"I was down there at the clinic crying, literally begging for help,"
said Piffero, 48, who lives in Southern Bands, near Elko, Nev.
When Piffero's 14-year-old daughter hurt her foot in gym class in
November, Piffero took her to the Indian Health Service clinic near
Elko because there are no IHS hospitals in Nevada.

An X-ray revealed a deformity of the bone, Piffero said, and the
doctor recommended magnetic resonance imaging, possibly surgery,
services not available through the Indian Health Service. Piffero
was told her daughter was being referred out, but that the service
wouldn't pay for it. Piffero, who is unemployed, was told to apply
for Medicaid.

"Medicaid took the full 45 days to decide," Piffero said. "We had to
wait."

Her daughter limped through school on crutches.

When Piffero finally was approved for Medicaid, Piffero said the
private doctor refused to do the MRI, saying he would lose money on
a Medicaid patient. He referred them to Elko Hospital. Piffero said
they still are waiting for an appointment. "I worry about what else
they won't do because it's Medicaid," said Piffero, crying.

"She's only 14. She doesn't deserve to be treated any less than
anyone else. This is her foot. I don't want her to be deformed.
"It just seems like unless you're on your deathbed, you can't go for
services."

Her legs, which peek out from her traditional three-tiered calico
skirt, are wrapped in cotton stockings, but they're still cold. She
has high blood pressure and thyroid problems, but otherwise Nettie
Yazzie, 92, who lives on the Navajo reservation, is remarkably
healthy.

She gets B-12 shots from a public health nurse who visits her home,
and occasionally sees a doctor for a check-up. But she attributes
her longevity to eating lots of corn, the symbol of life for many
Native Americans, and childhood visits to medicine men who taught
her to make medicinal teas from herbs.

In fact, Native civilizations had extensive knowledge of diseases
and medicines, knowledge that has contributed to Western medicine.
And many still use a combination of Native and Western medicine.
As part of a move toward self-determination, many tribes are taking
over their own health care, running their hospitals and clinics and
deciding how to spend federal dollars.

More than 40 percent of the system now is run by tribes or the non-
profit groups they have hired. In February, the Navajo Nation
rejected a takeover of its $500 million system, but is considering
running the programs in three small communities.

"IHS is going to continue to exist," the University of Rochester's
Kunitz said. "What is unclear is whether it will increasingly be a
pass-through program or continue to be a provider of services."
Either way, more money is needed.

Although the Native American population served by the Indian Health
Service is growing by about 2 percent each year, and medical costs
are rising at about 10 to 12 percent a year, the agency's budget has
remained nearly flat, which means services fall farther and farther
behind.

"If Congress in its wisdom, or malevolence, or thoughtlessness holds
funding constant or at a 1 to 2 percent increase, things will get
worse," Kunitz said.

Reach the reporter at judy.nichols@arizona republic.com or at 602-
444-8577.