Discussions of Native American health tend to homogenize Native populations, said Francisco Garcia, chief executive officer and chief medical officer of the Pima County Health Department and a member of the roundtable. “We tend to think all Indians are the same in the same way we think all Hispanics or all African Americans are the same,” he said.
In fact, Native Americans are an extremely heterogeneous population. The state of Arizona alone has 22 federally recognized tribes, Garcia noted. This heterogeneity is an advantage rather than a disadvantage in discussing Native American health because it enables “interesting and creative solutions” in addressing health and wellness issues in indigenous populations, he said.
These solutions are desperately needed, Garcia asserted. Across Native American groups, the leading causes of mortality are unintentional injury, homicide, and suicide. “What is killing Native youth today, and the sources of the greatest mortality for Native youth, are all preventable causes of disease,” he added.
The opportunities are in thinking creatively and engaging with communities to solve problems, said Garcia. Discussions of health disparities are often oriented around deficits. For example, the members of certain populations are seen as too fat, unhealthy, or just not good enough. This conversation needs to be turned on its head, said Garcia, adding that “we need to understand that we have true sources of resilience, true sources of strength, which we can draw upon and learn from each other.”
Though some risk factors are elevated in Native communities, these communities also have some very positive stories to tell. In some tribal com-
munities, the consumption of fruits and vegetables is higher than for white non-Hispanic populations. In general, physical activity among American Indian men is greater than among white non-Hispanic men. Tobacco use during pregnancy is exceptionally low among Native women in the southwestern United States. Though alcohol in Indian Country is a major issue that threatens the viability of these communities, the rate of binge drinking is lower than among non-Hispanic whites. “It is important to understand these strengths,” said Garcia, “because it allows us to do creative things.” For example, working from a position of strength rather than a deficit model points to many opportunities for policy enhancements, such as reducing automobile accidents, that would yield quick wins in terms of mortality and morbidity.
In the session Garcia moderated, three health care providers described their work on physical and mental health interventions among Native American youth. An important aspect of these interventions is that they build on Native cultures, thereby gaining both relevance and resonance.
“What is killing Native youth today, and the sources of the greatest mortality for Native youth, are all preventable causes of disease.” —Francisco Garcia, Pima County Health Department
CULTURALLY BASED INTERVENTIONS FOR THE PREVENTION OF SUBSTANCE USE AND ABUSE AMONG NATIVE AMERICAN YOUTH
Guided by a group of elders from the Kituwah Cherokee tribe, John Lowe, Wymer Distinguished Professor of Nursing at Florida Atlantic University, has been working on the prevention of substance use and abuse among Native American youth. When he asked the elders of his tribe what questions he should pose to young people, they pointed to three:
- Who are you?
- Where are you?
- Where are you going?
Unless young people have a solid cultural identity, they will have trouble answering these questions, Lowe said. In turn, they will be more susceptible to substance abuse, which is a major problem for Native American communities. Compared with the national average for adolescents ages 12 to 17, American Indian or Alaska Native adolescents had higher rates of past-month cigarette use (16.8 versus 10.2 percent), marijuana use (13.8 versus 6.9 percent), and nonmedical use of prescription drugs (6.1 versus
3.3 percent), according to data from the National Survey on Drug Use and Health. These higher rates of substance use among American Indian or Alaska Native adolescents are found among males, among females, and across age groups. In particular, drug use is substantially higher among 10- to 12-year-old Native American youth than in the population at large. By age 11, American Indian youth are more likely, compared with all other racial and ethnic groups, to have initiated substance use and to be on the path to lifelong substance abuse, said Lowe.
Substance use is not a single problem, Lowe continued. It is correlated with historical trauma, forced removals, boarding schools, destabilization of families, economic disadvantages, and other social, psychological, and economic stressors. As prevention researcher Fred Beauvais (1998, p. 256) has written, “Many Indians believe that the loss of their culture is the primary cause of many of their existing social problems, especially those associated with alcohol.”
Early in his doctoral work, Lowe did 5 years of ethnographic study, which resulted in what he called the Cherokee Self-Reliance model. In this model, the self is not individualistic, said Lowe, adding that “self, for us as Cherokee Kituwah people, is everything that we are connected to by the creator.” Though the term self-reliance may sound Western, it is really about interdependence. This model has been generalized into a Native Self-Reliance Framework. A circular model for cultural tailoring (which features interconnections among self, tribe, relationships, and time) has emerged that provides guidance when tailoring the Talking Circle intervention for use with various tribes.
In applying this model to substance abuse, Lowe and his colleagues and students developed what they called the Talking Circle Intervention. It is a 10-week counseling session conducted in the traditional talking circle format. It has been used both with older adolescents and with fifth and sixth graders. A comparison of the intervention, with the DARE (Drug Abuse Resistance Education) or Be a Winner1 programs serving as the control groups, demonstrated a substantial increase in self-reliance scores after intervention and, especially, 3 months later, while self-reliance decreased among the control groups. Substance use decreased among those taking part in the Talking Circle Intervention, with, again, a greater effect 3 months after intervention. By comparison, the control group showed the opposite effect. “We have been sharing this and getting interpretation from my elders. What they say is it takes time when you are circular thinkers2
1 DARE and Be a Winner are drug education programs that are delivered in the school setting by law enforcement officers.
2 Circular thinking as opposed to traditional Western linear thinking.
and you internalize what you have learned. Once it is there, you are going to see it increase,” Lowe explained.
In the earlier studies that tested the Talking Circle intervention, stress levels were reported to be down immediately after the intervention, but rose nearly to the baseline level 3 months later. According to Lowe, this observation prompted a closer look at historical and intergenerational trauma experienced by program participants.
Lowe and his colleagues have received another grant of nearly $3 million to test the Talking Circle Intervention for the prevention of substance use among Native American youth ages 10 to 12. This grant will make it possible to test combinations of in-person implementations and virtual implementations of the talking circle concept, with sessions facilitated by an elder who is a substance abuse counselor. The intervention also will train other members of tribes who can implement the program in the future. In addition, Lowe has been working in Australia to tailor the talking circle approach to the Aboriginal practice of “yarning,”3 and his graduate students are interested in tailoring talking circles for obesity prevention.
“Self, for us as Cherokee Kituwah people, is everything that we are connected to by the creator.” —John Lowe, Florida Atlantic University
“Native folks like to tell stories,” said Susie John, a pediatrician at the Northern Navajo Medical Center Teen Life Program in Shiprock, New Mexico. “That is how they do their teachings. Legends are passed on. I was happy to see the kids this morning. Many times I work with kids, and a lot of times they want to tell us their story in their own words. That is as you saw this morning. It was good to hear,” she said.
Behind every statistic are individuals, families, and stories, John reminded the group. For example, statistics about alcohol and drug use reflect the aggregate experiences of many individuals, each of whom deserves respect. “One thing that the kids keep telling us is they want us to listen to them,” said John. “You heard that this morning. They want us to listen to them and treat them with respect and compassion. Also, they want us to treat ourselves with respect and compassion. They want us to hear them, and they also want us to hear ourselves.”
3 Yarning is a term used by Aboriginal peoples in Australia to describe an Indigenous style of conversation and storytelling.
As Garcia noted, Native American youth are very diverse. They are urban and rural, have different sexual orientations, and have different educational and health care needs. Some are traditional and may be more comfortable speaking Navajo than English. “You can’t make assumptions,” said John.
John also pointed out that healing systems are different. People coming to a hospital expect a particular kind of system. But “there are healing methods that have been there for eons, for thousands of years, and people still use that,” she added.
As a pediatrician, John often finds herself serving as a confidant or surrogate family member. She is someone who can listen who also knows about health and wellness. With adolescents, she often uses motivational interviewing, which is something that the elders talk about as well. For example, through an initiative called Project Trust, behavioral health providers interview adolescents to help work through historical traumas and other issues that arise in Native American communities.
Children and adolescents do not necessarily seek out health care, which requires that John be a community worker. “With school-based health services, we go to them,” she explained. She talks with people about both their problems and their successes. Many reservations have strength-based prevention efforts, which need to be continued, said John. Working in the community provides young people with role models and helps prevent the siloing of efforts. Young people say “it is good to see all of these people with Ph.D.s or different degrees coming from somewhere else, talking to us, and encouraging us,” she said.
Adolescents often say they want to come back after getting an education and work with their communities, John observed. Yet once they get an education, they may not have the skills that are needed in their communities. “I told the kids it is okay, get educated,” said John. “Stay where you are and work for us in the university setting in Denver, Colorado, or Washington, DC. That is okay. You can work from there on our behalf.”
“Native folks like to tell stories. That is how they do their teachings.” —Susie John, Northern Navajo Medical Center Teen Life Program
By the age of 7, children need to acquire four essential skills, said Gayle Dine’Chacon, director of the Center for Native American Health at the UNM School of Medicine.
The first is reading. Reading is “what got me where I am,” said
Chacon. Her father worked at the Bureau of Indian Affairs cleaning boarding schools, and he brought home old books from the schools when new ones arrived. “I read and read and read, because we didn’t have TV, and we didn’t go to the movies,” she said. Only 56 percent of the people in Navajo Nation have a high school diploma by age 25, compared with 75 percent of the U.S. population. Only 5 percent have a bachelor’s degree by age 25, compared with more than 20 percent of the general population. More and better reading could make a critical difference in these numbers, said Chacon, adding that “reading by age 7 is what our children need.”
The second thing they need is music. Music uses the other half of the brain, and “the full potential of a human person is using both sides of their brain,” she explained. Understanding music and learning a musical instrument, whether a piano, violin, guitar, drum, or the human voice, teaches children how to express themselves in a way that transcends words.
The third thing they need is a second or even third language. Native American children need to understand and be proficient in their Native language, said Chacon. Aspects of Native culture and spirituality cannot be expressed in English. They have deeper meanings based on thousands of years of history. Native American culture is also conveyed through an oral tradition. “I am a grandma,” said Chacon. “Being a grandma encompasses everything I do as a professor, as a woman, as a teacher, all of those things, because I have a chance to impart what I know to the next generation. My grandson is the seventh generation of my great-great-grandmother, who was at Fort Sumner. Fort Sumner, for those of you who don’t know, is in our genes. It is in our blood. It is in our memories. We will never forget. . . . We were forced from our home to Fort Sumner and lived there, people say, to die. But we didn’t. We are here. We survived. We are survivors. We are resilient. We need our language in order to carry that through.”
The fourth thing children need is a sense of who they are and where they are going. When Chacon speaks to Native American groups, she tells them she is from Chinle. “As Indian people, I ask where you are from. That is part of our introduction. . . . It is our identity,” she said.
Chacon closed with a story about how the seed to attend medical school was planted in her. When she was 5, she was reading one of the books her father brought home from the boarding school. On the first page were “two people who had clothes on,” she said. “You turn the page and they are naked. The next page they have no skin. You just see the muscles. On the next page, you see their blood vessels and nerves. On the next page you see their organs. On the last page there was a skeleton. I was 5 years old. I was scared and crying. I didn’t know.” Her father told her it was an anatomy book that doctors use to understand the body. “Someday you are going to be a doctor,” he told her. “I was 5. You don’t know what that means. Just as you plant a seed, you don’t see it. You don’t know where it
goes. You hope there is enough fertile ground, enough opportunity, enough water, and enough sunlight,” she said.
All children face challenges, yet they have the capacity to overcome those challenges, said Chacon, adding, “I am so inspired every day when I get to talk with our students and meet with our students. They motivate me. They inspire me. Those are the next generations. . . . We have 27 graduate Native students in our medical school, which I am so proud of, and we will graduate 2 next week.”
“I am so inspired every day when I get to talk with our students and meet with our students. They motivate me. They inspire me. Those are the next generations.” —Gayle Dine’Chacon, UNM School of Medicine
During the discussion period, the presenters focused largely on the topic of learning a Native American language. As Chacon said, children have many ways to learn a language, including language classes, immersion schools, and even a Rosetta Stone program for Navajo. But for children to embrace a language, they need to value it. That value comes from its connection to culture, said Chacon. “For us, it encompasses who we are, the whole culture, the tradition, the ceremony, the being healthy. You cannot understand some of the ways that we live. When we talk about food being sacred and our bodies being sacred, that is something that we need to translate to people who have diabetes and obesity,” she said. Although learning a language at 50 is difficult, children can absorb a new language much more easily.
John pointed out that “using a few words of the language works.” For example, when people hear terms of endearment, “they come closer to you. They know what that means,” she added.
Lowe noted that the use of a Native American language connects children to an identity. He told the story of a young man, just 19, who had a terminal illness. His proudest moment, he told Lowe, was being able to identify with his tribe in his Native language. “It was truly a gift to us,” Lowe said.
Finally, Garcia noted that many of the words in Native languages are unique and do not have a literal translation, adding that “they have an emotive quality that attaches us to those words and carries very special and important messages.”
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