ࡱ> %` }bjbj"x"x *@@z'<<<rD82N<DDL"CCCCCCC$0EhGC</././.C<<CC3C3C3/.<<CC3/.CC3C3#B|<<C Žq5/BCD0DDB&H1&H$C&H<C($VC3'*CC2DD/./././.DPdr.<<<< Reclaiming Native Womens Health through Community By Kristina Ackley, AV Abstract: Getting communities healthy is a major challenge facing Indian Country. Tribes and organizations that serve Indian people have struggled to alleviate disproportionate rates of health-related problems, both on the reservation and in urban areas. This case study introduces students to the ways health concerns of Native women are inextricably tied to colonialism, particularly in the area of prenatal and well-child care. Tribal health clinics working closely with community organizations can provide a promising way to improve Native womens health and empower tribes. Students will analyze a fictional meeting in which several characters identify health disparities and envision ways to work more closely together. They then critically evaluate possible outcomes of the meeting including challenges and successes, and suggest areas for further research. Grace is a new womens health nurse practitioner at the tribal clinic. Getting ready for an important meeting, she reflects on how excited she is to be back home and working for her Tribe, particularly since she has spent a great deal of time away from her community because of her schooling. She feels a bit disconnected and doesnt really know many people very well. Already she feels overwhelmed. There are few comprehensive reviews of Native womens health, so Grace was a little unprepared for some of the health problems she has seen in the clinic. The statistics for Native Americans of both genders generally illustrate higher rates of death than for the general population in many areas, particularly diabetes and cardiovascular disease. When gender is taken into account, the differences between Native Americans and the general population are even more stark. Native women are second only to African American women in terms of death rates due to homicide and drug abuse. The infant mortality rate for Natives residing within the 35 state Indian Health Service (IHS) areas is 22% higher than the overall U.S. rate (9.3 vs. 7.6 per 1000 live births). Factors related to this increased mortality include Native womens lower rates of prenatal care in the first trimester (18% lower than for all races combined), higher rates of alcohol consumption during pregnancy (3 times higher than for all races combined), and higher rates of tobacco use during pregnancy (1.5 times higher than for all races combined) (Walters and Simoni, 2002). A significant challenge for Grace has been in reconciling her Western medical training with tribal peoples different ideas of health. Western medicine today typically concentrates on defining and treating illness, disease, and pathology. Health for many American medical professionals is defined by the absence of these deviances from a normal or efficient condition. Health for Native Americans, in contrast, is often dependent on the harmony of many different factors: the individual, family, landscape, spirituality, politics, and culture. In her short time back, Grace has learned to patiently listen to the women she sees, for what others may dismiss as just small talk may uncover the interconnection between mind, body, and community in ways that illuminate her patients condition. This was made starkly clear to Grace with one early encounter she had with an elder patient. The woman talked about how she used to gather herbs with her grandmother, but how difficult it seemed to be for her own grandchildren to accompany her lately. They were missing experiencing the plants with all their senses: touch, smell, sight, taste, and hearing. The plants needed to be talked and listened to, the woman said. She worried that things were out of balance. Her youngest grandchild, age 7, she continued, had difficulties at school so the grandmother was going to make a more concerted effort to take her granddaughter to gather herbs. The elder was sure that this would help both the plants and her granddaughter. Something clicked in Graces mind. The child the woman mentioned had been diagnosed with attention deficit/hyperactivity disorder (AD/HD). Recent studies have shown that children exposed to outdoor settings can concentrate for longer periods of time and that a range of AD/HD symptoms are reduced (Kuo and Taylor, 2004). This brief interaction underscored for Grace how interconnected things were and how she would think differently about how tribal people viewed health. Talk about things out of balance, Grace thought to herself, as she tried to prepare the speakerphone for her meeting. Some of the fish which we used to eat are now too polluted with mercury for pregnant women and children to safely eat more than a few times a week. Grace is torn between adequately warning her patients but fears turning them away from the fish her people have traditionally relied on for centuries. Some studies have shown that the health benefits of fish clearly outweigh the dangers, and her people have typically relied on fish as the mainstay of a healthy diet. Balance! Well, her next meeting will deal with her main concern: prenatal care and well child care in the community, particularly with the high number of pregnant/mothering teens that she has seen. Grace has ideas about implementing programs that will help these women, but needs the help of others in the tribal community. A few weeks ago Grace scheduled this brainstorming meeting to include Dorothy Jones, Sofia Smith, and Charlotte Adams. They plan to meet in a conference room in the tribal clinic. At the last minute, Charlotte cant make the meeting in person, but she is willing to be included in a conference call. This leads to increasingly desperate attempts on the part of Grace to get the speakerphone to work. In the meantime, her other two guests arrive. Dorothy is the first to walk in the door. She is a tribal health care administrator who has been with the Tribe for over 20 years. Grace reports to her, though the relationship is more of an indirect supervision than a daily one. Dorothy is very knowledgeable about tribal issues as well as how to work with the state and federal government for grants. She has a great deal of experience working with IHS and has experience in administering federal programs for the Tribe: her Tribe maintains a 638 contract with the IHS through the Indian Self-Determination Act (P.L. 93-638). Dorothy recollects that tribal health services have changed a lot since they relied mainly on the Indian Health Service (IHS) for direct delivery of services. Several types of relationships have evolved during her career in tribal health because of the unique relationship tribes have with the federal government. The IHS has provided health care to Indians in different ways. Direct service delivery by the Bureau of Indian Affairs (BIA) was the oldest form of service provision. This came about through the minimal health services provided through the federal trust relationship and sometimes as a treaty right since the mid-nineteenth century by the BIA. The IHS was eventually created in 1955 to provide services through federally administered programs within what is now the U.S. Department of Health and Human Services. The IHS also runs urban Native health clinics, though they account for less than 1 per cent of the budget. A second method for providing health services came about under the Indian Self-Determination and Education Assistance Act of 1975 (ISDEAA) that began the process of self-determination leading to government-to-government relationships in the 1990s and beyond. Under ISDEAA, tribes contracted with the IHS to actually transfer administrative control, operation, and funding to the tribe. This is called 638 contracting. Dorothy remembers that change it enabled her as a tribal member to get a job working for her Tribe in health care. Without contracting, healthcare professionals were mainly non-Indians who transferred in from other jobs across the country. Even with self-determination there were still problemsfunding was never enough and they did have to work with federal administrative regulations. But at least the Tribe had authority for local hiring and the methods of managing and administering programs. Dorothy also thought about the newer self-governance amendments. She had heard that they strengthened self determination by having tribes assume full administration and operation of their own health services including the budget and participation in a negotiated rulemaking process. A 1988 amendment to the ISDEAA created the first Tribal Self-Governance Demonstration Project. In 1992 amendments to the Indian Health Care Improvement Act of 1976 (IHCIA) extended the self-governance demonstration project to the IHS and its programs. Then in 1994 the success of the self-governance project led Congress to create a permanent self-governance authority for tribes. Finally, in 2000 Congress passed the Tribal Self-Governance Amendments of 2000, amending the ISDEAA, which specifically authorized the IHS to make the tribal self-governance program permanent. (PL 106-260) Dorothy didnt know too much about this newer method of service delivery, but she thinks it might be a good alternative, and it seems to represent the trend of tribes taking over the administration of most federal programs for tribal health care. Still, problems exist with tribal governments administering their health programs without adequate funding. Tribal governments who administer health programs tend to have more costs than the federal government, and appropriations from the federal government have not met the need. It is estimated that funding is less than 60% of the total need. (Holt) In fact, funding for health programs for Native people had plummeted in the late twentieth century and it does not look as though funds will meet the need in the near future. In addition, urban health programs for Native Americans had been recently targeted for massive cuts or total elimination. Furthermore, funds are not distributed equitably among Indian Health Service regions, all leading to diminished access and quality of care. Nor do all Indians enjoy equal access to IHS services: federally approved competition for limited funds favors the large and the strong over the weak (Kunitz, 1996). Dorothy often struggles to administer the health programs in ways that meet the needs of her community, given the dwindling funds and narrowly defined programs of the federal government. Feeling that she only understands a small fraction of the policies of the Indian Health Service, Grace is glad to have Dorothy, who brings years of experience and expertise in dealing with both the Tribal and federal governments, involved. Grace has also come across the compact alternative on her own. She has learned from a native healthcare professional from Alaska about the Self-Governance Program in the IHS that was authorized by Congress in 2000. She had checked it out on the Internet and found that many tribes have already moved to implement this new model. They negotiate written compacts that set forth the terms of the relationship between the tribe and the Secretary of the Department of Health and Human Services that can only be amended by mutual agreement of the parties (Title 25 Chapter 14 Subchapter 11 Part E 45aaa-3). The legislation shows how the negotiated self-governance compacts transfer the funding associated with programs, functions, services and activities assumed by the tribes from area and headquarters budgets directly to the tribal government. What this means is the tribes have the money and the authority to develop their own health services and programs. By 2006, there were 72 compacts and 93 funding agreements. Overall, the number of tribes in the Tribal Self-Governance Program was 322. ( HYPERLINK "http://www.ihs.gov/NonMedicalPrograms/SelfGovernance" www.ihs.gov/NonMedicalPrograms/SelfGovernance). Still with all these changes, Congress does not appropriate enough funds to cover the services offered. Besides the Self-Governance alternative, Grace was intrigued by the work of Sofia, who is a midwife who moved to the community 7 years ago and is married to a local tribal member. She is enrolled in another tribe in the state, but has family in the local tribal community. Since she has been living in the community, she has founded a womens health non-profit called The Womens Place, as well as running a midwifery practice. Her group has been very involved in sex education efforts in the Tribal middle and high school, providing information about birth control and abstinence programs. She advocates for the recovery of traditional midwifery knowledge from Indigenous traditions as a way for healing. She is a proponent of breast feeding and home births. Sofia has been a vocal critic of the IHS because she views the agency at its worst as a tool of colonialism and genocide, but at the very least as a burdensome bureaucracy distanced from the people. From her conversations with Sofia and other women in the community, Grace has learned why Sofia was distrustful of the role the IHS had played historically in Native American communities. Health care has reflected the colonized nature of the relationship of Native Americans to the United States. This is particularly true in the case of sterilization of Indian women without fully informed consent which occurred in 1960s-1970s, Sofia told Grace during one of their first meetings. The majority of Indians living on reservations were using the medical services of the IHS as their primary caregiver then. IHS began providing family planning services for Native Americans in 1965 under the authority of the Department of Health, Education, and Welfare, and the Public Health Service. IHS targeted American Indians for family planning in the 1970s because of their high birth rate. Family planning services typically provide a range of services, including information on birth control. Providing patients with information on contraceptives and helping them decide which one is right for them is a right that only works when the women and men are free to choose which contraceptive will work for their needs, particularly since sterilization is virtually irreversible. It soon became clear that the IHS was implementing troubling practices that were too widespread to be dismissed as anything but a structural, or systemic problem. Because of concerns of both Native and non-Native patients, activists, doctors and hospital personnel, the Senate Interior Subcommittee on Indian Affairs requested the Government Accounting Office (GAO) to conduct an investigation on American Indian sterilization in 1975. A year later, the GAO released a report that did not verify that the IHS had performed coerced sterilizations, but it did state that the IHS had not followed the necessary regulations and that the informed consent forms did not adhere to standards set by the Department of Health, Education, and Welfare. Among the violations were sterilizations performed on women under the age of 21. The GAO could not find evidence that informed consent was presented orally to these patients (many of the forms just had a signature), and there was no statement on the form that the patients had to right to refuse sterilization procedures. These conclusions, while far short of what many activists were arguing, were nonetheless damning (Ralstin-Lewis, 2005). Some have argued that the IHS sterilized between 25-50 percent of Native American women between 1970-1976 (Lawrence, 2000). The reasons given by doctors were often economic and social in nature and not medically warranted. Given the concerns over informed consent, this was a significant violation of trust on the part of medical practitioner to patient, not to mention the colonial implications of a society that routinely limits the ability of reproduction to those who are from certain racial, economic, or social groups. The legacy of distrust left by these policies has been profound. It led to many tribal communities asserting a more active critique of the top-down ways that federal government policies could be implemented. Family planning has also become a more sensitive issue for many tribal communities, fraught with historical trauma. In her own way, Grace has tried to focus on prenatal and well-child care as a way of contributing to the overall recovery of a community damaged by colonialism. There is ample evidence of the link between discrimination and poor health, particularly in the effects of psychological distress, depressive symptoms, anxiety, poor physical health, and high blood pressure. Recent evidence suggests that a combination of oppression and the chronic strains associated with multiple forms of discrimination may lead to more cumulative physical and mental health symptoms among people of color (Walters and Simoni, 2002). Sofias group has been active in trying to study the link of historical trauma and health outcomes as it relates to womens health. The final person invited to the meeting is Charlotte, a non-Native medical doctor and administrator with the federal government. She has ideas about implementing federal programs to lower the number of teenage births in the community and ways to expand the prenatal health programs. Charlotte is very interested in ways to better utilize the resources in the tribal community. Community-based public health interventions that target families have had success in many Native American communities (Teufel-Shone, et. al, 2005). Tribes have implemented programs in parenting skills and childcare, and have made it a priority that health clinics offer prenatal and well-child preventive care. In addition, some tribal communities have sought to reclaim and restore traditional knowledge of health practices to the community by identifying individuals who hold that knowledge and supporting the training of others. Western medical care has also come to embrace some of what used to be called alternative medicine only a few years ago and is now studying the efficacy of herbs, the mind-body connection, and the effect the physical environment has on individuals. All of this means there is an opportunity to work more closely with tribes, Charlotte thinks, even though she hasnt been able to facilitate this yet. Grace has had some concerns about how best to use the federal programs. She agrees with Charlotte that community-based public health organizations can be used to alleviate health concerns, but goes a step farther than Charlotte. Grace also thinks that tribal organizations, whether they are funded by the tribe or not, can be used to empower the people as a whole. For many tribes, negative health outcomes are not alleviated when they merely administer health programs that are designed by outsiders, such as the federal government. Yet this is the model in which the federal government typically implements health program on tribal reservations as well as in urban communities with high Native American populations. Though these programs may be well intentioned and work well in mainstream communities, it less certain whether programs designed and administered in a top-down fashion, without significant input by the community, are of much use to tribal communities. For many Native people, who have been historically displaced by colonialism and had their control over their own affairs limited or taken away from them, this lack of control can be further dispiriting. Further, for tribal communities, many of which rely on historical and cultural collective processes, Western medicines focus on the individual may not address the root of the health problem. What is important from a tribal mental health or public health perspective is collective agency the community doing the work themselves, from designing the public health approach to its implementation (Kral and Idlout, 2006). Of course, that is why the Self-Governance compacts are becoming more popular because they allow tribes to design their own healthcare programs without the top-down designations or budgetary restrictions of the direct delivery programs. Grace is very concerned, however, that these tribal programs are not adequately funded and that the tribes must assume part of the costs. Grace expects Sofia to provide a critique of top-down knowledge transfer from governments and agencies to communities. She has heard Sofia argue that knowledge based on this type of transfer from outsider to tribe is historically and experientially incongruent. It excludes local knowledge. However, Grace has found Dorothy to be a moderating voice because she believes the federal government has resources (both financial and intellectual) that their Tribe can take advantage of. So the challenge for Grace has become, how do you make sure that local knowledge is validated and affirmed? She is keenly aware of the importance of knowledge transfer going in the other direction. Of course, self-determination at the community level is not simple. Internal disagreements about specific goals, people, and methods occur. But in many tribal communities there is a focus on sustaining community-developed action over time. The tool for community wellness lies in respecting and listening to the collective wisdom of the community. With all this in mind, Grace starts the meeting. MEETING: A little flustered because of technical problems with the telephone call (and because the room that they were originally supposed to be in was double-booked), Grace starts the meeting. Okay, everyone, Id like to thank you for coming to the meeting. I have lots of ideas and I know you have ideas, so I thought if we all came together we could come up with some great things. Dr. Adams, thank you especially for putting up with the telephone equipment problems. No, problem, comes Dr. Charlotte Adams disembodied voice from the speakerphone. Im really interested in letting you know more about our teenage abstinence program and well baby care program. Id just like to say that I have known Dr. Adams since she gave me information on federal funding for training tribal members in the health care profession over 7 years ago, Grace says. You know Dorothy, of course, and Sofia is here from The Womens Place. Dr. Adams. Weve never actually met. Sofia smiles. No, but Ive heard of your work and have been really interested in it. Please, call me Charlotte, she says. And yes, Dorothy and I have worked on several grants for over the past years. Well, youve all read my initial thoughts on what Im seeing as areas of concern in prenatal care and well-child care. Grace begins. Native American women are less likely than the dominant population to have regular prenatal care and that may be a partial reason why the infant mortality rate is 22% higher. Ive been concerned that I havent seen as many of the women as regularly as I thought I would, given that prenatal care is routinely covered under tribal health care. Im not sure thats really the definition of the problem, Grace, Sofia breaks in. In most cases, normal pregnancy progresses very well without overt medical intervention. What women need are support and places to talk about issues with trained people in a culturally appropriate environment. Thats what we do at The Womens Place. But we have a large number of women who dont go to either place, the tribal clinic or The Womens Place. Shouldnt we be concerned about getting them to go somewhere? Dorothy asks. Our incidence of miscarriage and stillbirths is higher than the area non-Native community in the state. Thats what I think we need to focus on. Id also prefer that they go to the tribal clinic, given those statistics. But prenatal care has been made more available to women from a variety of racial, cultural, and class backgrounds and still the infant mortality rate is higher in many Native communities, Sofia argued. A study that some people are working on for the Seattle Indian Health Board is looking at the ways racism affects the miscarriage rate of Native women, for example. Its had to see why women are not participating and whether its because of lack of access to medical care, or knowledge, or something else. They may not need the clinic. Of course, youd say that. You advocate for home births. I think its easier for women to go to the tribal health care center or local hospital, Dorothy says. Uh, what do you think, Dr. Adams I mean, Charlotte, Grace says. I think both Dorothy and Sofia have good points. Wellwe do have a federal program especially for teens that provides funding for a drop-in clinic of some sort. Once a month, you can bring in your baby to get checked or, if you are pregnant we can provide someone who will do a weight check, vitals, give you some info on nutrition, that sort of thing. We had some success in an immigrant Latino community downstate with that program last year. The medical staff that took part found that it really helped them connect with the women and they had a better sense of what was happening with the women and children. But we tried something similar three years ago, dont you remember? Dorothy asks. We had very low attendance, and the ones who did come tended to already be coming to the tribal clinic anyway. Tribal health administrators cut that program because of what they felt was that duplication of services. Oh, right, Charlotte said. Ive got so many women of color health organizations that I work with, its hard to remember. We do that sort of thing at the Womens Place, Sofia said. Sometimes we get lots of people in. But also, I think you have to realize that a number of women still associate the federal government and IHS with colonial policies, particularly forced sterilization. It wasnt so many years ago that doctors were telling Native women that they shouldnt have children because they werent educated enough, rich enough, or they already had too many children. So I can see why some women avoid the tribal health clinic. You have a point, Sofia, Dorothy said thoughtfully. But I dont know how many women think about it explicitly in that way. But, she says before Sofia can argue against that, one thing Ive been really intrigued by is your groups community involvement. I see you at all the festivals and powwows and health fairs and whatnot. You go into the schools if needed. I wonder if theres a way we can use your knowledge of that to our benefit. We might be able to access federal funding for something with like that, right Charlotte? Yes, Charlotte said. Although it would have to have a tribal health clinic component to be considered. Thats whats always stopped us before because we arent, strictly speaking, a tribal health organization, Sofia said. Our group also goes into Metro City to work with tribal women there. We have a large number of tribal people in urban areas that we would like to reach, even though Metro City is an hour and a half away. Maybe we could link together somehow, Grace said, excited again. I think that sounds promising. Id just like to make sure that The Womens Place is not taken over by the Tribal health clinic. Weve worked really hard to make it non-political, and not just seen as an arm of the tribe, but as a place for tribal women in this community. Its for them and the community. Sofia said. But youre missing out on some funding and resources they can offer. My main concern is that we reach the broadest number of people and make the program work for the Tribe, Dorothy answered. You both just said the same thing, Grace said. And I agree. I want this to be an effort for the tribal community. Lets start thinking of some ways to do that. References Bayne-Smith, M.A., Graham, Y.J. & Guttmacher, S. (2005). Community-Based Health Organizations: Advocating for Improved Health. San Francisco: Jossey-Bass. Dodgson, J. E. and Struthers, R. (2005) Indigenous Womens Voices: Marginalization and Health. Journal of Transcultural Nursing. 16(4), 339-46. Holt, L (2007) Testimony of Linda Holt, Chairperson, Northwest Portland Area Indian Health Board and Suquamish Tribal Council Member, before: U.S. Senate Finance Committee. Retrieved 8/04-07 from: www.senate.gov/~finance/hearings/testimony/2007test/032207testlh.pdf Indian Health Service. (1998) Trends in Indian Health, 1997-1998. U.S. Department of Health and Human Services, Indian Health Service, Office of Public Health. Indian Health Service. (2006) Facts on Indian Health Disparities. U.S. Department of Health and Human Services, Indian Health Service, Office of Public Health. Kauffman, J. A. & Joseph-Fox, Y. K. (1996) American Indian and Alaska Native Women. In M. Baye-Smith (Ed.) Race, Gender, and Health. London: Sage Publications. Kral, M. J. & Idlout, L. (2007) Community Wellness and Control in the Canadian Arctic: Collective Agency as Subjective Well-Being. In L. Kirmayer and G. Valaskakis (Eds.) Healing Traditions: the Mental Health of Canadian Aboriginal Peoples. Vancouver: University of British Columbia Press. Kunitz, S. J. (1996) The History and Politics of U.S. Health care Policy for American Indians and Alaskan Natives. American Journal of Public Health, 86:10, 1464-1473. Lawrence, J. (2000) The Indian Health Service and the Sterilization of Native American Women. American Indian Quarterly. 24:3, 400-419. Long, C. R. & Curry, M. A. (1998) Living in Two Worlds: Native American Women and Prenatal Care. Health Care for Women International. 19, 205-215. Moffitt, P. M (2004) Colonization: a Health Determinant for Pregnant Dogrib Women. Journal of Transcultural Nursing. 15(4): 323-30. Ralstin-Lewis, D. Marie. (2005) The Continuing Struggle against Genocide: Indigenous Womens Reproductive Rights. Wicazo Sa Review. 20.1, 71-95. Teufel-Shone, N. I. et. al. (2005) Family Cohesion and Conflict in an American Indian Community. American Journal of Health and Behavior. 29(5), 413-422. U.S. Census Bureau (2002). The American Indian and Alaska Native Population: 2000, Census 2000 Brief. (C2KBR/01-15). U.S. Department of Agriculture, Food and Nutrition Service, Office of Analysis, Nutrition and Evaluation (2002). The Characteristics of Native American WIC Participants, On and Off Reservations. Nutrition Assistance Program Report Series, NO. WIC-02-NAM. Walters, K. L. & Simoni, J. M. (2002) Reconceptualizing Native Womens Health: an Indigenist Stress-Coping Model. American Journal of Public Health. 92:4, 520-524. Websites Facts on Indian Health Disparities  HYPERLINK "http://info.ihs.gov/Files/DisparitiesFacts-Jan2006.pdf" http://info.ihs.gov/Files/DisparitiesFacts-Jan2006.pdf Natality and Infant/Mortality Statistics (Chart 3.8 and Table 3.8)  HYPERLINK "http://www.ihs.gov/PublicInfo/Publications/trends98/front.pdf" http://www.ihs.gov/PublicInfo/Publications/trends98/front.pdf The Health of Seattle Women  HYPERLINK "http://www.seattle.gov/womenscommission/Documents/SeattleWomenDataSummary2005.pdf " http://www.seattle.gov/womenscommission/Documents/SeattleWomenDataSummary2005.pdf  Copyright held by AV. Please use appropriate attribution when using and quoting this case. For further information on the Native Cases Project see  HYPERLINK "www.evergreen.edu/tribal/cases" www.evergreen.edu/tribal/cases.  Dorothy has found a 2002 speech on the internet by Dr. Charles Grim, director of IHS in which he stated that tribal governments have 3 choices of how to have health care provided. 1) Directly by the IHS as was done in the past, 2) To contract with the IHS for those programs or services they wish to provide for their own members. And 3) For tribes to assume, through compacts, the total operation and control over their health systems from the IHS. (Grimm, Healing Our Spirit, Worldwide Conference, (http://www.ihs.gov/PublicInfo/PublicAffairs/Director/index.asp)  In 2007 as many as 70% of Americans identifying as American Indians and Alaska Natives live in urban areas. 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Tribes and Y888dd2Yddd888YN2cYc88dY18N2d2d7dN2Ydd87YddX28dY8dd1Cdd8cd2ddd8NY22oN8dYN2ddd1 T  @E@ <L'3organizations that serve Indian people have struggled to alldNddd8Nd78dcN28dd82NXNYY1Cdd8dd2dYdc7Y2ddYY2N8Ndcd8Yd28d2c88T ! @E@ L'3eviate disproportionate rates YX8d8Y2c8NdNdcdN88ddd7Y2Nd7YN2 T  @E@ L'3`of healthd82dYd78dTT  @E@ L'3P-CT  ^! @E@ NL'3related problems, both on the reservation and in urban areas. This case study NX7d8Yd2dNdd7XN22dd8d2dd28dY2NYNXNYd77dd2ddd28d2dMddd2dNYdN22od8N2YdNY2M8dcY2 Td !@E@YL'3introduces students to the ways health concerns of Native women are inextricably tied to 8d8NdddXYN2M8ddYd8N18d28cY2dYN2dYd87d2YddYYNdN2c82d88YY2cYd2dNY28dXY8N7Ydd8Y188Xd28d2 Tt@E@q1L'3colonialism, particularly in the area of prenatalYd8dd8c88N12ddN88Yc8dN7X28d28dY2dMYd1d82dNYdd8c8T@E@q L'3` and well1ddd2Y88TT@E@qL'3P-CT "@E@q"L'3child care. Tribal health clinics Yc78d2YdNY22oN8cd82dYd78d2Y77d8YN1 TD!@E@WTL&" WMFC ?'3working closely with community organizations can provide a promising way to improve dNY8dd2Y8cNY8Y278d2Ycdd88Y2dNddd8Nd88dcN2Xdd2dNdY8dY2c2dNd8N8dd1dY28d28dNdYY2 TXu!h@E@=WL'3Native women s health and empower tribes. Students will analyze a fictional meeting in d88YY2dYdCN2dYd78d1ddd2YddYN28N8dXN22d8cdYd8N28782dcd8YNY2d188X88cdd82YY88dd18d2 TDpN@E@#)L'3which several characters identify health d8Yd2NYYYMd82YddNdX8YMN28dYd788Y2cXd88d2TPp^ N@E@#+L'3disparities and envision ways to work more d8NdcN778YN2ddd2YdX7N8dd2dYN28c2dNY2dNY2 TpV!4@E@ [L'3closely together. They then critically evaluate possible outcomes of the meeting including Y8dNX8Y28ddX7dYN22odYY28cYd2YN788Yc88Y1YYd8dd7Y2ddMN8d8Y2dc8YdYN2d828cY2YY88dd18dY8dc7dd2 T<@E@BL'3challenges and successes, and suggest areas for further research. Ydd88YdcYN2cdd2NdYYYNNXM22ddd2NdddYM82dNYdN28cN27dN8dYN2NXNYcNYd22TT<@E@L'3P i % TT 6@E@L'3P [ T@E@6L'3Grace is a new women s health nurse practitioner at thCYYY28N1Y2cY2eYdCN2dYY88d2dcCNX2dCYY7878ddYC1Y828dT0!@E@&L'3e tribal clinic. Getting ready for an Y18B8dY81Y88c8Y22Y877dd2CYYdd2BdB2Yd2 TP7!@E@VL'3important meeting, she reflects on how excited she is to be back home and working for 8ddC8Yd82YY88dd21NdY2BYB8YY8N2dd2dc2YdY88Yd2NcY28N28d2cY2dXYd2ddY2Yde2dCd8dd2BdC2 Td!@E@YL'3her Tribe, particularly since she has spent a great deal of time away from her community dYC2zC8cY22cYC78Yd8XC8d2M7dYY2NdY2dYN1NdYd82Y2dBYY72dYY82dB288Y2YYd2BCe3dYC2Ydde88d1 TP@E@l+L'3because of her schooling. She feels a bit ddYYYdNY2dB2cYC2NYddd78dc22odY2BYY8N2Y1d882dTD @E@l)L'3isconnected and doesn t really know many 8MYdddXY8Yd2Ydd2ddXNdC82BYY78d2cdd3Ydd3 Tt~@E@R1L'3people very well. Already she feels overwhelmed. dYdd8Y2dXCd1Y88228CXYcd2NdY2BYY8N2cdYCdY8Yd22TT~@E@RL'3P [ TT6d@E@8L'3P [ TDj J@E@TL'3There are few comprehensive reviews of Native women s health, so Grace was a little zdYCY2YBY2BY2YedCYdYdN8dY2CYc8YN2dB2Y88dY2eYdCN2dYY88d22Nd2CXXY2YN2Y287878X2 T,P0@E@PL'3unprepared for some of the health problems she has seen in the clinic. The statidddCYdYBYd2BdC2NdY2dB29dY2dYY78d2dBdd8YN2NdY2dYN2NYYd28d17dY2Y88c8Y22zcY2N8X88TPA!0@E@ L'3`stics for M88YN2AdC2 Td61!@E@YL'3Native Americans of both genders generally illustrate higher rates of death than for the Y88dY2ZC8YYdN2dB2dd7d2dYddYCN2dXdYCY78d2788dM7CY8Y2c8ddYC1BY8YN2dB2dYY8c28dYd2B&" WMFC dC28dY1 Td!@E@YL'3general population in many areas, particularly diabetes and cardiovascular disease. When dYdYCX82ddcd8Y78dd28d2Ydd2YCYXN22cYC78Yd8XC8d2c8YdY7YN2Ydd1YYCd8dcYNYd7YC2d8NXYNY21dYd3 T@E@DL'3gender is taken into account, the differences between Native AmericadYddYC28N18YcYd28d8d2XYYcdd8228dY2c8BCYCYdYXN2dY7YYd2Y88dX2YC8YYTs!@E@L'3tns and the general dN1Ydd28dY2dYdXCY81 T4s @E@QL'3population are even more stark. Native women are second only to African American dddd8Y78dd2XCY2YdYd2dCY2N8YCd22X87dY2eYd2YCY2NYYddd2dc8d28d2BC8YYc2YC8YYd1 T\! @E@ XL'3women in terms of death rates due to homicide and drug abuse. The infant mortality rate eYd28d28YCN2eB2dYY8d2CY8YN2dcY28d1de8Y8dY2Ycd2dCdd2YddNX22zdY28dBYd81dC8Y878d2CX7Y2 T !@E@h!DL'3for Natives residing within the 35 state Indian Health Service (IHS)BdC2Y88dYN2BYN8d8dd278c8d28dY2dd2M8X8Y2Cdc8Yd2XY88d2oXCd8YY1CCoCT !!@E@h!L'3x areas is 22% higher 2YCXYN27N2dd2d8ddXC2 TX!=z"@E@N"WL'3than the overall U.S. rate (9.3 vs. 7.6 per 1000 live births). Factors related to this 8dYd28dY2dcXCY7822o22CY8X2Cd2d2dN22d2d1dYC2dddd278cY2d8B8dNC22oXY8dCN1CY7Y8Yc28d28d8N1 TL" `#@E@4#UL'3increased mortality include Native women s lower rates of prenatal care in the first 8dYCXYNYd2dC8X888d18dY7ddY2Y88dY1eYdCN28dYC2CY7YN2dB2dCYdY7Y82YXBY28d28dY2B7CN81 Tf#F$@E@$?L'3trimester (18% lower than for all races combined), higher rates8C8YN8YC1Ccd28dYC28cYd2BdC2Y881CYXYN2Ydd8dYdC22d8ddYC1CX7YNTf#F!F$@E@$L'3| of alcohol consumption 2dB2Y8Yddd72YddNdd88dd2 T@L$,%@E@%SL'3during pregnancy (3 times higher than for all races combined), and higher rates of ddC8dd2dCYcdYdYd2Cd278YN2d8ddYC18dXd2BdC2Y882BYYXN2Ydd8dYdC22Ydd2d8ddYC1CY8YN2dB1 Td2%"&@E@%YL'3tobacco use during pregnancy (1.5 times higher than for all races combined) (Walters and 8ddYYYd2dMY1ddC8dd2dCYcdYdYd2Cd2d277YN2d8ddYC28dYd2BdC2Y881BYYYN2Ydd8dYdC2CY88YCM2Ydd2 T& &@E@&L'3lSimoni, 2002). o8dd822ddedC22TT & &@E@ &L'3P [ TT&6'@E@'L'3P [ TP'_(@E@(+L'3A significant challenge for Grace has been 2N8dd8B8YYc82YdY78YddY2AdC2CYYY2dYM2dYYd2TT`'+!(@E@`(,L'3in reconciling her Western medical training 8d2BYXddY878dd2dYC1YN8YCd2Zd8YY818CX8d8cd2 T4()@E@~)QL'3with tribal people s different ideas of health. Western medicine today typically 88d28B8dY82cYdd8YCN2c8BBYCYd818dYYN2dA2dYY88d22YN8YCd2Yd8Y8cY28ddYd28dc7YY88d1 Td)!*@E@d*YL'3concentrates on defining and treating illness, disease, and patholog & WMFCy.  Health for many YddYYd7CY8XM2dd2dYB8d8dd1Ydd28CXY88dd1888cYNN22d7NYXNY22Ydd2dY8cd8ddd22YYY78dY2BdC2Yde2 TH*_v+@E@J+*L'3American medical professionals is defined YC8YYd2Yd8YX82dCdBXNN8ddY7N28N2cYB8dYd2TD`*W v+@E@`J+)L'3by the absence of these deviances from a dd28cY2YdNYdYY2dA28dYNY2dYc8XdYYN2BCd2Y3 % !'3T<+ ,@E@s,(L 2222222222222222222222222222222222222222T| +;,@E@ s,L\ 22222222" '% Ld?,;H,?,` !??% ( % TT<+,@E@<s,L'3P [RpY@Times New RomanA*0( / =!"!$% 0X\(i0X\X\0X\Gz Times ew Roman0lN0dv% Rp@Times New Roman +8 30554 ,+05,,055tkT0Gz Times ew Roman!8/b1$0lN0dv% % %  % !'3% TT,-@E@,LP16" % T,; _-@E@:-cL'3 Copyright held by The Evergreen State College. Please use appropriate attribution when using and *oSTS8.ST.*TJ-T)TS*eTJ*eTJ7T8JIT)].J.J*oS..JTJ***].JJAI*SAJ*JST7ST8.J.J)J..8.TT..ST)yTIT)TA.ST*IST) Td-%.@E@-KL'3quoting this case. For further information on the Native Cases Project see TST..ST*.T.@*JIAJ**\T7*7T8-TJ7).T7T8J..TT*SS*.TJ)yJ..TJ*oJ@JA*]7S/JJ.*AJJ)RpY@Times New Roman<52dpˮ0-- 0-Gz Times ew Roman\b00lN0dv% %  T&d-!.@E@&-L'3www.evergreen.edu/tribal/casesyxy*ITJ7S8JIT*ITT..8-TJ..JJAJA' % Ld& .!.& .Z!??% (  TT!d-!.@E@!-L'3P.*TT!d-!.@E@!-L'3P K TT#.'.@E@.L'3P L% 636'36'6636'36'6636'36'6636'36'6636'36'6636'36'6636'36'6636'36'6636'36'6 6 36'36' 6  6 36'36' 6  6 36'36' 6  6 36'36' 6  6 36'36' 6 636'36'6636'36'6636'36'6636'36'66~36'~36'66}36'}36'66|36'|36'66{36'{36'66z36'z36'66y36'y36'66x36'x36'66w36'w36'66v36'v36'66u36'u36'66t36't36'66s36's36'66r36'r36'66q36'q36'6 6 p36'p36' 6 !!6!o36'o36'!6!!""6"n36'n36'"6""##6#m36'm36'#6##$$6$l36'l36'$6$$%%6%k36'k36'%6%%  $4."System-@Times New Roman-  2 ?4" ,"4' 2 y4" ,"4', 2 1 2  ,''@Times New Roman-@Times New Roman--- V2 ry24"Reclaiming Native Womens Health through Community             -,"4- 2 iB1'- 2 rH4" @Times New Roman- 2 y4" -2 y4"By  2 4"  2 y4" M2 y,4"Kristina Ackley, AV       2 4" - 2 y4" -2 y4"Abstract - 2 4": 2 4" @Times New Roman-2 yS4"Getting communities healthy is a major challenge facing Indian Country. Tribes and t     e2 y<4"organizations that serve Indian people have struggled to all82 4"eviate disproportionate rates 2 y 4"of health 2 4"-2 N4"related problems, both on the reservation and in urban areas. This case study    2 *yY4"introduces students to the ways health concerns of Native women are inextricably tied to g    U2 =y14"colonialism, particularly in the area of prenataly 2 = 4" and well  2 =4"->2 ="4"child care. Tribal health clinics  2 OyT4"working closely with community organizations can provide a promising way to improve      2 byW4"Native womens health and empower tribes. Students will analyze a fictional meeting in        I2 ty)4"which several characters identify health e L2 t+4"disparities and envision ways to work more e    2 y[4"closely together. They then critically evaluate possible outcomes of the meeting including      n2 yB4"challenges and successes, and suggest areas for further research.   2 #4" - 2 y4" \2 y64"Grace is a new womens health nurse practitioner at th    D2 &4"e tribal clinic. Getting ready for an  2 yV4"important meeting, she reflects on how excited she is to be back home and working for       2 yY4"her Tribe, particularly since she has spent a great deal of time away from her community g      L2 y+4"because of her schooling. She feels a bit de I2 )4"isconnected and doesnt really know many    U2 y14"people very well. Already she feels overwhelmed. a     2 4"  2 y4" 2 ,yT4"There are few comprehensive reviews of Native womens health, so Grace was a little          2 ?yP4"unprepared for some of the health problems she has seen in the clinic. The stati   2 ?u 4"stics for 2 QyY4"Native Americans of both genders generally illustrate higher rates of death than for the g    2 dyY4"general population in many areas, particularly diabetes and cardiovascular disease. When g q2 vyD4"gender is taken into account, the differences between Native America   (2 v84"ns and the general 2 yQ4"population are even more stark. Native women are second only to African American       2 yX4"women in terms of death rates due to homicide and drug abuse. The infant mortality rate       q2 yD4"for Natives residing within the 35 state Indian Health Service (IHS)      +2 ,4" areas is 22% higher  2 yW4"than the overall U.S. rate (9.3 vs. 7.6 per 1000 live births). Factors related to this    2 yU4"increased mortality include Native womens lower rates of prenatal care in the first s      j2 y?4"trimester (18% lower than for all races combined), higher rates   /2  4" of alcohol consumption  2 yS4"during pregnancy (3 times higher than for all races combined), and higher rates of t    2 yY4"tobacco use during pregnancy (1.5 times higher than for all races combined) (Walters and g   "2 y4"Simoni, 2002).   2 4"  2 /y4" L2 Ay+4"A significant challenge for Grace has been e  M2 A,4"in reconciling her Western medical training   2 SyQ4"with tribal peoples different ideas of health. Western medicine today typically f   2 fyY4"concentrates on defining and treating illness, disease, and pathology. Health for many g   J2 xy*4"American medical professionals is defined  I2 x)4"by the absence of these deviances from a  -,"4C2 y( 2  '- @ !y-- 2 :4" @Times New Roman-@Times New Roman----,"4- 2 y1'-2 }c4" Copyright held by AV. Please use appropriate attribution when using and    |2 yK4"quoting this case. For further information on the Native Cases Project see s   @Times New Roman- - 82 4"www.evergreen.edu/tribal/cases - @ !-   2 4". 2 4"  2 y4" -""44""44""44""44""44""44""44""44!!44!!44!!44!!44!!33!!33!!33!!33!!33!!33!!33!!33!!33  33  33  33  22  22  22  22  22  22  22  22  222222222211՜.+,D՜.+,` hp  )AVg5x' $Title: Native Womens Health Issues References Websites Title Headings 8@ _PID_HLINKSAQ Rhttp://www.seattle.gov/womenscommission/Documents/SeattleWomenDataSummary2005.pdfE\>http://www.ihs.gov/PublicInfo/Publications/trends98/front.pdfn77http://info.ihs.gov/Files/DisparitiesFacts-Jan2006.pdfF5http://www.ihs.gov/NonMedicalPrograms/SelfGovernanceMR../../../../../../../DOCUME~1/SMITHB/LOCALS~1/TEMP/www.evergreen.edu/tribal/cases  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOQRSTUVWYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|~Root Entry F2ŽqData P1TableXJHWordDocument*SummaryInformation(}DocumentSummaryInformation8CompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q