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Introduction and Themes of the Workshop1

In Native American tradition, the medicine wheel encompasses four different components of health: physical, emotional, mental, and spiritual (see Figure 1-1). Health and well-being require balance within and among all four components. Thus, whether someone remains healthy depends as much on what happens around that person as on what happens within.

On November 14, 2012, the Roundtable on the Promotion of Health Equity and the Elimination of Health Disparities of the Institute of Medicine (IOM) held a workshop in Seattle, Washington, to explore the ideas at the heart of the medicine wheel. Titled Leveraging Culture to Address Health Inequalities: Examples from Native Communities, the workshop brought together more than 100 health care providers, policy makers, program administrators, researchers, and Native advocates to discuss the sizable health inequities affecting Native American, Alaska Native, First Nation, and Pacific Islander populations and the potential role of culture in helping to reduce those inequities. The Roundtable on the Promotion of Health Equity and the Elimination of Health Disparities was created to enable dialogue and discussion of issues related to (1) the visibility of racial and ethnic disparities in health and health care as a national problem; (2) the development of programs and strategies to reduce disparities; and

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1 The planning committee’s role was limited to planning the workshop, and the workshop summary has been prepared by the workshop rapporteurs as a factual summary of what occurred at the workshop. Statements, recommendations, and opinions expressed are those of individual presenters and participants, are not necessarily endorsed or verified by the Institute of Medicine, and they should not be construed as reflecting any group consensus.



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1 Introduction and Themes of the Workshop1 In Native American tradition, the medicine wheel encompasses four different components of health: physical, emotional, mental, and spiritual (see Figure 1-1). Health and well-being require balance within and among all four components. Thus, whether someone remains healthy depends as much on what happens around that person as on what happens within. On November 14, 2012, the Roundtable on the Promotion of Health Equity and the Elimination of Health Disparities of the Institute of Medi- cine (IOM) held a workshop in Seattle, Washington, to explore the ideas at the heart of the medicine wheel. Titled Leveraging Culture to Address Health Inequalities: Examples from Native Communities, the workshop brought together more than 100 health care providers, policy makers, program administrators, researchers, and Native advocates to discuss the sizable health inequities affecting Native American, Alaska Native, First Nation, and Pacific Islander populations and the potential role of culture in helping to reduce those inequities. The Roundtable on the Promotion of Health Equity and the Elimination of Health Disparities was created to enable dialogue and discussion of issues related to (1) the visibility of racial and ethnic disparities in health and health care as a national problem; (2) the development of programs and strategies to reduce disparities; and 1  The planning committee’s role was limited to planning the workshop, and the workshop summary has been prepared by the workshop rapporteurs as a factual summary of what oc- curred at the workshop. Statements, recommendations, and opinions expressed are those of individual presenters and participants, are not necessarily endorsed or verified by the Institute of Medicine, and they should not be construed as reflecting any group consensus. 1

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2 LEVERAGING CULTURE TO ADDRESS HEALTH INEQUALITIES FIGURE 1-1 In the medicine wheel, health has physical, mental, spiritual, and emotional components. SOURCE: White Earth Nation. (3) the emergence of new leadership. All three objectives were achieved at the Seattle meeting. “Culture is so important in our well-being,” said Ralph Forquera, exec- utive director of the Seattle Indian Health Board, in his opening remarks at the workshop. Native Americans have struggled and continue to struggle to find their identity and place in Western society. Yet, they have inherited strong and enduring cultural traditions that continue to evolve in response to new circumstances. The resulting cultural dichotomies have become a defining element in the effort to use culture to improve the health prospects of Native people. “This searching for culture, this searching for identity, the searching for belonging transcends many of the social factors that are often- times viewed as being important characteristics of the health dilemma,” said Forquera. Organization of the Summary This summary of the workshop describes the observations, conclusions, and recommendations made by the individual presenters at the workshop and by individual workshop participants during the rich discussions that followed the presentations. Chapter 2 summarizes the keynote address made by James Knibb-Lamouche, director of research for the Blue Quills First Nations College, who wrote a commissioned paper for the workshop (see Appendix A). Chapter 3 addresses the broad role of culture in contrib- uting to and ameliorating health inequities. Chapter 4 probes more deeply into the effects of culture, looking at issues such as the training of clini- cians and researchers and the effects of federal policies. Chapter 5 provides case studies that examine three programs aimed at diabetes prevention and management. Chapter 6 presents case studies for cancer prevention and

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INTRODUCTION AND THEMES OF THE WORKSHOP 3 treatment programs. Finally, Chapter 7 summarizes comments made in the final discussion session, when workshop participants were invited to iden- tify lessons they had drawn from the day’s presentations and discussions. Key Themes Over the course of the day, several prominent themes emerged from the individual presenters’ remarks that framed much of the subsequent discussion. These themes are presented here not as conclusions or recom- mendations from the workshop but as a way of organizing the material summarized in this report. • Many factors affect health, including factors such as social environ- ments, education, and responses to colonialism that are subsumed under the broad label of culture. • Any efforts to understand the culture of Native peoples should take into account the historical trauma and loss of land suffered by these groups. • Culture varies greatly across communities, yet a common denomi- nator across communities is that unbalanced cultural forces can produce ill health. • Similarly, culture can be a powerful force for good health when cultural forces are aligned with the traditions and beliefs of a community. • Cultural safety, in which the services provided are based in the culture of the individuals seeking the services, is the ultimate goal for the health care system. • Culture is also an important factor in research on communities, given that communities need to be involved in the planning and performance of research for that research to be useful. • Members of Native communities can be essential partners in community-based research even if they lack research training. Part- nerships are seen as essential to research conducted with tribes. • Governmental and institutional policies should reflect traditional medicine and cultural advocacy for the staff who provide services. • More pathways into health care, better academic preparation, more culturally aware faculty, and continual mentoring are all needed to increase the number of Native clinicians and researchers. • Diabetes prevention and management, as an example of a health issue prominent among Native peoples, require an integrated and multifaceted set of activities and programs that can leverage Native traditions to improve health.

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4 LEVERAGING CULTURE TO ADDRESS HEALTH INEQUALITIES • Similarly, cancer prevention and treatment programs should reflect the characteristics and needs of local communities if they are to be successful. • Every program should be tailored to the local community, because every community is different. “This searching for culture, this searching for identity, the search- ing for belonging transcends many of the social factors that are oftentimes viewed as being important characteristics of the health dilemma.” —Ralph Forquera