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Looking back on Dr. Charles Grim's tenure as IHS director

Part one

WASHINGTON - From his new assignment as a policy adviser to the IHS in Washington at the W.W. Hastings Indian Health Service Hospital in Oklahoma, Dr. Charles W. Grim can look back on a successful tenure during four years as the IHS director.

The needs of his immediate and extended family prevented him from fulfilling an uncontested second posting in Washington. When word that he was withdrawing his nomination got around, a comment often encountered in Indian country was that in tight-fisted times for the overall federal budget, the IHS budget increased every year on Grim's watch.

That was a good thing. But with his encyclopedic grasp of the health challenges before Indian country, Grim also took the job knowing full well that no amount of funding alone or, for that matter, health care services alone, would adequately advance the health profile of Indian country.

Transition was in the Washington air, with policy heavyweights everywhere talking up the need to eliminate ''stovepiping'' of government services into one delivery channel and expand ''siloed agencies'' from their lone preoccupations to the full range of services intended by Congress. The background to all that was a war-straitened federal budget that had many saying ''there's not enough money to do our job,'' Grim said.

But from his experience in Indian country, Grim knew that another transition was coming in Indian health care. The IHS and other federal agencies had been on a war footing against infectious disease in Indian country for years, and their successes have raised the life expectancy of American Indians by nine years. But now more than a third of the demands on health facilities in Indian country trace back to mental health problems, alcoholism and substance abuse. Chronic conditions of the U.S. population at large, especially cardiovascular disease and diabetes with their high-cost treatments, have assumed an ominous presence in Indian country.

As an IHS annual report from 2005 states it, ''The IHS public health functions that were effective in eliminating certain infectious diseases, improving maternal and child health, and increasing access to clean water and sanitation are not as effective in addressing health problems that are behavioral in nature, which are the primary factors in the current mortality rates. The prevalence of diabetes, in particular, has reached epidemic proportions in Indian communities. Changing behaviors and lifestyles and promoting good health and a healthy environment are critical to improving the health of American Indians and Alaska Natives.''

An agenda like that would take more than funding for direct health care. It would take a network of outside partners still to be woven, early interventions, and a show of accountability to clients and Congress that demonstrated the effectiveness of IHS funding.

Grim began close to home, reorganizing performance management within the IHS. The process yielded goals and objectives for programs, and management could ''cascade those down'' to departments and employees, producing a high-performance work force that has scored well on the Program Assessment Rating Tool that President George W. Bush, a business major, has instituted to justify federal funding decisions.

He also embarked on a project to computerize the health care records of the IHS. ''I'm very proud of that,'' he said of the modest-sounding accomplishment, aware of efficiency gains a patient may never suspect. For instance, drop-down menus on IHS computers now remind physicians of when a client was last seen, what his or her blood pressure was, whether blood sugar levels should be checked, and so forth. The time saved against a paper-based records system means physicians can see more patients in a day; and more importantly, those patients can be assured no routine indicator will be overlooked.

While Grim was establishing a model of more and better health care within the IHS, he was reaching beyond it on many fronts. ''We really, really focused on partnerships while I was in there,'' he said.

(Continued in part two)