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

Part two

WASHINGTON - The need for a behavioral health initiative preoccupied Dr. Charles Grim ''from day one when I entered the directorship,'' said the former head of the IHS.

After years of focus on acute health care and the reduction of infectious disease factors in Indian country, the IHS itself was poised for a transition toward health promotion, disease prevention and chronic disease management. ''Some of the times you kind of lighten up your effort a little on that when acute care is beating down your door,'' Grim said.

But no more. Acute care cases, denoting patients with severe but short-term symptoms (in layman's terms, a patient suffers but recovers), have been crowded on the IHS medical charts by chronic care cases, denoting patients with persistent or recurring symptoms (a patient suffers less at first perhaps, but recovery may be long-term and less certain). And chronic health problems, with cardiovascular disease, diabetes, mental health disorders, alcoholism, substance abuse and certain forms of cancer leading the list for Indian country, often have roots in behavior, environment or both.

In the context of a war-constrained federal budget, collaboration made sense budget-wise for the IHS on many fronts. But it made especial sense in the campaign for behavioral health. By encouraging tribes and tribal programs to graft evidence-based approaches onto the organic growth of tradition and culture in Native communities as a foundation for behavioral health, the IHS has mobilized local buy-in as a change agent in health-challenged environments. Though many American Indian and Alaska Native communities still have no membership gyms of the kind found in cities and towns of any size, a growing number of them do have a cadre of healthy lifestyle leaders, so to speak, and more resources to work with, all courtesy of several partnerships that got their start on Grim's watch:

*Healthy Native Communities Fellowships is an effort of the IHS and tribes to establish a sustainable approach to behavioral health. Volunteers from within a community, 95 percent of them with no health care experience but from all walks of life, complete training sessions that qualify them to advocate and to organize for healthier behavior in their communities. If healthier choices are an all-out embattled matter in modern times, Native communities are beginning to get their foot soldiers on the ground.

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*The formation of Boys and Girls Clubs in Indian country, centers of wholesome activity and support groups against peer pressure, exceeded Grim's goal of 200 on his watch.

*The ''Just Move It'' campaign, gone national in 2005, has become something of a phenomenon in 2007, aided by Nike Corp.'s manufacture and marketing of an athletic shoe geared toward Native peoples. The shoe got mixed reviews; largely, it seemed due to the perceptions around identifying apparel by race or ethnicity. But once the initial reaction spent itself, the shoe remained at wholesale prices with profits reinvested in Just Move It communities, Grim said. The collaboration between IHS, Nike and the National Indian Health Board aims to get Native people more physically active through local wellness and fitness programs, among them basketball camps, nutrition classes, health education fairs, wellness walks, a variety of benefit runs and special recognitions staring with a ''100 mile club.'' The program's Web site boasts 17,255 participants through 300 partners, impressive enough given the overall Native U.S. population. But the slogan and goal of Just Move It is to get a million Native people moving, or almost one in three.

During Grim's tenure, the IHS either forged or enhanced productive further partnerships with the Veterans Administration (given the eligibilities of Native veterans in both systems); with the federal health authorities in Canada, Mexico, Australia and New Zealand (based on the commonalities of Native health issues in these Native-populous nations); with Johns Hopkins and Harvard universities (family programs, research and looking ''strategically forward, with much forethought, to kind of help our national system,'' Grim said); with the Mayo Clinic (clinical care, research and the training of health care professionals); and with others, including tribes, tribal programs and Native organizations too numerous to name.

Acute care continues every day, everywhere within the IHS system; it remains the source of extraordinary effort and fulfillment, most of the budget, many complaints, and an unremitting effort by the IHS to improve its own performance and the public's understanding. But also within the IHS, behavioral health professionals began to be present, for possible intervention, at patient in-take - a chronic care specialist keeping watch on the acute care episode, sign of the sea-change Grim oversaw. ''It's trying to pull back and make whole again our health care system,'' he said.

(Continued in part three)