Funding uncertainty

The question of funding HP 2010 goals and existing IHS programs remains central to the solution of such large-scale health problems.

"Healthy People 2010 is a framework, not a piece of legislation, designed to be used by states and communities to document their needs and as an agenda for action," said Deborah Maiese, senior prevention policy adviser, Healthy People team leader, Office of Disease Prevention and Health Promotion. "We have seen the Cherokees and other tribes do their own Healthy People [programs] and encourage it."

Other healthcare experts who have studied AI/AN health issues offer different perspectives. "IHS has been underfunded for many, many years," said Louise Kiger, MN, RN, past director of the division of nursing of Indian Health Services. "It can be from 40 to 60 percent funded for the level of need. The funding is discretionary, depending on the whims of the congressional leaders and their understanding and sensitivity toward Native-American health issues." Kiger, a Pueblo Indian, has seen improvements during her 40 years of nursing, including the process of self-determination where tribal entities seek funds directly from IHS to run their own health programs. "When I left [IHS], more than 40 percent of the Indian tribes were running their own healthcare programs. The only problem with that is the overall funding isn’t enough."

From 1992 to 1998, IHS did not receive appreciable increases, yet had to absorb $650 million in costs, including inflation. In 1999 and 2000, President Clinton supported the largest increase of about 7.5 percent, or $230 million, according to Craig Vanderwagen, MD, director of clinical and preventive services for the IHS. "We recently compared IHS funding on a per capita basis with the medical insurance of a federal employee, and we are funded at 60 percent of what that package buys. I believe the major threats to AI/AN health are poverty, job opportunity, and education. When you trace back what it takes to prevent substance abuse, chronic lifestyle diseases like diabetes and heart disease, one has to address the economic future of young Indians."

Bob Schacht, PhD, the task force coordinator for "Emerging Disabilities: American Indian Issues," a detailed report of AI/AN health issues by the American Indian Rehabilitation Research and Training Center, Northern Arizona University, sees interrelated problems. "These are very different communities with varying needs, and IHS funding is way short of what’s needed for all the programs," said Schacht, who also is a research associate at the center. "Between the two clusters of health problems—one related to alcohol, the second related to diabetes, and the consequences of the combination—there’s virtually a national epidemic in Indian populations, all affected by poverty-related issues. One place we could start helping would be to live up to our treaty obligations."

The past president of the National Alaska Native American Indian Nurse Association sees leadership needs as essential to addressing the disparities in health care. "IHS funding is bare bones, but medicine costs real dollars and there’s no way around getting the right antibiotic or surgery," said Bette Keltner, PhD, RN, dean of the Georgetown University School of Nursing. "The people who decide what program will be funded and how it will be implemented are the people who shape very powerfully what healthcare delivery will look like, and we need Indian people at all of those levels for equivalent representation."

Despite the scope of the current situation for American Indians, Vanderwagen, who began his career as an LPN, believes nurses serve as front-line catalysts for change. "Our facilities are staffed by trained nurses, many Indian women, who provide continuity of care for community members," Vanderwagen said. "They provide cultural relevancy, and are the first and last contact with patients. They serve as learning mentors for the community, including new physicians. For these important reasons, nurses will be critical to the successful implementation of new programs. They are the mainstay, working to help natives transform their health status."