5

Addressing Health Disparities
Through Education

Education is related to the success of young people in a variety of ways, noted roundtable member Jeffrey Henderson, president and chief executive officer of the Black Hills Center for American Indian Health and moderator of the panel on education at the workshop. In particular, education can generate resilience, he said, and resilience in turn can drive educational attainment.

Three speakers at the workshop examined aspects of the relationship between education and health equity. Most of the interventions they described are designed to increase the representation of Native Americans in the health care and health research workforce, but experience with those interventions has produced lessons that can be applied much more broadly.

VALUING TRADITIONS AND NEW PATHWAYS

The UNM Health Sciences Center (UNMHSC) has established the vision that, working with community partners, it will help New Mexico “make more progress in health and health equity than any other state by 2020.” To help achieve this vision, it has established a wide variety of programs to engage, enroll, and encourage students in its health profession schools (see Table 5-1). Even if these students end up going into a different field, the interventions can benefit them, said Valerie Romero-Leggott, vice chancellor for diversity and professor of family and community medicine at UNMHSC. “If they continue their education, then we have been successful in the programs that we provide,” she explained.

Diversity is the key to helping the center achieve that vision, said

TABLE 5-1 University of New Mexico (UNM) Programs Targeting Native American Youth

NOTE: DAT = Dental Admissions Test for dental school; MCAT = Medical College Admissions Test; PCAT = Pharmacy College Admission Test.

^a Numbers are estimates based on text.

Romero-Leggott. The United States is rapidly becoming a more diverse nation, where non-white racial and ethnic groups will constitute a majority of the U.S. population. In addition, health care workforce diversity is a strategy for eliminating health disparities and a key to excellence in health care for the nation, said Romero-Leggott. Diversity helps prepare effective health care providers for work in multicultural environments. “It is about improving access to health care for vulnerable populations. It is about cultural humility. It is about being prepared for this multicultural environment that we live in,” she added.

HOPE, ENRICHMENT, AND LEARNING

Preparing a diverse health care workforce requires “growing our own,” said Romero-Leggott. One of the approaches the Health Sciences Center has taken to do this, with support from the state and federal governments, is known as the Hope, Enrichment, and Learning Transform Health in New Mexico, or HEALTH NM, program.¹ The program consists of a wide variety of initiatives ranging from middle school through high school and college to graduate education in the health professions, providing a pipeline that students can follow from one level to the next.

The Dream Makers Health Careers Club, which has about 80 participants, is an afterschool program for middle school students to stimulate interest in the medical and health professions. Twice per month, hands-on activities are led by community and UNM Health Sciences Center professionals to provide students with positive role models that they can emulate.

The Dream Makers Plus Health Careers Club is an academic-year program for high school students and also involves about 80 participants. It includes in-depth workshops from many health disciplines, journaling on health issues, parent meetings on financial aid and the college application process, and a precollege entrance exam workshop.

The Health Careers Academy is a 6-week, nonresidential summer program for high school freshmen, sophomores, and juniors that is designed to raise entrance exam and academic performance and provide exposure to and information about various health care professions. Originally based in Albuquerque, the program, which serves about 35 students, has recently been expanded to other communities in New Mexico.

The Undergraduate Health Sciences Enrichment Program is a 6-week residential program for about 25 incoming college freshmen, regardless of where they will go to college. It offers academic enrichment and an extended introduction to the programs and services offered by universities.

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¹ The number of students/participants in the HEALTH NM programs has continued to expand, as partnerships increase in rural communities throughout the state.

Shadowing of health care professionals provides the students with clinical exposure.

The Mental and Behavioral Health Academy is a new program that provides opportunities to about 15 students who are interested in mental and behavioral health careers. The program meets every Saturday for 15 weeks. It is a hybrid program that includes standardized test preparation, academic enrichment, and rural clinical immersion experiences.

The MCAT+/DAT+/PCAT+ is a 6-week summer program designed to strengthen about 25 students’ applications to medical, pharmacy, and dental schools by providing preparatory courses and preadmissions workshops and seminars.

The New Mexico Clinical Education program is a 6-week summer immersion program for about five preprofessional students. It provides clinical and community experiences by placing students in primary care settings throughout rural and tribal New Mexico.

The UNM-New Mexico State University (NMSU) Cooperative Pharmacy program is a 7- to 8-year program for students to complete prepharmacy coursework at NMSU and be admitted to the UNM College of Pharmacy. About 10 participants are involved in pharmacy practice experiences and preparatory courses for the PCAT.

The final two programs are postbaccalaureate/prematriculation programs. The Pathways to Pharmacy program is for college graduates selected by the UNM College of Pharmacy admissions committee to improve their academic qualifications and facilitate their entry into the college. The Premedical Enrichment program participants are selected by the UNM School of Medicine admissions committee. The program is designed to help educationally disadvantaged students in their long-term professional success toward the achievement of the medical degree.

HEALTH NM rests on four fundamental pillars, said Romero-Leggott: identity formation, service learning, cultural competency and humility, and reciprocal information corridors. For example, in this last category, the initiative recognizes that it needs to provide information to families and communities and also get information from them about their needs and how to meet those needs. With the exception of the Dream Makers programs, all of these programs offer stipends so that students will not have to take jobs.

Of course, not every student makes it through every step of the pipeline, Romero-Leggott said. But mentoring and role modeling make a big difference in retention, as does maintaining a strong network among participants, role models, and advisors.

Romero-Leggott also mentioned several other initiatives involving Native American youth in New Mexico. The Native Health Initiative conducts workshops on health careers, conducts a mentoring/shadowing pro-

gram, and offers internships on health issues for the state. The Center for Native American Health has an Indians into Medicine grant designed to have Native Americans go into those careers. The Institute for Indigenous Knowledge and Development does work on public health, community participatory research, and the self-determination of indigenous knowledge for students and communities. Furthermore, the Four Corners Alliance works with the Association of American Indian Physicians to hold annual preadmissions workshops.

As an example of these programs’ success, Romero-Leggott cited Erika Garcia, a physician from Clovis, New Mexico, who was in three of the pipeline programs. Now she is working in Portales, New Mexico, near her hometown of Clovis. As Garcia described her experiences, “The biggest impact that I immediately felt in my community is that I am filling a cultural void with Spanish speaking-individuals, especially females.” Recently, Garcia took on one of the clinical education students, bringing the story full circle. Said Romero-Leggott, “This is one of several stories that we have of how these pipelines work and how they really do have people returning to serve in their communities.”

THE COMBINED B.A./M.D. DEGREE PROGRAM

Romero-Leggott also described the Combined B.A./M.D. Degree program at UNM. The program is built on the idea that the health care providers most likely to serve rural areas are from rural areas themselves, are members of underrepresented groups, were trained in rural or underserved areas, or graduated from primary care training programs. With the overall goal of improving the health and well-being of New Mexicans, the program admits a diverse class of 28 New Mexico high school seniors who are committed to practicing in the state in the communities of greatest need, thereby increasing the medical school class from 75 to more than 100.

The program provides an array of curriculum and support services, including specialized academic advising, scholarship and financial aid, peer and faculty clinician mentors, living and learning communities, tutoring and supplemental instruction, and MCAT preparatory courses. The students also participate in summer service-learning experiences in rural communities that are medically underserved.

Eight years into the program, students have come from across New Mexico. Two-thirds are rural students, about half are female, and two-thirds are minority students. Thirty-one of the students identify as American Indians, representing 14 percent of the total. Many of the students have gone on to win scholarships, awards, and other recognition.

Romero-Leggott closed by pointing to a few areas in which the program could improve, including encouraging students to participate in Advanced

Placement and dual-credit courses, ensuring school districts give access to these courses, standardized testing support, greater awareness of summer enrichment programs, scholarships and funding for qualified applicants, and greater connectedness to identity, culture, and tribal communities. She also quoted one of the students in the program, Jaron Kee, who also spoke at the workshop:

The Combined B.A./M.D. Degree program “is serving New Mexico one physician at a time,” said Romero-Leggott.

SHEEP, CEREMONY, AND TEXTBOOKS: A NATIVE UNDERGRADUATE’S TESTIMONY

In his presentation at the workshop, Jaron Kee, who is a third-year student in the Combined B.A./M.D. Degree program, said he grew up in the small town of Crystal, perched in the mountains of western New Mexico. He attended and graduated from St. Michael Indian School, and at UNM, he is pursuing degrees in biology and chemistry with a minor in health, medicine, and human values.

Up until middle school, Kee spent his summers herding sheep and attending ceremonies with his grandparents, and he said that his family remains very traditional and still keeps about 200 head of sheep and 100 head of cattle. But his family is also very pro-education. They sent him to a variety of summer academic enrichment opportunities, including the Cushing Academy in Ashburnham, Massachusetts, and the Arizona State University Math–Science Honors Program in Tempe. “I grew up with the mentality that education is something important and something that all Native students should be part of because it is for the betterment of our people,” he said.

He also has become involved with health issues and experiences on the reservation. He has shadowed at a local clinic of the IHS, where he

gained experience with pediatrics and family medicine and observed several operations.

Transitioning to college was difficult at times, Kee said. He got a C on his first chemistry test, which he described as “devastating.” He felt disconnected from his community and underprepared for college. His response was to create a new family through the B.A./M.D. Degree program. He began to study with the other people in the program and raised his grades. He then became a tutor for calculus, chemistry, and biology, which he continues to do as a junior, and he became involved with the Center for Academic Program Support on campus.

As his confidence grew, he applied to the Native Health Initiative and became a leader in the program. One activity of the initiative is known as the Healers of Tomorrow program, which he oversaw. He then applied to and was accepted at a research program at the National Institutes of Health, where he conducted research on human motor control.

The summer before his junior year, he did a practicum in his hometown, which he described as a “gratifying experience and one of the reasons why I think what I have chosen in my life is something important. . . . Seeing a lot of the health disparities and diseases that continue to plague the Navajo people is a bit startling.” He also has done summer programs with the Association of American Indian Physicians.

Kee closed with three observations. First, continued involvement with his community has allowed him to remain committed to his education. Second, his traditional upbringing has had a tremendous influence on his life. Third, having a network of support has been the most important aspect of his life. He also quoted the words of his grandfather, James D. Kee, Jr.: “Anyone has the ability to create for themselves a good life from their hands and thoughts—now go do it!”

TRIBAL SCIENCE: ENSURING THE EVOLUTION AND PRACTICE OF INDIGENOUS SCIENTISTS AND RESEARCHERS IN THE 21ST CENTURY AND BEYOND

Jerry Elliott—or J. C. High Eagle—was a flight mission operations engineer at the National Aeronautics and Space Administration’s Mission Control Center who was responsible for designing the trajectory around the moon that brought men back from the darkness of space. He was awarded the Presidential Medal of Freedom, the highest civilian honor bestowed by

the U.S. government. Yet his path to success began one afternoon on the plains of Oklahoma during an intense experience with his grandfather. “I urge all of you to think very critically and very openly about what children share with you,” said Jacqueline Bolman, director of the Indian Natural Resource, Science, and Engineering Program (INRSEP) and the Center for Academic Excellence in STEM (science, technology, engineering, and mathematics) at Humboldt State University. “Those moments of sharing constitute what I will call blowing on the coals of who they are and literally setting them free to create their own destiny,” she said.

Native Americans represent only 1.2 percent of the nation’s population, but they own or are entrusted with 10 percent of the land in North America. On those lands are 20 percent of all of North America’s natural resources and 27 percent of U.S. fresh and clean water. This land represents not only “the health of our environment, but the health of our future children,” said Bolman.

As Gregory Cajete (2000, p. 186) has written:

Cajete also wrote that human development is predicated on interaction with the soil, the air, the climate, the plants, and the animals of the places in which we live. In this way, tribal or Native science is based on what he called a “creative participatory process.” The initial insights, immersion, creativity, and reflection of tribal science do not differ from the process of Western scientific inquiry. However, Native science is imbued with spirituality, while Western science is founded on the separation of the two. Tribal science also builds on direct experience with natural phenomena and building on the accumulated knowledge of others through such means as oral histories and stories. “Stories are a very intricate means of moving highly detailed quantitative and qualitative information through thousands of years,” said Bolman.

Tribal science is laden with associated “values,” while the scientific

community prides itself on data that are “value” free. It includes an “ethic” of reciprocal respect and obligation between humans and the nonhuman world. Nature is the subject, not the object. In this way, tribal science offers not only biological insights, but a framework for health and environmental problem solving that incorporates human values.

The future of tribal science and traditional ecological knowledge (TEK) ultimately is related to the entrenchment of tribal rights, Bolman said. Tribal knowledge cannot be separated meaningfully from the people who hold it. To protect tribal science and TEK, the people themselves and their way of life must be protected. That means that Native students, once they enter higher education, should not be transformed. “They certainly don’t come to those public universities or private universities as empty containers,” said Bolman. “They are full of experience and knowledge. They are there to transform those tribal colleges and those universities.”

Bolman has been directly involved, through a number of programs, with the use of tribal sciences to teach students. For example, she described working in the Black Hills to study the role of keystone species in reforestation. “Here, I began to see that renewal or restoring of the relationship between our children and land. Where I had tried to forcefully put chemistry and calculus into them, I found by helping them understand who they were and then showing them the relevancy of why they need to know this and when they are going to use it, I set them free to learn in their own way,” she explained.

In a program called Opportunities for Enhancing Diversity in the Geosciences, Bolman took students to the seven sacred sites in the Black Hills, many of which the students had never seen, and used remote sensing to connect them with the traditional concepts of earth, wind, fire, and water. In partnerships with elders and other Lakotas, she helped students understand their relationship to those sites; the oral histories associated with them; how earth, wind, fire, and water had created these sacred sites and changed them; and how those primal elements were expressed in them. The students hiked with the elders to show “that Lakotas were strong people not only physically but mentally, emotionally, and spiritually, as a way to help our children reconnect,” Bolman said.

In intergenerational camps at the center of the Black Hills, the students drank water rather than soda and returned to their traditional foods like dried buffalo, dried nuts, and berries. Bolman noted that “the students began to see, after a week or two, their bodies began to change. They began to feel more well and more physically active. That was expressed in their understandings with each other.”

One of the students involved in these programs, who lives on the Pine Ridge Indian Reservation, was graduating from high school just 3 weeks after the workshop and had been accepted to Dartmouth, Harvard, Stan-

ford, and Berkeley. She also had presented her research at the International Science and Engineering Fair. “I talk a lot about leadership with our students,” Bolman said. “It is about self-determination, and about being self-determined, not only as a tribe but as a person.”

Intergenerational experiences are critical in tribal science, according to Bolman. The greatest gift one can give is that of experience, education, and understanding. The truth is forged through millennia of participation with the natural world and the other members of a community. “We have the expertise. We have the education. We have the knowledge to assume our own stewardship, to take care of ourselves in a way that is culturally appropriate for us. . . . It is about forging those relationships between those of us whose lives are half over and those whose lives are just really truly beginning,” she said.

Research is also a large part of tribal science. Every year Bolman’s students participate in research experiences from the tip of Alaska to the tip of South America, working with Indigenous and tribal people. She noted that “the goal is to ensure that the next generation of tribal and non-tribal scientists and researchers is more diverse, more highly educated, more experienced, and more leadership oriented by the time they complete our programs.”

“We must be responsive to our responsibility to that seventh generation,” Bolman concluded. All tribal nations need to develop a culturally appropriate means to protect, sustain, and restore traditional ancestral lands. They need to push for equitable representation on national and international forums addressing the underrepresentation of tribal science and earth system science professionals. The planners of programs need to consult with students, she said, adding that “children have a capacity well beyond what a majority of people believe that they have. We need to set forth to build what they say they need.” Finally, said Bolman, all nations should recognize the value of tribal and indigenous science perspectives.

AMERICAN INDIANS AND THE HEALTH PROFESSIONS: A GROWING CRISIS

Sam Deloria, director of the American Indian Graduate Center, Inc., in Albuquerque, New Mexico, took exception to the idea that Native American students should be expected to return to the places where they grew up. “Why are we the only ones who have to go back?” he asked. When

he first came to the American Indian Graduate Center, he fought a battle over requirements that Native American students pay back their scholarship money unless they took particular jobs. “I fought that—risked the program—but won it. It was an important battle for me,” he said.

The American Indian Graduate Center is a scholarship program (primarily for graduate students) that also sees itself as an advocate for students. Its mission statement is to build strong Indian communities, and “I am all for that,” said Deloria. But he also pointed to the complications inherent in that mission. For example, 70 percent of the federally recognized tribes have 1,000 people or fewer, adding that “if we are going to construct our education programs around each one of these kids taking their degree back to their home community, think about how you are going to manage that.” A Native American student fascinated by medieval French literature could not pursue such a degree and hope to use it in a small community. “I grew up thinking that education was an end in itself. So why are we the only community in the country that has to justify education on the ground that our kids are going to go back and implement some government program?” Deloria asked.

Native American students today are citizens of the world, just like other young people. They have been watching television since they were infants. “I am not at all against nurturing programs,” he said. “I run one. What I am against, what I want to caution people about, is to think about the ways in which you are projecting or you may be projecting onto these young people expectations of their behavior,” Deloria explained.

Native American students also have many of the same insecurities as other students. When high school students go to college, they all have to get used to the idea that they are not necessarily the smartest person in the room. “Virtually every negative feeling you are going to have, every other kid in your class feels the same way. Don’t think it is just because you are an Indian,” he said. But they would not be there if they could not succeed, Deloria added. “These kids have got to be tough. [For law students] In 3 years . . . somebody’s life is going to be in your hands, so we are not going to coddle you. You are going to work, and they work, and 95 percent of them finish law school,” he noted.

One of the greatest failings of current programs, Deloria said, is their lack of coordination. The IHS, Bureau of Indian Affairs, and Bureau of Indian Education all have a major presence on Indian reservations, but they do not talk with each other, he said. These programs encounter many of the same problems, such as substance abuse among the populations they serve, and they miss opportunities to make progress against these problems because of poor communication. In 1971, Deloria helped form a commission in the federal government to improve coordination between what was then the Department of Health, Education, and Welfare and the Bureau of Indian Affairs on issues such as health services in Bureau of Indian Affairs

schools. However, the initiative “sank to the bottom of the Potomac before I got home, because nobody is forcing them to do that,” he said, adding that federal agencies need enforceable measures to communicate with each other.

For those students who do return to their communities, a major problem is matching trained people with the opportunities that exist. For example, Native communities need school teachers and Head Start teachers, but many positions go unfilled. Changes in certification could make it easier to fill these positions, which is also the case in many health fields. “If we are going to meet the challenges of the Affordable Care Act, and if we are going to keep some semblance of medical care in Indian communities, we are going to have to face this, because there are not enough people,” Deloria explained. Expecting all Native American students to return home to become primary care physicians instead of becoming heart surgeons is unrealistic, Deloria said. Also, because many Native Americans want to return to their communities, they are in schools of public health rather than medicine because they can more quickly return to the community with an M.P.H. degree.

Deloria also called attention to the lack of good advisement systems for students. They may have unrealistic expectations about where they are going to go to college or what they are going to do. They may pick a school they want to attend, even though it is absolutely the wrong place for them. “They are not getting the right kind of advice,” he said.

Institutions also need to talk with each other. Deloria helped run a program that increased the number of Indian lawyers from 25 to more than 5,000, yet people in similar programs never asked him how he did it. The technology exists now to put all institutions in touch with each other. “There should not be an elementary or high school in this country that is so remote that it is out of touch with the best resources that are possible,” he said.

Finally, Deloria expressed his concern about what he called the “intellectual scholasticism” of Indian affairs. Two or three reigning theories and political groups hold sway, but these theories have not undergone a robust examination. “You start by stating those theories as conclusions, and you work your way back to find data. That is a disservice to the professions, that is a disservice to the idea of scholarship, and it is a disservice to Indian communities,” he concluded.

SCHOLARSHIP REQUIREMENTS

A topic that arose during the discussion session was whether students should be required to pay back a scholarship through a particular form of service. Deloria pointed out that he was not, in his remarks, objecting to all such requirements. “It is a bargain that they can take or not take,” he said. But if all financial aid were structured that way, it would be a problem, he added.

Romero-Leggott observed that the Combined B.A./M.D. Degree program does require that students serve in underserved communities, but students know that and have signed a letter agreeing to those terms. “It is a great opportunity for some students who would otherwise be in huge amounts of debt,” she added.

The presenters also talked about how to make pipeline programs sustainable after the initial rounds of financing have dried up. Romero-Leggott said that sustainability of the pipeline programs comes from engaging the community and enlisting their support, adding that “we negotiate and we work with them from the beginning.”