It’s an extraordinary moment in public healthcare, as countries across the world react to the coronavirus pandemic. While governments and medical researchers work to decide how to respond, it’s already clear that vulnerable communities will be disproportionately affected by the spread of the virus.

A first of its kind PhD program in Indigenous Health at the University of North Dakota (UND) will equip a new generation of researchers, advocates and physicians to serve those in Native American communities who suffer worse health outcomes than the general population, especially in times of crisis.

The program will bring together study of the cultural aspects of Native American reservation populations with training in the medical sciences, with the aim of better evaluation and health care policymaking for indigenous communities.

While leaders of tribal reservations throughout the United States work to secure resources to combat the effects of the coronavirus, the UND program hopes to build longer term relationships with the Centers for Disease Control and Prevention (CDC) and the medical community to tackle disparities in health outcomes and ensure that Native American populations aren’t left behind.

Evidence-based practices: whose evidence?

Dr Donald Warne is the Associate Dean and Director of the Indians into Medicine program at UND – which has graduated 240 American Indian physicians since 1973 – and will now head up the new PhD program in Indigenous Health.

One of the challenges of current health policy for Native American populations, says Warne, is its focus on evidence-based practice.

“I understand the idea of evidence-based practices,” explained Warne. “The question I always have is whose evidence is it? If we have well-studied populations in Boston or New York or Atlanta, does that apply in [South Dakota reservation] Pine Ridge?”

He continued: “Unfortunately in policy we tend to take a one-size-fits-all approach, so you have a good evidence-based practice in a city and you just assume it's going to work on a reservation, which quite often it does not . . . I wish policymakers understood that better.”

The first cohort of PhD students will work with federal and tribal leaders to design evidence-based programming that actually makes sense for reservation communities.

“What I've observed in my own career is that the researchers don't even know the right questions to ask and make assumptions that are incorrect. They don't involve the community in driving the research agenda. I see that as a big missing piece in academics”, explained Warne.

This issue with one-size-fits-all policy came to the fore with the CDC’s evidence-based practices around tobacco use.

Many state and federal grants stipulate tobacco-free workplaces and environments. But at first the CDC failed to distinguish between commercial tobacco and traditional tobacco –– a blend of herbs used by Northern Plain tribes in traditional ceremonies.

The CDC’s tobacco-free stipulations work, Warne says, “when you're talking about non-Indian people in New York City. But when you're saying ‘tobacco-free environment’ in a reservation in the Northern Plains, what you're saying is ‘prayer free environment.’”

Traditional communities were ineligible for critical funding until community leaders were able to persuade the CDC that there was a difference between traditional and commercial tobacco.

“They don't know our culture, they don't know our history, so they take these broad brushstrokes in policy that are actually detrimental”, said Warne.

The new Indigenous Health program will involve stakeholders from the Indian Health Service – the Federal Agency that provides health services to American Indians and Alaska Natives – as well as the governments of the tribes themselves. By engaging all these levels of government, the hope is that policy makers will better understand the cultural needs of the reservations long before inept policy is rolled out.

Practice-based evidence

While evidence-based practices often fail to address the context-specific needs of tribal populations, there’s also a dearth of what Warne calls “practice-based evidence”: effective health practices in these communities that haven’t been formally evaluated and therefore lack sufficient evidence to convince policy makers to invest in them. Without official data collection and reporting, funding and support for these practices may never materialise.

Warne gives the example of the traditional ceremonies of the Oglala Lakota tribe from Pine Ridge, South Dakota.

As a participant in the ceremonies himself and a medical doctor, Warne swears by the health benefits incurred by young people in his community who take part in rituals in which they connect to their heritage and traditions and learn a new language.

He thinks of this “cultural connectedness” as powerful medicine. But “we’re not measuring cortisol levels or blood pressure levels or blood sugar . . . I don't have laboratory data that's pre- and post- Sun Dance, but I know it's effective because I participate in it myself and I observe it.”

These experiences have convinced Warne that the public health system should be doing whatever it can to promote traditional practices and cultural connectedness among reservation communities. But evaluation and data-collection has to come first. “The policymakers will say, ‘Well, show me the data’”, he says.

A main focus of the Indigenous Health PhD program at UND, therefore, will be to initiate large scale evaluations of community-based programs that are known by the communities themselves to be beneficial to health outcomes.

Warne explains, “It has to be community-driven and there has to be a sense of community-ownership over any public health intervention, otherwise it's just something that the government does to people, as opposed to working collaboratively to develop programs with populations.”

Long term bridge building

The fact that public health programs don’t often work for American Indian populations presents an unprecedented challenge during the health crisis caused by the coronavirus.

Warne hopes that the slower, long-term work of the PhD program and those it graduates will help prevent the inequalities that these communities currently suffer when crises such as these arise in future.

“The time to develop community champions and community engagement is long before there's a crisis . . . those relationships should have been built over decades, not waiting until there's a crisis to try to identify ways to engage a community.”

Warne is among many who have called for an equitable distribution of public health resources during this crisis, to try to mitigate the disastrous consequences on populations with less infrastructure like reservation communities.

Investing in smarter policy during ordinary times is the only hope he has for protecting those who’ve been chronically underserved during moments of crisis.

– Megan Dent

(Photo by Andrew James on Unsplash)