Editor’s note: This is the second of two articles by the author—a healthcare specialist and former facility director at the Indian Health Service.
To combat the growing epidemic of diabetes on Indian reservations, we must learn how to bridge the gulf that sometimes separates physicians who work there from individuals who have the illness. I say this with no thoughts of blame. It is simply a lesson I have learned in many years working for the Indian Health Service (IHS) and tribal organizations at the Wind River Reservation in Wyoming.
Meeting a patient for the first time, a doctor sees that the individual is overweight. Tests may also show that the patient’s blood sugar is elevated. The doctor can recommend lifestyle changes that would keep the patient healthy. But who will visit the patient’s home in coming weeks and months, get to know the family, and find out if exercise and nutrition habits are changing for the better?
Doctors who see many patients have no time to take on this role, nor do nurses, with their own heavy caseloads. My message is that collaboration between the IHS, tribal authorities and various community groups can extend and amplify the positive impact of doctors and nurses who specialize in diabetes.
At Wind River, where about 12 percent of adults have diabetes and as many as two-thirds show signs of high blood sugar, we struggled for many years to educate people on lifestyle changes. The picture improved significantly in 2009, when the Merck Foundation’s Alliance to Reduce Disparities in Diabetes started supporting our efforts with professional expertise and funding.
I’ll explain one of the pillars of this program in a moment. First, I’d like to say that in the five years we worked with the Merck Foundation’s Alliance, we observed an impact that goes beyond caring for diabetes patients. I think of it as the first green shoots of a culture of health.
I use this metaphor because some of the people who participated in the program became exercise buffs, immersing themselves in popular national fitness trends, such as Crossfit and P90X. Others started to see connections between their lifestyle choices, physical health and something resembling a spiritual sense of well-being. Participants came to understand that the benefits of a healthy lifestyle aren’t limited to warding off diabetes. The changes can also lower the risk of cancer, heart disease, and other chronic illnesses.
I mentioned a “spiritual” component, and I don’t use this word lightly. For communities grappling with historic trauma, high crime rates, domestic violence and substance abuse, as well as chronic illness, the behaviors we promote in relation to diabetes seem to enhance our collective ability to heal.
The program we developed with the Merck Foundation’s support had several components, but the cornerstone was an education program to train a corps of tribal “lay health educators.” Ultimately, these enthusiastic men and women would help doctors and health authorities spread the word about behavior change. Over a period of 12 weeks, the educators and other program staff learned about the causes and consequences of diabetes, what patients can do to “self-manage” the illness, and how to reduce risks.
Many of the lay health educators and other program staff also participated in a training program called Group Lifestyle Balance that focused on nutrition and exercise from a more practical angle. Once the training was complete, the lay educators were able to share what they learned as they visited patients’ homes, interacting with families in ways that doctors are rarely able to do.
To me, one of the great attractions of this training framework was the two-way nature of the instruction. Consultants shared technical and practical expertise relating to diabetes. And the tribal participants helped integrate cultural and traditional themes into the curriculum. Exercise routines were enriched with traditional music and games; menus were improved by adding traditional foods and cooking techniques.
In the first year of the program, only six individuals with diabetes showed up for the first self-management class. But word-of-mouth proved a powerful ally. By the end of that year, 88 tribal members had completed the classes and the numbers grew from there. The Group Lifestyle Balance classes proved even more popular. By the third program year, 136 tribal members with pre-diabetes completed the program.
In surveys and follow-up studies, we’ve seen substantial numbers of participants shift their eating habits in a healthy direction. Blood pressure readings and blood glucose levels have also improved in measurable ways, and many people who joined the Lifestyle Balance sessions were able to shed some excess pounds. Most important, we saw the green shoots I mentioned—a shift in attitudes toward simple activities that make up our daily lives.
We have seen these benefits on the ground at Wind River. We hope that the examples and lessons we’ve put together with the Merck Foundation will inspire people in other parts of the country, and that the community-based tools we describe to combat diabetes will contribute to a much larger movement toward healing and health.