IHS budget cuts threaten gains by Native Americans
Diabetes fueling activation of TB infections
To hang onto impressive gains in public health, TB control among them, Indian Health Services (IHS) needs to do just one thing, experts say — hold the line. Instead, however, by the time the next federal budget is drawn up, it seems likely that IHS will be losing ground, IHS officials fear.
Earlier this year, Michael Trujillo, MD, director of the federal agency, asked for an extra $170 million for IHS, which would mean an increase of 8% over last year’s budget. In his request to Congress, Trujillo noted that his agency’s budget has failed to keep pace with inflation and population growth, and that diseases like diabetes and TB afflict Native Americans at rates much higher than the general population.
For a variety of reasons, Congress probably will hand Trujillo a budget that is 10% to 15% lower than 1995 levels. That could be "devastating" to the 2 million Native Americans who depend on IHS for health care, says Mike Mahsetge, IHS legislative liaison.
Care gap will widen
For one thing, the cuts would widen the already substantial gap between annual per-capita health care expenditures for Native Americans and those for average Americans with health care insurance.
For Native Americans, the annual federal health care per-capita expenditure comes to about $2,100. That compares with $4,000 for the average American, according to Cliff Wiggins, senior operations analyst for IHS. The gap looms even wider when money spent for public health services most Americans take for granted — clean water and sewage disposal, for example — is subtracted from the $2,100 amount.
Piping clean water onto reservations and subduing the TB epidemic that raged through Indian populations at mid-century are exactly the kinds of gains — all but invisible yet enormously significant in improving the quality of life among Native Americans — that IHS is all about, say Wiggins and Mahsetge.
IHS’s TB control program is a case in point. Among the Navajo, the country’s biggest tribe, TB controllers see very little active disease and virtually no cases among children, says Bruce Tempest, MD, a longtime medical consultant for IHS who is stationed in Gallup, NM. Instead, the bilingual lay workers who perform most outreach services on the 22,000-square-mile Navajo reservation spend their days screening for latent infection and, when indicated, providing preventive therapy, says Tempest.
The diabetes epidemic that has arisen over the past few decades lends special importance to these simple tasks, almost as if it were taking the place of the TB epidemic that has subsided. The fact that the TB epidemic subsided just as the diabetes epidemic took off has resulted in two overlapping cohorts: a large group of Native Americans, mostly middle aged and older, who are diabetic, and another large group of older Native Americans who were latently infected with TB.
Add to these two cohorts the fact that diabetes raises by fivefold the risk of reactivation of latent TB infection, and it’s easy to see why Tempest and others at IHS worry about hits to the public health budget.
Diabetes takes its toll
Among all Native Americans, about one in eight suffers from diabetes, experts say. Among the Navajo, one in five suffers Type 2 diabetes, says Doug Peter, MD, chief medical officer for the IHS at Window Rock, AZ. Rates are even higher among the Pima, a tribe south of Tucson where fully half the inhabitants are diabetic.
Heredity probably plays a part in the epidemic, says Tempest. "There have been big changes in peoples’ diets. But basically, the problem is too many calories."
With as many as 70% of older Native Americans latently infected with TB, the typical patient with active TB in an IHS clinic is, not surprisingly, an elderly diabetic, Tempest says. To quell the threat of TB reactivation, many more diabetics receive isoniazid prophylaxis, which is routinely prescribed for all diabetics regardless of age, unless liver problems or other prohibiting conditions are present.
"We couldn’t do it without our tribal outreach workers, and we couldn’t do it without isoniazid," says Peter. "Slowly, we are working out our way through the cohort."
TB outreach workers are paraprofessionals, all of whom are members of the Navajo tribe who must demonstrate fluency in Navajo as well as English, a language many elders still speak. Besides speaking Navajo, the workers must learn how to perform skin testing, monitor for side effects, administer medications, and keep good records, Peter says.
Health as harmony with nature
Physicians and outreach workers strive to educate patients about the potentially devastating effects of diabetes, including neuropathy, vascular disease, and retinal damage, Peter says. At the same time, the newspapers and other media are full of advice, counseling better diets and more exercise.
"But here, you have to be careful," he adds. "Some elderly Navajo believe that if you talk about all the potential complications of an illness, it’s as if you’re basically making it happen. So there are certain ways in which you have to approach people."
Along with a belief in the primacy of the family and a conviction that ill health reflects an imbalance with natural forces, most Navajo also believe health care is something to which they are entitled. "We get really angry when people compare Indian Health Services to a form of welfare or something we get for free from the government," says Mahsetge. "The way Indians see it, it’s something we are entitled to, in exchange for our land and our lives."
But in fact, the IHS budget is a discretionary item, not an entitlement. That means the IHS must contend for funding alongside other discretionary items in the budget, often with bad results, note Peter and Mahsetge. "It’s not as if we have a single congressman who can represent our interests," Peter says. "Tribes are scattered all over the place. There’s not one single congressperson who can represent their interests, and even taken altogether, Indians are a long way from being a major voting block."
Another factor is at work as well, say Wiggins and Mahsetge: a profound reluctance on both sides of the political fence to remove the caps on federal spending that were enacted to balance the federal budget. Those caps probably will mean deep cuts to the IHS budget and, for that matter, to every other program that falls under the wing of Health and Human Services.
There is a partial remedy afforded by federal law that an increasing number of tribes are choosing to invoke: that is, to assume direct control of their health care, a step the Navajo plan to take sometime next year, Peter says. So far, more than half of Native Americans have taken over administration of their health care services. It is a trend that worries some observers, Tempest among them.
"Among the concerns are that public health services won’t be maintained," he says. "That’s always been one of the biggest strengths of IHS — providing clean water systems, making sure there is a strong immunization program, and providing good TB control."
Peter is philosophical about the potential impact of the coming takeover. "Because we have to ration health care on a daily basis anyway, we make these kind of painful decisions all the time," he says. "I’m not about to predict when or if the day will come when we won’t need TB workers."
Wiggins is confident the change will proceed more or less uneventfully and public health will be maintained. "Every issue has its own set of advocates," he says. "People who worry about alcoholism or child immunization have the same kinds of concerns [as TB control advocates]. I don’t think you’ll see any abrupt changes. Most tribes do as good a job or better than the feds."
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