American Indians’ Growing Presence In The Health Professions

Photographs courtesy of the University of North Dakota

On September 30, 2020, the day after the general election’s first presidential debate, thirteen doctoral students gathered on Zoom for their weekly Indigenous leadership and ethics course with University of North Dakota professors Donald Warne and Joycelyn Dorscher. Hanging on the wall behind Warne was a white quilt with an eight-pointed star composed of green, gray, and black diamond-shaped patches arranged in concentric circles, a pattern representing Northern Plains tribes in the University of North Dakota’s colors.

Warne spoke about the course textbook’s description of “self-analysis,” including steps such as assessing one’s greatest strengths and accomplishments. “This is coming from a Western European viewpoint,” he said. “Might there be any challenges in Indigenous communities asking these questions of ourselves?”

He called on Amy Stiffarm, a member of the Aaniiih Tribe in Montana. Similar to many people from Indigenous cultures, she was raised to be humble, she said. She also has survivor’s guilt because she comes from a community with high unemployment, so she dislikes drawing attention to her successes. “But, as leaders, we have to build ourselves up. It’s a fine line,” she said.

Aiming to train the next generation of Indigenous health research, program, and policy leaders, the University of North Dakota launched the country’s first Ph.D. program in Indigenous health last summer—the latest in a long line of efforts to increase American Indian representation in health care. In 1973 the University of North Dakota launched Indians Into Medicine (INMED), a program that has since recruited, supported, and trained 250 American Indian doctors. INMED eventually expanded to physical therapy and occupational therapy and has served as a model for similar initiatives at the University of North Dakota’s nursing and psychology graduate programs. Over time, the Indian Health Service—the federal program for tribal communities that provides grant funding to support the University of North Dakota’s efforts—has extended funding to similar programs at other medical schools.

Through INMED, the University of North Dakota’s medical school has established itself as a leader in American Indian representation. From 1980 to 2017 it led US medical schools in the proportion of American Indian or Alaska Native graduates, according to a 2018 report.¹ And in 2020 one in ten students at the University of North Dakota’s medical school were American Indian or Alaska Native, the highest ratio in the country.²

The coronavirus disease 2019 (COVID-19) pandemic has highlighted the stakes for programs such as these. Among many COVID-19 disparities, American Indians and Alaska Natives with the virus have been hospitalized at five times the rate of White Americans, according to the Centers for Disease Control and Prevention (CDC).³ (Some American Indian or Alaska Native health experts caution that the CDC data sets still underestimate American Indian or Alaska Native COVID-19 disparities.)⁴ Widespread, persistent shortages of health care providers in Indian Country are linked to limited access to care and higher rates of chronic health conditions—both of which are risk factors for poor COVID-19 outcomes.^1,5,6

Increasing the number of Native doctors could help alleviate these shortages, as Native doctors are more likely than their peers to serve Native patients.¹ But American Indian or Alaska Native students are scarce in medical schools: Nationally, only 1 percent of medical school students are American Indian or Alaska Native.² “It’s clear from the numbers that the pathways to medicine aren’t serving our population,” says Siobhan Wescott, INMED’s assistant director.

Photograph courtesy of the University of North Dakota

From Middle School To Medical School

Wescott, an academic physician and an Alaskan Athabascan tribal member, says that Native students are less likely than their peers to receive encouragement early in their education to pursue medicine or have doctors in their families to guide them through the “arduous” process of becoming a physician, so INMED tries to “re-create that support system at every step of the way.”

Kristal Hudson, a fourth-year University of North Dakota medical school student and a member of the Navajo Nation, coming from its New Mexico region, first encountered INMED through Med Prep, a six-week summer program that helps prepare American Indian undergraduate students for the Medical College Admissions Test (MCAT) and the medical school application process.

As someone who financed college largely through scholarships and often avoided writing in her textbooks so that she could sell them back to the bookstore at the end of her courses, Hudson displays palpable excitement when she recalls the moment she realized that her free MCAT course books were hers to keep: “Oh my goodness! I can highlight in them!” Being able to write in these books, she says, made studying much easier.

Financial barriers are a commonly cited reason for American Indian or Alaska Native students not pursuing or staying in medical school.

Financial barriers are a commonly cited reason for American Indian or Alaska Native students not pursuing or staying in medical school. INMED summer programs such as Med Prep are free and provide students with stipends, and INMED helps its medical school students identify potential scholarship options.

Even after Med Prep students take the MCAT, INMED maintains contact, encouraging them to apply to medical school and helping them navigate the University of North Dakota’s admissions process in particular. Hudson says that she doubted whether her MCAT score was competitive enough to apply to medical school, but Kathleen Fredericks, an INMED staffer, convinced her that it was and encouraged her to apply. After Hudson landed an interview at the University of North Dakota, Fredericks helped her prepare with a mock interview that boosted her confidence.

Incoming first-year INMED students learn medical school test-taking techniques and establish a support network in a program immediately before matriculation known as CLIMB (Career and Life Instruction for Matriculation Building). Once the school year starts, the students have access to tutors; emergency loans; and a dedicated INMED office with a study area, computers, and printers. Hudson describes the space as “home away from home.”

Before the pandemic, the program hosted regular social and cultural events to build community, as well as a blanket ceremony, a ritual where INMED medical school graduates are draped in a traditional blanket, at the university’s annual spring powwow (a formal American Indian cultural celebration). Hudson says this community is part of why she’s stayed in medical school, even in the face of challenges. Eating traditional tribal foods at INMED-hosted potlucks helped her battle homesickness and “made the hard times not that bad.”

Hudson’s years-long connection to INMED goes all the way back to her MCAT preparations. But the organization’s investment actually begins even farther upstream: INMED offers American Indian middle school and high school students supplemental STEM (science, technology, engineering, and mathematics) summer courses and exposure to American Indian health professionals through a six-week on-campus summer program known as Summer Institute. Similar to the University of North Dakota’s other INMED programs, Summer Institute is open to all enrolled members of federally recognized tribes, but it recruits most heavily from tribes in North Dakota and four neighboring states.

Believing that students need rigorous STEM education year-round, not just during the summer, INMED has also started trying to improve STEM education infrastructure in tribal communities, where it is chronically underfunded.⁷ In the summer of 2019 five middle school and high school reservation teachers conducted biomedical science research on the University of North Dakota campus and learned about the latest STEM education strategies.

Requiring laboratory equipment use, this program, known as NEURO (Native Educator University Research Opportunity), was postponed last summer because of the pandemic, but the other summer programs pivoted to shorter, remote models, says Warne, a family and community medicine professor and INMED’s director.

Hudson aspires to practice primary care in her hometown reservation. She wants to build trust among people like her grandmother, who hesitates to open up with doctors, given their high turnover in her community. “I want to be the person that goes into this community and stays,” Hudson says.

Warne says many of INMED’s 250 alumni have served tribal communities, noting that up to half of INMED’s medical school students are on an Indian Health Service scholarship, which obligates them to practice at Indian Health Service sites after graduation, and many remain at these sites long term. The medical school also facilitates exposure to careers in tribal communities by offering clinical rotations on reservations.

‘Trust’

Gilbert Falcon, a University of North Dakota medical school and INMED alumnus, practices hospital medicine on the Turtle Mountain Band of Chippewa Indian Reservation in Belcourt, North Dakota, where he is a member.

The hospital where Falcon practices sits about fifteen miles south of the Canadian border and faces persistent physician shortages. As a consequence, he wears many hats, seeing both adult and pediatric patients, covering the emergency department when needed, and conducting the physical exams required for commercial driver’s license applicants—a particular point of pride, he says, given that commercial driving is one of the few gainful employment opportunities in the community. Falcon is also an assistant clinical director and trains health professional students rotating at the hospital to provide culturally competent care.

Although Falcon was the first in his family to become a physician, he won’t be the last. One of his daughters is now a medical school student at the University of North Dakota, demonstrating that enabling even one American Indian person to become a doctor can have a multiplying effect.

Kellie LaFloe, one of Falcon’s patients and a dental assistant supervisor at the hospital, says that in the past she has delayed seeking care at the hospital—the only one on the reservation—because she felt uncomfortable visiting a doctor she might bump into at work. But with Falcon, things are different. “I went to the same high school as Dr. Falcon,” she says. “You know when you can trust someone.”

Physician Lois Steele, one of INMED’s first directors, started Summer Institute in the early 1970s. As someone who grew up on a Montana reservation and taught at junior high and high schools there, she knew that an effective program would need to reach youth well before college, even though some parents in tribal communities might fear the implications of sending away their teenagers for one summer. “How many people want their kids to become professionals and move away?” asks Steele, emphasizing that the fear wasn’t about only physical but also cultural separation—that those who became doctors could “forget who they were.”

To show tribal communities that being Native was not incompatible with wearing a white coat, INMED commissioned a coloring book for reservation children about an Indigenous turtle named True Heart who left home to study medicine but returned to its reservation after becoming a doctor. In 1974 the program also sent groups of American Indian pre–health professional students to reservations in and around North Dakota to encourage youth to pursue health careers, Steele says. The groups drove in an eighteen-wheeler with a turtle—a sacred figure that represents healing in many tribes—painted on both sides, according to Edwin Chappabitty, an INMED graduate who co-led this effort and who went on to become a doctor. This initiative was called the “traveling medicine show.”

Steele says that many people at the University of North Dakota played pivotal roles in INMED’s early days, including Thomas Clifford, the university president at the time, whose strong support of the program set the tone for the institution. But because Steele knew that buy-in and guidance from tribal leaders would also be instrumental, one of her first moves was establishing a tribal advisory board in the early 1970s representing more than twenty tribes in five states—North Dakota, South Dakota, Wyoming, Montana, and Nebraska. She was familiar with these tribes, and they had some cultural and economic similarities. She assembled the board by visiting tribal councils and asking, “How we should do this, and how it could serve you,” Steele says.

The board, which meets quarterly, has helped recruit students for INMED programs and provided feedback on how to support tribal community needs, and according to Twila Martin Kekahbah, a charter advisory board member, through its tribal government relationships the board has also influenced a senator to secure INMED in the Indian Health Service’s budget as a line item that can’t be eliminated without a congressional act.

Today, Warne says, there are twenty-six federally recognized tribes in the “vitally important” board’s five-state territory, but the number of tribes actively participating in the board fluctuates, given, in part, that tribal leaders have to juggle many priorities with “a dearth of resources.” Since taking the helm of INMED in 2018, Warne has visited tribes in three states to learn more about their priorities and identify potential new members for tribes with no current board representative. “Like any relationship, it needs nurturing,” he says. The pandemic has temporarily “derailed” his efforts to visit every tribe in the five states.

Warne also credits the medical school leadership for enabling the program to flourish. In each admissions cycle, the medical school adds up to seven slots for enrolled members of federally recognized tribes who are qualified candidates. “The reason we have INMED is those seven spots,” Warne says. “And those spots are set aside because of INMED.” (All INMED programs are limited to members enrolled in federally recognized tribes, which Warne notes is a political classification, not a racial one.) Warne stresses that the seven spots are add-ons that don’t take anyone else’s place and apply only to qualified candidates; if there are fewer than seven qualified candidates, the remaining slots go unfilled, and if there are more, the remaining candidates are placed on a wait list.

The medical school has also contributed funds to INMED infrastructure such as faculty, granted the program a dedicated office space, and appointed diverse academic leadership—steps critical for this type of program to succeed, Warne says, noting that he is one of only two American Indian associate medical school deans in the country and that the University of North Dakota’s medical school is one of a few with programs similar to INMED. Describing graduate medical education in general, he says, “We don’t have enough American Indians in leadership, but where we do, we see programs that affect American Indians. …People with lived experience know what needs to be done.”

Challenges

Gene DeLorme, who held Warne’s INMED director position for more than twenty years, echoes Warne’s appreciation for the medical school’s investment in resources such as INMED’s physical office space. “The secret to maintaining this population is to maintain family,” he says. “INMED needs a space to be that family and community.”

DeLorme says the school’s former Fighting Sioux logo—widely criticized as offensive to tribal communities⁸—created a “hostile environment” for some American Indian students on campus, raising the stakes for building a tight-knit INMED community. (A university spokesperson said that the Fighting Sioux name and logo were retired in 2012 and scrubbed from sports uniforms, communications, the website, and booster club but can still be found in and outside the privately funded and managed hockey arena and in limited commercial use.)

Warne says that the logo is “much less of an issue now.” The need for INMED’s familylike culture remains, however. Hudson, the fourth-year medical school student, says she has rarely encountered the logo but has experienced isolated incidents of racism from community members off campus, and she credits the INMED community as “a safe cultural environment” where she can turn to “feel welcomed.”

One of the program’s long-standing challenges has been insufficient funding that must be constantly diversified, DeLorme and Warne say. At this time, funds come from a patchwork of sources, including the University of North Dakota, private foundations, and federal grants from agencies such as the Indian Health Service and the National Institutes of Health (NIH). Warne says that the Indian Health Service—the largest source—grants $700,000 annually, but these funds haven’t increased in more than twelve years. (At this time, three other medical schools also receive INMED grants from the Indian Health Service—the University of Wisconsin, Oregon Health and Science University, and the University of Arizona.) Another federal grant was eliminated in 2006, DeLorme says.

As a result, the program has had to reduce staff in the past, and Summer Institute has to reject qualified applicants. Last summer the program received more than a hundred applications for forty-eight slots. “It’s a travesty we have to turn anybody away,” Warne says. “It’s not because they’re not qualified.”

The Next Chapter

American Indians and Alaska Natives have higher rates of diabetes, asthma, heart disease, and posttraumatic stress disorder than White Americans.^9–12 In the face of these persistent challenges, increasing the supply of American Indian or Alaska Native doctors is absolutely necessary, but it is not sufficient, Warne says. Other factors beyond the control of physicians—such as poverty, adverse childhood experiences, and limited access to healthy food—remain stubborn drivers of extreme health disparities.

Warne envisions building a public health workforce with expertise on Indigenous health issues.

To address these root causes, and prevent—not just treat—illness, Warne envisions building a public health workforce with expertise on Indigenous health issues: Indian Health Service, CDC, and NIH administrators; researchers; doctors with dual degrees; and more. To this end, the University of North Dakota’s public health program started offering an Indigenous health specialization in its master of public health (MPH) degree in 2019. In the summer of 2020 the university launched the Ph.D. in Indigenous health degree.

Warne says that this workforce needs both Indigenous people and “non-Indigenous partners and champions”; both the MPH Indigenous health specialization and the Ph.D. program are open to students of any ethnic background or country. (They explicitly encompass Indigenous health more broadly, not only American Indian health, Warne says, noting that Indigenous populations across the world tend to experience similar health disparities.) And to include people who can’t relocate or leave their jobs, the programs are offered part time and full time, both online and on campus (before the pandemic).

Amy Stiffarm says that as a single mother, living near family is critical, and if the Ph.D. program weren’t offered online, she couldn’t have enrolled. The doctorate, she says, will enable her to strengthen her research skills, develop deep expertise in Indigenous health issues, build a strong network of Indigenous health experts, and acquire “clout”—assets she believes she needs to advance in her career.

Ultimately, she wants to reduce Native American maternal health inequalities, a goal “ignited” by her seeing limited breastfeeding resources in the reservation where she grew up. She believes that improving public health could ultimately empower Indigenous health care providers. “I want to help create opportunities for healing in tribal communities,” she says.

NOTES

• 1 Association of American Medical Colleges. Reshaping the journey: American Indians and Alaska Natives in medicine [Internet]. Washington (DC): AAMC; 2018 Oct [cited 2020 Dec 21]. Available from: https://store.aamc.org/downloadable/download/sample/sample_id/243/ Google Scholar
• 2 Association of American Medical Colleges. FACTS [Internet]. Washington (DC): AAMC; 2021. Table B-5.2, Total enrollment by U.S. medical school and race/ethnicity (alone or in combination), 2020–2021 [cited 2021 Jan 5]. Available from: https://www.aamc.org/system/files/2020-11/2020_FACTS_Table_B-5.2.pdf Google Scholar
• 3 Centers for Disease Control and Prevention. Cases, data & surveillance: COVID-19 hospitalization and death by race/ethnicity [Internet]. Atlanta (GA): CDC; 2020 Aug 18 [last updated 2020 Nov 30; cited 2020 Dec 21]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-race-ethnicity.html Google Scholar
• 4 Wade L. COVID-19 data on Native Americans is a “national disgrace.” This scientist is fighting to be counted. Science [serial on the internet]. 2020 Sep 24 [cited 2020 Dec 21]. Available from: https://www.sciencemag.org/news/2020/09/covid-19-data-native-americans-national-disgrace-scientist-fighting-be-counted Google Scholar
• 5 Association of American Indian Physicians, Association of American Medical Colleges, UnitedHealthcare. Expanding the Native American health care workforce: strategies to recruit American Indian students into the health field and help improve health care quality and access to care in Indian Country [Internet]. Oklahoma City (OK): AAIP; 2019 Aug [cited 2020 Dec 21]. Available from: https://npr-brightspot.s3.amazonaws.com/legacy/sites/wusf/files/201908/uhc_aaip_white_paper.pdf Google Scholar
• 6 Centers for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19): people with certain medical conditions [Internet]. Atlanta (GA): CDC; 2020 Oct 16 [last updated 2020 Dec 1; cited 2020 Dec 21]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html Google Scholar
• 7 Fonseca F. Report: US fails in funding obligation to Native Americans. AP News [serial on the Internet]. 2018 Dec 20 [cited 2020 Dec 21]. Available from: https://apnews.com/article/b0809ce879294ca7b07ef7ef633adb12 Google Scholar
• 8 Thomason A. The long, strange demise of North Dakota’s “Fighting Sioux.” Chronicle of Higher Education [serial on the Internet]. 2015 Oct 22 [cited 2020 Dec 21]. Available from: https://www.chronicle.com/article/the-long-strange-demise-of-north-dakotas-fighting-sioux/ Google Scholar
• 9 Department of Health and Human Services, Office of Minority Health. Minority population profiles: American Indian/Alaska Natives: diabetes and American Indians/Alaska Natives [Internet]. Rockville (MD): OMH; 2019 [last updated 2019 Dec 19; cited 2020 Dec 21]. Available from: https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=33 Google Scholar
• 10 Department of Health and Human Services, Office of Minority Health. Minority population profiles: asthma and American Indians/Alaska Natives [Internet]. Rockville (MD): OMH; 2019 [last updated 2017 Mar 3; cited 2020 Dec 21]. Available from: https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=30 Google Scholar
• 11 Department of Health and Human Services, Office of Minority Health. Minority population profiles: heart disease and American Indians/Alaska Natives [Internet]. Rockville (MD): OMH; 2019 [last updated 2020 Feb 14; cited 2020 Dec 21]. Available from: https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=34 Google Scholar
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