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Treatment with respect to traditions

BILLINGS, Mont. – Stephanie Iron Shooter was stuck.

One of her clients in a breast health screening program had cancer, but Iron Shooter couldn’t tell her.

Doing so would violate cultural norms so innate to Iron Shooter that it is difficult for her to explain them.

For one thing, the woman with cancer was her elder. For another, she was a member of a different American Indian tribe.

“There’s a way to deliver that news,” said Iron Shooter, who now works for the Montana-Wyoming Tribal Leaders Council in Billings. “It’s a big deal.”

Had she given the diagnosis the way it is done in Western medicine, Iron Shooter might have been run out of town and, because she would no longer be welcome there, lose her job.

But if she delivered the news the way her American Indian upbringing had taught her, she would be violating privacy rules held in high regard by the mainstream medical community.

In the end, Iron Shooter went with her heritage and asked a female elder in her family, who belonged to the same tribe as the woman with cancer, to help her explain the diagnosis.

Her dilemma encapsulates the friction felt in health care between Montana’s majority white population and its largest minority. About six percent of Montanans are American Indians.

“It is one of the places cultures intersect – the hospital,” said the Rev. Terry Hollister, a chaplain at St. Vincent Healthcare.

As a population, American Indians are in significantly poorer health than their white counterparts in Montana and the nation.

People from Native cultures live an average of 2.4 fewer years than do Americans of all other races. Their disease rates, especially for diabetes, are significantly higher, as is their infant mortality rate.

American Indians are much more likely to die from diabetes, accidents, homicide, suicide and alcoholism than are other Americans, partly because they are half as likely as people in other populations to receive needed medical care.

“The health disparities are absolutely critical,” said Deborah Peters, executive director of the Northwest Research and Education Institute. “We shouldn’t be sleeping at night because they are so great.”

Plenty of medical organizations, including Billings Clinic and St. Vincent Healthcare, recognize the severity of the problems facing tribal members and are striving to meet their needs, medically and culturally.

Both hospitals permit traditional rituals, such as smudging – the practice of cleansing or purifying one’s person by burning an herb such as sage, sweetgrass or cedar – in patient rooms. The hospitals also maintain teams of employees that advocate for and educate others about American Indian issues, and they work with tribal leaders to take health education to reservation communities.

But just because health care is available does not mean people can or will use it. And the reasons that American Indians lag behind other races in just about every measure of health cut much deeper than access, although access is certainly a barrier to care.

Poverty, mistrust, cultural differences and what could be considered a population-wide case of depression or post-traumatic stress disorder all factor into the equation, according to American Indians who work in medical fields in and around Billings.

It’s an old story but one still worth telling, said Marjorie Bear Don’t Walk, executive director of the Indian Health Board.

“These people who think historical trauma doesn’t count, they’re contributing to it,” Bear Don’t Walk said. “They’re perpetuating it.”

American Indian cultures were upended and their societal structures dealt near-fatal blows when white settlers arrived, and the fallout is still felt today, Bear Don’t Walk and others said.

“There is something that happens to people when they are traumatized,” she said. “There is something that happens to generation after generation of people who are traumatized and their complete way of life changed that makes them more susceptible.

“If you feel bad about yourself and have felt bad about yourself your whole life, you’re not going to take care of yourself,” Bear Don’t Walk said.

It is also difficult for people in fractured or marginalized societies to advocate for themselves, said Anna Whiting Sorrell, who took over as director of the state Department of Public Health and Human Services in January.

“I really have my feet in two different worlds,” said Sorrell, who is a member of the Confederated Salish and Kootenai Tribes and frequently goes home to the Flathead Indian Reservation.

“Poor health and people dying young are accepted in our culture. That’s really, really disturbing. Now that I spend time in another world, here in Helena, it’s not as accepted.”

Many American Indians receive health care at IHS clinics and hospitals, but the federal government funds IHS programs at about 60 percent of need, Sorrell said. That means some people do not get enough medical attention.

“When you live in a place where the health care isn’t acceptable, that’s your reality,” she said. “You don’t expect anything else. People have come to accept what’s available to them.”

Sorrell said it wasn’t until this year, when she went to a dentist on her state health insurance plan that she realized that she’d never had her teeth cleaned, despite having seen IHS dentists. “You can’t want something you don’t even know is there,” she said.

Even American Indians who know they need and deserve health care sometimes choose not to get it because of their people’s rocky history with the white medical establishment.

Two or three generations ago, when American Indians first saw white doctors, they were sometimes treated poorly or left in the dark about what was being done to them.

Some older women screened through Montana Breast and Cervical Health Program do not know if their uteruses are intact, said Kassie Runsabove, a preventive-health specialist at RiverStone Health.

Carol Whiteman, a member of the Crow Indian Tribe, grew up hearing stories about women who were sterilized by government doctors and other tribal members who were given experimental medical treatments.

“Some of that historical background the elders remember is very traumatic,” said Diana Sorensen, a Hidatsa Indian who works as a grants assistant at St. Vincent Healthcare. “White medicine has not always been a good thing for them.”

“As time goes on, that is changing,” Sorensen said. “But among the elder people, those memories are quite fresh. It was maybe their grandparents. They remember these things as if it did happen to them.”

Poverty, another effect of cultural upheaval, also affects a population’s health.

“We have a higher rate of poverty on reservations, much higher than other populations,” said Charlene Johnson, a supervisor at the IHS headquarters in Billings.

One-fourth of American Indians living on reservations subsist at or below the federal poverty level, partly because unemployment rates are sky-high.

In this region, reservation communities report 77 percent unemployment, Johnson said.

That leaves families without resources to buy healthy foods, and poor eating habits have contributed to the population’s health problems, especially obesity and diabetes, said Dr. Neil Sun Rhodes, a physician in the Montana Family Medicine Residency at RiverStone Health.

“As a health care provider, you treat the symptoms, but it’s really an employment problem,” Sun Rhodes said. “I can’t say, ‘Here’s a prescription for a job.’”

Whether they know it or not, Sun Rhodes and another doctor in the residency, Jenni Bigback, have key parts to play in the effort to improve American Indian health. Both young doctors are American Indians who grew up on Montana reservations and plan to work in Native communities after finishing their training.

“All these places I’ve been have need,” Sun Rhodes said of the IHS clinics where he has already worked. “I wish I could split myself up into three and help out.”

Reprinted with permission of The Billings Gazette.