Addressing American Indian Health Disparities: Q&A with Dr. Don Warne

by Beth Blevins

Donald Warne, MD, MPH, is the chair of the Department of Public Health at North Dakota State University and an adjunct clinical professor at the Arizona State University Sandra Day O'Connor College of Law, where he taught American Indian Health Policy. In addition, he serves as the Senior Policy Advisor to the Great Plains Tribal Chairmen's Health Board.

Dr. Warne, a member of the Oglala Lakota tribe from Pine Ridge, SD, received his MD from Stanford University and his MPH from Harvard University. Dr. Warne is a Certified Diabetes Educator and a Diplomate of both the American Board of Family Practice and the American Board of Medical Acupuncture. He completed Fellowships in Minority Health Policy at Harvard Medical School and in Alternative Medicine from the Arizona Center for Health and Medicine. His work experience includes working as a primary care and integrative medicine physician and as a Staff Clinician with the National Institutes of Health in Phoenix. He serves as a member of several national committees and boards including the March of Dimes, the CDC Health Disparities Subcommittee, and the National Advisory Committee for Rural Health and Human Services.

We recently discussed health disparities among American Indians and his transition from medicine to public health policy.

How did you get from an Indian reservation in South Dakota to Arizona State University, where you received your undergraduate degree in science?  

I am originally from Kyle, SD, on the Pine Ridge Indian reservation. When I was in grade school there was, unfortunately, violence at Pine Ridge. It was the early 1970s – the Wounded Knee occupation. President Nixon sent the National Guard and tanks. It was an unsafe community to be in at that time. My parents decided they wanted to find a safer place to raise their family. We moved to Arizona. My dad had relatives there.

I grew up in the shadow of ASU. My dad went there, and my mom got her bachelor's and master's in nursing there. I grew up with the expectation that I would go to ASU too. It was a bigger achievement for my mom – she was the first person in her family to go to college. I was fortunate to grow up in a family that had experience attending college and that it was an expectation for my brother and me.

What drew you to science and medicine?

I was spending the summers back in Pine Ridge with my uncles who were traditional healers and medicine men. I was given my grandfather's Lakota name then: “Pejuta Wicasa,” which means “Medicine Man.” So I was learning a lot about traditional arts and sciences related to healing. It was an apprenticeship without knowing it was an apprenticeship. I was interested in traditional medicine and my mom was a nurse. It exposed me to different perspectives on healing arts and sciences.

What made you want to pursue an MPH after completing your MD? 

I was tired of treating preventable issues and felt like I didn't have the tools in the clinic to focus on prevention. That's why I decided to focus more on public health.

I went into medicine a little naively, thinking I could have a big impact on American Indian (AI) health as a primary care doctor. What I learned very quickly is that I could have an impact one patient at a time, but the issues related to health challenges and health disparities occurred long before people got to the clinic or hospital. So working upstream is also focusing on primary prevention. The vast majority of AI health disparities are preventable. We don't put enough effort into community-based health promotion and disease prevention programs. We put most of our resources into managing issues once they become a crisis. I was tired of treating preventable issues and felt like I didn't have the tools in the clinic to focus on prevention. That's why I decided to focus more on public health.

The word “diabetes” appears more than 55 times on your CV. Why is the study of diabetes so important to you?

It is preventable. We didn't have a problem with diabetes until tremendous changes in lifestyle – when rivers were dammed, wild game and herds were taken away, land was seized by non-Indian people, and traditional farming went away. Then the lifestyle changed dramatically – from a healthy, organic paleo diet to one dependent on government commodity foods. Through the USDA there is a commodity food program that historically was horrible food – bleached flour, white sugar, white bread, canned meat, and pure corn syrup. The origin of fry bread is not traditional AI food — it's people doing the best they can with their commodities. We call it “traditional USDA food.”

I don't look at diabetes as a medical issue but as a social justice issue. It's a physical manifestation of colonization. We've had dispossession of resources, so it's one of the outcomes. It is preventable, but it requires systemic approaches, including things like food sovereignty and policy.

What health disparities affect rural AI populations? And what are some of their main causes?

When our children grow up in adverse conditions and with higher rates of poverty and instability in their homes and communities, they are at higher risk for all kinds of negative health outcomes.

In the Northern Plains, we have a higher prevalence of diabetes, heart disease, and cancer. We also have a higher prevalence of mental health conditions, including PTSD, depression, addiction, and suicide. The root of those, I believe, is unresolved trauma. We have a lot of historical trauma. If you look at the field of epigenetics, you see that when populations are under tremendous stress, it can have a negative impact on their DNA and it can be passed from one generation to the next. But also, when our children grow up in adverse conditions and with higher rates of poverty and instability in their homes and communities, they are at higher risk for all kinds of negative health outcomes. That's one of the reasons we see higher rates of depression, hopelessness, and suicidality. It's really because of the social circumstances.

We have unique patterns of health disparities for AIs. Our system of care historically has taken a one-size-fits-all approach. Empirical data shows that doesn't work. That's the reason I'm doing this work. We need to have AI-specific interventions to address our health needs.

What can be done to immediately address these health disparities? And what, particularly, are you doing?

We have to focus on intergenerational solutions – working upstream, working with communities and families to try to eliminate adverse childhood experiences.

There's very little that can be done immediately to resolve disparities. These are issues that have been building for generations. We have to focus on intergenerational solutions – working upstream, working with communities and families to try to eliminate adverse childhood experiences. And there are emerging practices that appear to be effective in preventing adverse childhood experiences and promoting stability in the home. These are home visitation programs and parenting skills programs. By working upstream, we have to work with those families, but also work with young people before they become parents. We need a whole generation focused on parenting skills and the impact of adverse childhood experiences. We need trauma-informed health systems, educational systems, legal and judicial systems. It is unresolved trauma that's causing intergenerational health disparities and we can't just put a band-aid on it. It's going to take a generation.

How do you define or describe this unresolved trauma?

It's ongoing discrimination. Racism is alive and well, unfortunately. When a population feels discriminated against or marginalized, it creates a great deal of emotional strife. That's not just a theoretical construct — it's a way of life for many of our people. There are highly stressful and toxic conditions and a lot of unresolved anger and depression based on these traumatic experiences. It starts historically and intergenerationally and then perpetuates through childhood and adulthood. In the Great Plains, there's a lot of overt racism against AIs. That has an impact on health.

NDSU offers an MPH degree with specialization in American Indian public health. Why is it important? And how is it different from other types of public health?

One of the frustrations I had with academic public health, historically and at many highly respected schools, is that we had a very good focus on international health and global health. But what I had to remind my colleagues is that you don't have to cross an ocean to find Third World health conditions. It's right here, in our reservation communities and many of our inner cities. In truth, AI public health has been mostly ignored by academic public health and the public health sector, in general. I think it's because there are so few AI leaders in public health.

The non-AI world doesn't understand the unique nature of Indian health, the unique nature of the patterns of our health disparities, and the impact of colonization. We don't learn accurate history in our educational systems in the United States. We are largely ignored as a population. I've complained about it for years. I had an opportunity to do something about it when I joined the faculty here, so that's why we started it.

AIs are the only population in the U.S. that is born with a legal right to health services. Most people don't know that, even health experts. Based on treaties and other legal bases, AIs have a legal right to health services – that's why there's an IHS and Bureau of Indian Affairs. The entire United States is AI land. We did not lose all of our land and natural resources in a war — they were mostly exchanged through treaties for social services, including housing, education, and healthcare.

We talk about cultural and social determinants of health, recognizing there are hundreds of AI cultures, not just a single AI culture.

We wanted to do something about it, so our program focuses on AI health policy, history, and the evolution of the IHS, looking at health disparities through an unresolved trauma lens, both historical and through childhood experiences. We look at the impact of colonization and the dispossession of resources and how that leads to things like diabetes. We talk about cultural and social determinants of health, recognizing there are hundreds of AI cultures, not just a single AI culture. There's lots of diversity within our populations and diversity regarding our health disparities. In addition, we have unique research issues. We have indigenous research paradigms, but we also have to respect tribal sovereignty when we are conducting health research, so we have a class focused on research issues within tribal communities. We have a lot of things that are working well in Indian country, but most of them have not been formally evaluated or published. We have a course called Case Studies in Indian Health, so we know what is working and why it is working.

In a recent talk, you said that Kyle, SD, is a food desert, with the nearest grocery store 100 miles away. What can be done to change government policy that funds expensive interventions (like dialysis) but not access to fresh and healthy food?

There's a whole area of focus on food sovereignty, recognizing that we have options in front of us to recapture some traditional foods. A lot of communities are doing it on a smaller scale, but we'd like to scale it up in terms of local gardens using modern technology, like greenhouses. We could potentially grow crops nearly year-round and have a local food base. In addition, a lot of tribes are raising buffalo herds. Buffalo meat has a higher protein concentration than beef and a better nutritional profile. So, many communities are trying to promote access to inexpensive traditional foods, which actually taste incredibly good! We haven't had access to it because of dispossession of land, but now we are at a point where some communities are stabilizing and are focusing on prevention and the benefits of traditional food systems.

We have a good partnership with our College of Agriculture here, particularly the College of Plant Sciences. They are studying traditional food profiles. For example, there's an ancient seed line of squash that we're studying for its nutritional profile. It's much healthier than the type of squash you purchase at the local grocery store. We're blending traditional culture with modern scientific principles.

Each community is different in how they are funding this. One of the approaches that a tribe is taking with one of our graduates is looking at developing a co-op – a community-owned food program where they would provide food to the community but also sell and package traditional foods as an economic development opportunity. Typically, it does need some investment on the front end. There are some opportunities for USDA small business loans and grants to get things jump-started. But it's potentially sustainable just through economic development.

You're the Chair of the American Indian Public Health Resource Center (AIPHRC) at NDSU. How does the Center work to address health disparities and achieve health equity for American Indian communities?

When I started working at NDSU, I did not want to focus only on academics. The needs in our communities for public health resources are tremendous, and I wanted to be sure that we are part of the solution in a direct manner. The AIPHRC is unique in academic settings in that we can combine the skillsets and knowledge base of academic public health directly with community needs, community champions, and we can do it in a culturally relevant manner. We are focusing on public health education, policy, research, and services, and we have successfully worked with all the tribes in North Dakota, South Dakota, Montana, Wyoming, and Minnesota, as well as communities across the nation. I think the future of AI public health looks bright – our graduates are well prepared and are already accomplishing great things to improve the health of our people.

Opinions expressed are those of the interviewee and do not necessarily reflect the views of the Rural Health Information Hub.