USD School of Medicine Education Efforts
to Address Native American Health Care in South Dakota
By Gerald Yutrzenka
Associate Professor, Director of Minority Affairs
Division of Basic Biomedical Sciences, School of Medicine
University of South Dakota
Vermillion, SD 57069
Paper presented at the First
International Conference on Race: Racial Reconciliation
October 1-4, 2003, University of Mississippi, USA
Introduction:
Since 1907 The University of South Dakota School of Medicine (USDSM) has
played a significant role in addressing the health care needs of the people
of South Dakota. To that end USDSM, operating as a two year medical school
until 1974 when it was granted the authority to award the four year MD
degree, is a community-based medical school with an emphasis on Family
Practice and primary care medicine 1. USDSM's mission
specifically directs it to "...provide the opportunity for South
Dakota residents to receive a quality broad-based medical education..."
and "...encourage graduates to serve people living in medically underserved
areas of South Dakota..." 2.
Over the years the medical school has evolved into a very comprehensive
healthcare training institution and is comprised of the MD granting program,
the Ph.D. level graduate program in the Division of Basic Biomedical Sciences
and, finally, the Division of Health Sciences which encompasses the Master's
degree programs in Physician Assistant Studies, Physical Therapy, and
Occupational Therapy. A recent University-wide reorganization effort has
also brought into the Division of Health Sciences the Bachelor's degree
granting programs in Medical Technology, Alcohol and Drug Abuse Studies,
and Social Work along with the Associates degree granting programs in
Dental Hygiene and Nursing.
USDSM has made efforts to have a recognizable presence throughout much
of South Dakota. For example, the medical school has four campuses located
at Vermillion, Yankton, Sioux Falls and Rapid City and the Nursing program
has satellite locations in Pierre, Watertown, and Rapid City. Some of
the efforts to spread the healthcare training opportunities throughout
the state have been due, in part, to recognition that many of the students
being served are non-traditional and may, in fact, be significantly place
bound. Additionally there is a desire for our students to gain practical
training experience and familiarity with the diversity of populations
and practice sites in the rural and frontier environment that defines
the majority of the state. In recognition of the community-based nature
of the medical school, the practicing health care professionals located
throughout the state are often called upon to provide significant clinical
experiences for the various health care training programs within the School
of Medicine.
Native Americans in South Dakota:
The School of Medicine, with its mission-directed mandate to serve the
people of South Dakota, has been actively involved in forming effective
collaborations with Native American and non-Native groups in attempting
to address the health care issues of the Native American people. This
effort may be viewed as just one of a series of positive and significant
steps that can go forward in attempting to address some of the past injustices
that have been perpetrated upon the Native America peoples of South Dakota
and to help these Nations work to establish a healthier way of life.
There are nine Indian reservations located throughout South Dakota with the Lake Traverse and the Standing Rock reservations also extending into North Dakota (Figure 1). According to the US Census Bureau 3 and the South Dakota KIDS COUNT project 4 there are about 62,000 Native Americans in South Dakota with about 42,500 living on one of the nine Indian reservations within the state. (Figure 2) Native Americans comprise about 8.3 % of the total South Dakota population (754,384) 3.
Figure1: Indian Reservations in South Dakota
Figure 2: Percent Native American by South Dakota County
Importantly, the Native American population on the reservations tends to be relatively young (Figure 3). For example, on the Pine Ridge Indian Reservation the median age for Shannon county is in the range of 20.6- 26.6 years of age and for Jackson county it is 28.3 - 34 years of age. Similar statistics are found for Corson, (Standing Rock Indian Reservation) and Dewey and Ziebach counties (Cheyenne River Indian Reservation). Other reservations tend to have median ages in the range of 34.5-38.6 years of age.
Figure 3: Median Age by South Dakota County
In addition to a population that is relatively young, the Native Americans on the reservations experience some of the highest levels of poverty (Figure 4).
Figure 4: Percent Poverty Level by County
The elements of geography, age, poverty and culture are all significant issues that may contribute to health disparities and must be taken into account when attempting to define possible remedies to these health care concerns.
Indian Health Service:
The Indian Health Service (IHS) is the primary source of health care for
Native Americans 5. As delineated in Table 1, the
existence of the Indian Health Service is, ultimately, a result of the
Federal government's obligation to provide health care to Native Americans
as stated in numerous treaties that have been enacted between individual,
sovereign, Indian Nations and the Federal government 6
(Table 1).
Table1. Time line of Significant Treaties Enacted between Indian Tribes
and the Federal Government
1803 - Lewis and Clark expedition
1851- 1st Ft Laramie Treaty
1851- Mendota/Traverse des Sioux Treaty
1858- Yankton Nakota Treaty
1863- Forfeiture Act:
1868- 2nd Ft. Laramie Treaty- established Great Sioux Nation
1889- Sioux Agreement- established reservations in SD
Over the years, health care for Native Americans has been administered and provided by a variety of governmental agencies including the War Department (prior to 1849), the Department of the Interior (1850-1954) and, since 1954, by the Indian Health Service as a component of the Department of Health and Human Services 5, 6. Enrolled members of federally recognized tribes and their descendents are eligible for health care benefits provided by the Indian Health Service 7.
The Indian Health Service acts as the primary Federal entity tasked with addressing health care needs of Native Americans. In this regard the Indian Health Service provides a comprehensive health service delivery system, addresses and works to eliminate health disparities and, importantly, promotes significant tribal involvement in designing and managing programs which the tribes may utilize to effectively address their health care needs. The Indian Health Services works with over 560 Federally recognized tribes and provides health care for approximately 1.6 million Native Americans (representing about 55 % of the 2.4 Native Americans/Alaskan Natives indicated by the 2000 census) living on or near reservations and an additional 150,000 Native Americans living within urban areas and utilizing the Urban Indian Health facilities and programs 5.
To help carry out this effort, The Indian Health Service is divided into 12 administrative units (Area Offices), encompassing some 35 states, each with an Area director and with a responsibility to address the health care needs of the Native American peoples residing within those geographic designations 5. The 12 individual Area Offices have responsibility for some 49 hospitals, 214 health centers, 280 health stations and satellite clinics and approximately 15, 000 employees including physicians, nurses, dentists, pharmacists engineers and sanitarians. The Aberdeen Area, encompassing the states of South Dakota, North Dakota, Iowa and Nebraska, has responsibility for providing health care to over 104,000 Native Americans 8. To do this the Aberdeen Area utilizes eight hospitals, five health centers, two school stations and several satellite clinics along with Urban Indian Health facilities.
The Indian Health Service has significantly addressed health issues related to tuberculosis, sanitation, clean water and maternal mortality and has now set it's sights on means to address significant Native American health disparities in areas such as; diabetes, obesity, heart disease, cancer, alcohol/drug abuse and accidental death 9. Significant vacancy rates among health care personnel coupled with a significant shortfall in Federal spending directed towards Native American health care are both issues which significantly hamper the Indian Health Service's efforts to effectively address these health disparities. According to a July 2003 report of the U.S. Commission on Civil Rights 10, per capita spending for IHS was a modest $1,914 as compared to per capita spending for Medicaid ($3,803), the Veterans Administration ($5,214) and Medicare ($ 5,915).
USDSM Efforts to Enhance Native American Participation in Health Care
Careers:
As an educational institution, USDSM has often taken a lead role in collaborating
with South Dakota tribes and other entities to attempt to address South
Dakota Native American healthcare issues. For example, beginning in 1990
the USD School of Medicine, through a formal medical student transfer
agreement, partnered with the Indians into Medicine (INMED) 11
program at the University of North Dakota School of Medicine to allow
two INMED medical students, each year, to transfer to USDSM as third year
medical students and complete their medical training. This agreement provides
additional educational capacity which in turn allows INMED to increase
the number of Native American M.D. graduates from a previous maximum of
five/year to a current level of seven/year. To date, USDSM has graduated
21 Native American students with 14 of these having affiliations with
the INMED program. An additional 5 INMED students are currently enrolled
in the USD School of Medicine. Since 1973, INMED has trained over 20%
of the Native American physicians in the United States.
USDSM has been creative in devising innovative means by which to enhance the "pipeline" for the recruitment of Native American students into careers in the health care professions. As an example, by virtue of the established association with the INMED program, USDSM has recently launched the Native American Scholars Program (NASP) which is designed to be a comprehensive program of academic, career and personal guidance available to those Native American undergraduate students at USD who are especially interested in pursuing careers in the health care professions.
Another creative effort has been the establishment of the South Dakota Science Education Enhancement Program (SD-SEEP) 12 which has been continuously funded, since 1994, under the Precollege Initiative for Biomedical Research Institutions sponsored by the Howard Hughes Medical Institute 13. SD-SEEP has evolved into a family of science-based education opportunities under the direction of three USDSM faculty members; Barbara Goodman, Ph.D., Robert Noiva, Ph.D. and Gerald Yutrzenka, Ph.D. SD-SEEP is designed to influence the capability for South Dakota middle school and high school students (with a special emphasis on disadvantaged students) to enhance their science skills and to learn more about possible careers in health care professions.
The overarching goal of SD-SEEP is to enhance science education opportunities
for secondary school students and this has been accomplished through development
of several different components of the SD-SEEP family. These components
included:
1) Science and Technology Enhancement Program (STEP); 2) the Research
Apprentice Program (RAP); 3) Gene Explorers; 4) the Lawrence Brothers
Science Camp; and, 5) the "Science on the Move" mobile science
laboratory. By design STEP, RAP and Gene Explorers specifically enabled
significant outreach toward Native American high school students, many
of whom have stated interest in pursuing careers in science/health care.
The Science and Technology Enhancement Program (STEP) directed by Dr Gerald Yutrzenka, provides the opportunity for up to 12 Native American high school students each summer to interact with and become more knowledgeable of the range of healthcare professions. For four weeks during the summer up to six EXPLORE students are able to gain a new understanding of the scope of health care professions and, importantly, are reminded of the vital role that science and the rest of their high school education plays in providing the academic preparation needed in order to be able to successfully pursue those health care careers. These science linkages and the enhanced knowledge of the health professions are reinforced through a variety of hands-on experiences and field trips to relevant science and health profession training programs as well as by shadowing opportunities within hospitals and clinics and, especially, within health care programs that serve Native Americans. Returning APPRENTICE students (up to six each summer) spend four weeks in rotations within several hospital departments and, beginning in the summer of 2003, receive training as Certified Nurse Assistants.
As a result of the summer experience the majority of the STEP students have acknowledged gaining a broader understanding of and appreciation for the scope of possible careers in the health profession. Importantly, the students also have gained a better sense of the academic preparation needed (both in high school and in college) in order to adequately prepare themselves to enter those careers. Figure 5 demonstrates the scope of stated career interests of students following completion of STEP.
Figure 5: Health Care Career Interests of STEP Participants
To date, we are aware that 22 of the 59 total STEP students (38%) have entered post-secondary education programs with many of them working towards health care careers (Figure 6). It should be pointed out that of these 59 students, ten students are still finishing their high school education and the majority of these students are also expected to proceed into post-secondary institutions following high school graduation.
Figure 6: Post-Secondary Education of STEP Participants: 1994-2004
The Research Apprentice Program (RAP), directed by Dr. Barbara Goodman, is expressly designed to engage Native American high school students in a seven-week summer mentored biomedical research experiences with the goal of attracting them toward pursuit of careers in medicine and/or biomedical research. RAP students learn basic laboratory techniques and participate in real research projects as part of their mentor's research team. Many students have elected to return in subsequent summers and have usually returned to the same research team. Students are encouraged to present their research at local as well as regional science conferences.
Encouragingly, the majority of RAP students have pursued post-secondary education (49/70 = 70 %) (Figure 7) although it is somewhat unclear as to how many will ultimately pursue careers in medicine, biomedical research or other healthcare professions.
Figure 7: Post-Secondary Education of RAP Participants
Gene Explorers, under the direction of Dr Robert Noiva, is a week long summer camp that provides middle school and high school students and their teachers with hands-on experience in molecular biology and relevant laboratory techniques. Topics explored include DNA purification, DNA fingerprinting, and bacteria culture among others. The teacher training sessions also prepares the teachers to be able to devise new science curricula incorporating the molecular biology techniques that have been learned and, importantly, allows the teacher to request use of the traveling science lab kits that have been especially developed to support Gene Explorers activities in their own classrooms.
Dr. Noiva, has specifically taken the Gene Explorers curriculum to a number of high schools that serve a significant number of Native American students and for several years has presented the Gene Explorers week long workshop to Native American students participating in the Four Directions Summer Research Program at Harvard Medical School 14.
Conclusion:
In the aggregate, then, the University of South Dakota School of Medicine
has been actively engaged in significant efforts directed towards encouraging
South Dakota Native Americans to pursue careers in medicine and other
health care professions. It is the hope that an increased participation
within these professions will not only enhance health care capacity but,
importantly, will serve to promote and sustain self-determination efforts
in effectively addressing health care issues of importance to the tribes
and tribal members. In addition, enhancing higher education possibilities
is vitally important in fostering an environment which strives to increase
our understanding of one another, allows for enhanced participation by
all members, values a true collaboration of efforts in addressing issues
of importance, and, above all, promotes both the spirit and the substance
of reconciliation for South Dakota's Native American peoples.
Acknowledgements:
This work was supported, in part, by a grant (PRCOL #51000124) from the
Howard Hughes Medical Institute Precollege Initiative for Biomedical Research
Institutions and by the USDSM Office of Minority Affairs. The valuable
assistance of Agnese Muravska is greatly appreciated.
Bibliography
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