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GeiselSchoolofMedicine

IndianHealthServiceSpringTripOjibweNations,Minneapolis,&Duluth,MN

March12–March19,2016

BoisForteKatieKozackaAlexTarabochiaGeorgiaGriffinEmilyGeorges

CassLake

ThomasKuczmarskiAngelaLeeJacobWasag

MaggieGrinnell

RedLakeDoraHuang

VeennaMinnalJessicaCharlesMargotLeNeveu

FondDuLacTommyFlynnSimrunBal

MeghanWendlandNayanAgarwalJoshRamos

FacultyAdvisorShawnO’LearyOfficeofMulticulturalAffairsGeiselSchoolofMedicineatDartmouthThistripwasmadepossiblewiththegenerosityandfundingfromtheByrneFoundation,Ohiyesa,GeiselOnDoctoringProgramandGeiselStudentGovernment

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Introduction ThiswastheseventhyearinarowthatwewereabletoofferthisexcitingexperientialculturallearningopportunitytotheDartmouthcommunity.Thisyearfifteenmedicalstudentsandtwomastersofpublichealthstudentsparticipatedinthetrip.

Newthisyearwewereabletoincorporatethetripintoanelectivethatincludedpre-tripcurriculumalongwithmid-tripandpost-tripreflection.Studentsweredividedintofourgroupsandeachwenttoadifferentreservation.Eachofthesereservationgroupstookonacurriculumtopic,researchedit,andleadthegroupinapre-tripsessiononthetopic.Thisyearthegroupchosetofocusonfourtopics:History,Culture,IndianHealthCareSystem,andHealthDisparitiesaffectingIndians. TripGoals

§ TobuildontherelationshipswiththeOjibwecommunitiesinitiatedbypastgroupsofGeiselmedicalstudents.

§ Tolisten,observe,andbegintounderstandthehealthcareandsocialissuesfacingOjibwecommunitiesthroughdirect,personalinteractions.

§ Toprovidemeaningfulcommunityservice,developedincollaborationwithcommunityleaders.§ TosharewhatwelearnedbyraisingawarenessamongourcolleaguesandpeersatGeiselMedical

School.Background

Thefollowingbackground information is takenfromthe2010tripreport,whichdidanexcellent jobconcisely describing the historical and cultural background relevant to a better understanding of therelationshipbetweenhealthcareproviders,theUSgovernment,andNativeAmericansinMinnesota.

OjibweIndiansarepartoftheAlgonquianfamilyofaboriginalNorthAmericans.“Anishinabe”,orfirstman,istheOjibwetermfor“thepeople.”OralhistorysuggeststhattheOjibwefirstlivedfurthereast,ontheAtlanticcoastofthenorthernUnitedStatesandCanada.Followingapproximately200yearsofmigration, inthemid-1700s the Ojibwe resettled in central and northernMinnesota where they supported themselvesprimarilybythecollectionofwildricenativetothearea’s lakes,supplementedwithhuntingandcultivatingvariousplants.

Inthe1880s,theUnitedStatesgovernmentadoptedapolicyofassimilationintheiractionsregardingNativeAmericanpeoples.Boardingschools,bothprivateandgovernment-run,wereestablishedandchildrenwere systematically taken from their homes in an effort to increase acculturation. At their height in 1902,there were twenty-five non-reservation boarding schools run by the Bureau of Indian Affairs. The schoolstaught primarily a vocational curriculum.1 Students were often renamed before being dressed in westernclothing and forbidden from speaking their native languages.Whilemost schoolshad closedby1950, theyhavehadanindeliblemarkonthepsycheoftheNativeAmericanpeople.2

The Indian Health Service was established in 1955 to replace the Bureau of Indian Affairs as theproviderofhealthcaretoNativeAmericans,aresponsibilityoftheUSgovernmentestablishedin1978withArticle I, Section 8 of the US Constitution. The IHS is a division of the Department of Health and HumanServices and today provides comprehensive health services to approximately 1.9million Native AmericansacrosstheUnitedStates.

1http://brownvboard.org/brwnqurt/04-3/04-3a.htm2http://www.lib.utexas.edu/taro/ttusw/00081/tsw-00081.html

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ReservationCommunities

This year the entire groupbegan inMinneapoliswherewewereable to visit the Little Earth Urban Indian community. Our group of 17studentssplitupintofourgroupsSundayafternoonandheadouttofourdifferentreservationstostayfortheweek.GroupsvisitedBoisForte,RedLake,LeechLake,andFondduLacreservations.

TripActivities

Saturday,March12Thefirstweekendwasspentasagroup inthehomeof twophysicians,Dr.AngelaErdrichandDr.SandeepPatel.Dr.Erdrich isanativephysicianwhospentmanyyearspracticingonherOjibwereservation inNorth.DakotaandwhocurrentlyworkswiththeLittleEarthnativecommunityinMinneapolis.HerhusbandDr.Patelcurrently isapediatrianwhosplitshis timepracticing inMinneapolisandonhiswife’s reservation inNorthDakota. Saturday afternoon, TommyWoon met us at Dr. Erdrich and Patel’s home,where he led us in asomaticexperience.Notonlydidthisexperiencehelpstudentsdecompressfromtheweeklongfinalswehadjustfinishedthepreviousday,butitalsopreparedusforpotentialracialandculturaltensionswemightfaceas outsiders traveling to our respective reservations. Following the somatic experience, we walked toBirchbarkBooks,alocalbookstoreownedbyDr.Erdrich’ssisterandrenownedauthor,LouiseErdrich.Atthebookstore,we heard a book reading from a Leech Lake Band of Ojibwe elder and author, Donald RichardWright.Aspartofhisbookreading,DonaldRichardWrightdiscussedtherolealcoholandalcoholabuseplayin the livesofnativepeopleandalso therolesmedicineandtraditionplay in thehealingprocess.We thenheaded back to the house for dinner and smaller conversations. We ended our day with a very movingpresentationbyDr.LaielBaker-DeKrey,whospoketothegroupabouthistoricaltraumaandtheimpactithasonnativecommunitiesandlives.Sunday,March13SundaymorningweheadedovertoLittleEarthofUnitedTribes.LittleEarthisaHUD-subsidizedhousingcomplexfornativepeoplelivinginMinneapolisandisacenterfornativeculturewithinthecity.Wewereintroducedtoamidwife,whospoketousaboutOjibweculture,traditionalpractices,andtheroleofamidwifeinthebirthingceremony.Shenotonlygaveusadditionalinsightsintothecommunitywewereabouttobeworkingwithbutsheofferednewwaystothinkaboutmedicineandthehealthprofession.Wealsoheardfromthemidwife’stwonephews,whoarebothdoingadvocacyworktoimprovethelivesofnatives.Theyhighlightedtheimportanceofworkingwithyouthinordertoeffectchangeinthefuture.Attheendoftheirpresentation,thegroupdividedandpeopledepartedforthedifferentreservationstoprepareforthenextday.

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RedLake(Margot,Jessica,DoraandVeenna)Monday(March14th):WearrivedattheRedLakeIHShospitalat8A.M.MondaymorningandreceivedawarmwelcomefromLindaBedeau,JoDudley,Dr.MichaelBorromeo,andDr.PaulDitmanson,thehospital’sclinicaldirector.Followingbriefintroductions,welearnedaboutthehistoryofRedLakeNationfromtheCommunityNurseManager,MaryAnnCook.WehadachancetoaskquestionsandhearabouttheconnectionbetweenTribalHealthandtheIHS.Followingthismeeting,weweregraciouslygivenatouroftheRedLakereservation.Onourtour,wehadachancetovisitRedLake’sfourdistricts,viewtheicefishinghutsonthefrozenRedLake,andhadthreebaldeaglesightings.Uponreturningtothehospital,weenjoyedaquicklunchfollowedbyhomevisitswithLaurelLussier,acommunityhealthnurse,andshadowingintheoutpatientclinicwithDr.Borromeo.AttheendofourfirstdaywedrovedowntoBemidjiforaleadershipdinneratTheGreenMillRestaurantwithTribalHealthleaders,membersoftheNationalHealthServiceCorps,andtheteamvisitingCassLake.

Tuesday(March15th):WestartedbrightandearlyatthehospitalonTuesday,shadowingbothinpatientandoutpatientproviders.Itwasagreatwaytoseetheday-to-daypracticeofphysiciansandnursepractitionersinthisarea,giventheresourcesavailabletothehospitalanditsstandinginthecommunity.Wewereabletoworkwithpatientsrangingfrom<1y.ototheelderly,andbegintoappreciatetherangeofintegrativecareneededintheclinic.Laterthatevening,wemetwithDr.Borromeofordinner,onefulloflaughter,conversation,anddeliciousbuffalognocchi.Overall,itwasagreatwaytoexperience,first-hand,thetypicalpracticeofprovidersinRedLake--andtheopen,collaborative,andextremely

heartwarmingcommunitytheyhavecreated.Wednesday(March16th):AnotherbrightandearlystarttothedayattheRedLakeIHShospitalshadowingcliniciansintheoutpatientclinics!WethenmadeourwayovertotheRedLakeHighSchoolwhereweconducteda3½hourseminarwith4-5highschoolsophomoresandjuniors.Afterintroductions,wehadlunchwiththestudentsandthenproceededtoguidethemthroughseveralcareer-buildingworkshopsdesignedtohelpthemhoneskillsforhighereducationandlatercareers.Thefirstworkshop,theGumdropChallenge,centeredaroundteamworkandhelpedthestudentsdeterminewhatkindofroletheywouldprefertoplayinateamsettingbasedontheirstrengths(i.e.visualvs.hands-on).

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Thesecondworkshopconsistedoflogicpuzzlestoencouragethestudentstothinkcriticallyaboutproblemsolvingandtothinkcreatively.ThistypeofexercisewasmeanttohelpthestudentspracticethekindofthinkingthatwouldbeemployedinprofessionslikeMedicineorEngineering.ThenextworkshopincludedthreestationsdemonstratingvaryinglevelsoftimeddexteritychallengestoencouragethestudentstoconsiderprofessionsthatrequireexcellentfinemotorskillslikeSurgery,Tailor/Seamstresswork,orArt.ThelastworkshopentailedreadingSATpassagesandcorrectingthegrammarandpunctuation.ThiswasimmediatelyapplicabletothestudentsastheywouldsoonbetakingtheSATsandACTsandalsohelpedthestudentsconsidercareersinlinguistics,writing,editing,orineducation.Wethenaskedthestudentstomakealistof5goalsfor

theirfuturewithatleastonethatcouldbeattemptedthisyear,3obstaclesthattheywouldneedtoovercome,and2resourcesthattheyhavenowtohelpthemovercomethesechallenges.Ourlastexercisewiththestudentsinvolvedaskingthemtowriteletterstotheirfutureselves,whichwouldbedeliveredtothematgraduation.Thestudentshadagreattimeandwehopethattheyfoundthisseminarusefulastheycontemplatetheirfuturecareers.

Thursday(March17th):WecheckedoutofthehotelonThursdaymorningbeforeheadingtotheclinic.WethenhadaninformativediscussiononbehavioralhealthwithDr.CaseyMcDougall.Welearnedabouttheirservices,whichincludepatienteducation,psychotherapy,andmentalhealthevaluation.Dr.McDougallalsotalkedabouthowthedepartmentintegratesculturaltraditionswithwesternmedicinepractices.Afterourmeeting,wehadlunchinthecafeteria,whichincludeddeliciousfrybread,andsaidourgood-byestoRedLakeHospital.WethenstoppedbythelocalfisheryinRedbybeforeheadingtoDuluth.

BoisForte(Katie,Georgia,Alex,Emily)SundayMarch13th2016:WearrivedattheFortuneBayCasinoHotelinVermillion,Minnesota.Wepreparedourselvesforanearlymorningthenextday.MondayMarch14th2016NettLakeClinic:WhenarrivedattheNettLakeclinic,servingtheBoisFortebandofChippewa,weweregreetedbyfrontdeskstaffanddirectedtoclinicaldirectorSueLarsonwhohadplannedourclinicalactivitiesfortheweek.Shegaveusatourofthehealthanddentalclinicsandintroducedustostaffandhealthcareproviders.Aftergeneralintroductions,wesplitupandshadowedtheproviders.TheseincludedDr.Halleloidwhoofferedverythoroughprimarycareservicesanddidnotmissabeatwiththepatients,RaymondHawk,aPAwhowequicklylearnedwasnotonlyanoutstandingprovider,butaclassact;Dr.ShanaLandgren,a

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primarycarephysicianreturninghometoservethecommunity;andSigridCasey,ayoung,vibrantPAalsoservingthepatients.Afterlunch,wemetwiththediabeticcoordinatorDorisIsham,whoexplainedherrole

educatingcommunitymembersaboutdiabetesandeducatingthosewiththedisease.Laterthatafternoon,wecontinuedshadowingtheprovidersuntilallofthepatientswereseen.TheclinicalshadowingattheNettLakeclinicgaveusgreatglimpseintoIndianhealthcareandmoregenerally,thepracticeofprimarycareinaruralarea.Italsogaveusaglimpseintohealthcarewithlongerappointmenttimeswheretheprovidershaveampletimetolistenandbecomprehensivewithpatients.TuesdayMarch15th2016VermillionClinic:Wewereexcitedtospendthemorningat

thenewTribalClinicinVermillion.ThisclinicwassimilartotheNettLakeclinicinitssetupbutwasmuchnewerandwasnotyetfullystaffednorstockedforthepharmacy.ManyoftheproviderswhoworkattheNettLakeclinicwillalsoworkattheVermillionclinic.WemetSueonceagainandtwoofusshadowedprovidersintheclinicwhiletheothertwowereabletogoonhomevisits.Homehealthvisits:meetingpeoplewherethey’reat:GoingonhomevisitswithJill,acommunityhealthnurse(CHN),waseye-openinginmanyways.ItilluminatedsomeofthehealthchallengesfacedbyindividualsinLakeVermillionandNettLakeareas(themajorityofwhomareBoisForteBandmembers).Itrevealedtheunbelievablyhighunemploymentrates(38%),theinaccessibilityofhealthyfoodandhealthcareservices,thepervasivenessofopioidandalcoholaddiction,thewidespreadproblemofchildabuseandlackofparentingskillsthataredirectresultsofforcingNativeAmericanchildrentoattendboardingschoolsawayfromtheirfamiliesinthe1800sand1900s,andthecoldrealityofgenerationsofhistoricaltrauma.Moreimportantly,itputhumanfacestothesehealthdisparities.Itwasacrisp40°dayintheparkinglotlookingoutoverLakeVermillion.Iwasbundledinacoatandmittens,whileJilldonnedcapris,Chacos,herstethoscope,andagoodnaturedsmile.Unfortunately,someofthepillsfortwoofJill’spatientshadnotarrivedfromthepharmacyatNettLakeClinic,75minutesawayfromVermillionClinic.Suchdelaysarecommon,Jillexplained.Shewouldhavetovisitthosepatientsagaintomorrow.Weloadedherminivanandsetouttodeliverpillboxestosixpatients.Jillisinchargeofthepillboxdistributionprogramtohelpelderlypatientskeeptrackoftheirpillregimensandavoiddifficulttripstotheclinictofulfillprescriptions.Shealsofollowsupwithpatientsathome,checkstheirvitalsigns,providestransportationtotheclinicwhennecessary,explainsdoctors’instructions,andplaystheessentialroleoflinkingthecareprovidedbytheclinicwiththecarereceivedbypatients.Jill’spassionismaternalhealth.ShecoordinatestheWICsupplementalnutritionprogramformotherswithchildrenunderfiveyearsold,andmonitorsthegrowthanddevelopmentofthechildrensheworkswith.Jillsupportsandeducatesmothersaboutbreastfeeding,childnutrition,andparentingskills.Aswedrovearounddeliveringpillboxes,Jilltoldmestoriesaboutthepeoplewhosehomeswepassed.Shesmiledandsaid,“that’swhatIloveaboutthiswork,everybodyhastheirstories.”ThefirstpatientwevisiteddoesnotusuallyletJillinside,whichshesuspectsisbecausethefamilydoesalotofdrugs,soshehadmewaitinthevanwhilesheknocked.Thatdayshewasinvitedinforthefirsttime.IwasinspiredbyJill’sunconditionalcompassion,herpatience,andherprocess-orientedapproach.Whileprogresswasslow,shenotedthatbreastfeedingrateshaveincreasedinthecommunitysinceshebegandoinghomevisitsasaCHN

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over5yearsago.Jillisremarkablyunjadedbyherjob,thechallengesofhelpingpeopleevenwhenitdoesnotfeelappreciated,andthefrustrationsofwitnessinginjusticesthatshecannotfix.Jillreflectedthatshejust“meet[s]peoplewheretheyareat.”Oursecondpatientwasanelderlymanwithcomplexchronichealthneeds,whoisnotaBoisForteBandmember,buthaslivedinthecommunityforalongtime,andhasanimpishsenseofhumor.Jillhasbeenhelpinghimmonitorhisbloodpressureforyears.HegotakickoutofteasingmethatIwasnotasgoodattakinghisbloodpressureassheis.Hispersonalitypercolatedthroughthevisit.Itwasaprivilegetogettochatwithhimaboutlifeandhishealthinthecomfortsofhishome.Meetingpatientsasguestsintheirhomeschangesthedynamicbetweenpatientandprovider.Iwasimpressedbyhowhomevisitsenablesmoreeffectiveeducationabouthealth-relatedissuesandhowmuchperspectivewegainbymeetingpeoplewheretheyare.Infact,IthinkthatincorporatinghomevisitationprogramsintomainstreamU.S.healthcarewouldimprovecoordinationofcare,andhelppreventsomeoftheburdenofchronicdiseaseweseeinoursociety.

NettLakeSchool:Wewerefortunatetospendtheafternoonwith5thand6thgradersattheschoolonthereservation.Wefocusedourvisitoncareersinmedicine.Wemadethreestationsthroughwhichstudentswouldrotate.Onestationtaughtthemhowtouseastethoscopeandwespokeaboutanumberofcareersthatusedstethoscopesincludingdoctor,nurse,EMT,etc.Thekidsputonourwhitecoatsandlearnedtotakeabloodpressureaswell.Thesecondstationfocusedonwaterfiltrationandtheimportanceofwaterconservation.Thestudentsmadefilterstocleanwaterandlearnedaboutpublichealthandenvironmentalengineering.Thefinalstationinvolvedcreatingaworkinghandfrompaper,string,andstraws.Thestudentslearnedaboutbiomedicalengineeringinthisstation,astheyweretaughtaboutprosthetichandswhiletheymadetheirown.Overall,wehadagreattimewiththestudentsandthe

teachersandhopethattheylearnedsomethingnewaboutcareersinmedicine.Theteacherswerewelllikedbythestudents,andseemedtocarealotabouttheireducation.CommunityDinner:WemetupwithShawn,Grampie,andMiketohavedinner.WespokewithGrampieaboutthewildriceharvestingonNettLake.NettLakeisthelargestproducerofwildriceinthecountry.Itisextremelynutritiousandwasawayoflifeforthenativecommunityhere.Recently,itseemedthatfewerfolkshavebeeninterestedinharvesting.Wherethereusedtobe200canoesonthelake,nowthereareonlythreeduringtheharvest.Now,thereisacommitteethatcontrolswhenharvestingisallowedtooccur.Grampiestillharvestswildricebecauseititapartofwhoheis,andheandShawnharvesttogethereveryfall.WednesdayMarch16th2016SnowDay:MeetingwiththeCasinoCEO:Unfortunately,wehadsomeunexpectedsnowthatclosedbothclinicsandtheschooltoday;however,wewereabletospendtheafternoonspeakingwiththeNormAdams,theCEOofthecasino.Wewereinterestedinhowthemoneyhelpsthetribe.Someofthatmoneydoesindeedgobacktofundtheclinicandschool,howeverthecasinoalsobringswithitproblemsonitsown,includinggamblingandotherformsofaddictionforbothnativesandnon-natives.Itwasinterestingtohearhis

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perspectiveonthecasinoashehadworkedthereforanumberofyears.Afternoonwithcommunityelders--Jose,Rita,andKaren:ThefourofusplusShawnandGrampybravedthestormanddroveontothereservationtovisitRitaandJoseforcoffeeintheirhome.KarenDrift--acaptivatingstory-tellerandoneofthefewOjibweIndianswhoisfluentinthelanguage--joinedaswell.Afterofferingtobacco,Karenbegantotellstoriesaboutherchildhood,naturalmedicines,thehistoryofTurtleIsland,andtheOjibwewayoflife.WediscussedthepreservationoftheOjibwelanguage.Karenisworkingwithintheschooltryingtoestablishlanguageasacomponentoftheirculturaleducation.Indeed,itdidseemlikewhenwewereattheschoolthedaybeforethatthestudentswerehappilyusingOjibwelanguagewhentheyknewtheword.Karenexpressedfrustrationthatnotasmanypeopleareaspassionateasheratlearningandsharingthelanguage.Theyoutharelessinterestedintraditionalwaysoflifesuchaswildriceharvesting,hunting,andfishing.Theyhelda“takeyourkidswildricing”dayatwhichtheyhadalowerattendancethanhoped.Shewouldliketobringbackthingslikeblueberrycampfortheyouthtogetthemengagedwiththeirenvironment.Astheeveningsetin,wedecidedtocontinuetheconversationoverdinneratTheDamRestaurant.Thediscussionturnedtomedicinalhealing.Karenwaswellversedinnaturalmedicines.Shedescribedmanythathelpedwithcancers,skinrashes,andtherewereevenstoriesoflovemedicine.Whentheinformationwastoldtous,itwasusuallyintheformofastory.Modernproblemslikediabetesandheartdiseasedonothaveanaturalcure.Theyneedthemodernmedicinetofixit.ThursdayMarch17th2016OurlastmorninginBoisForte.Weweresadtoleaveourfriendsattheclinic,especiallySuewhohelpedustremendouslywhilewewerethere.

TribalCouncil:Wemetwiththetribalcouncilandtouredtheirfacility.Itlookedfairlynewandhadalotofnativeartworkliningthewalls.Weofferedthemtobaccoandtheyspokewithusaboutanumberoftopics.Therewerefourcouncilmemberswhometwithus,threemenandonewoman.Theyallseemedmiddleagedandactiveinthecommunity.Acoupleofthemenwerewearingbasketballjerseys.Theyspokeaboutthechallengesinrecruitingphysicianstothearea,butalsosaidthattheywereabletopaythedoctorswellwhoworkedatBoisForte.Webroughtupthewildriceharvestandtheconcernsthatitwasnotbeingharvestedinthesamewayasitusedto,andtheystatedthatpeoplestilldidharvestthericeat

veryhighrates.Itwouldbealmostimpossibletoharvestitall,anditwasgoodforsomeofthericetofallintothewater.Therewereeffortsfromthetribalcounciltobringbackthosetraditions.Itseemedthattheywereallengagedinthecommunitybybeingcoachesandupholdingtheirnativeculture.Onecouncilmember,BrandonBenner,showedushisofficewherehehadacollectionofgiftshehadcollectedthroughouttheyears.Hehadmanyeaglefeathersthatweregiventohim.Whenatribemembergraduatesfromcollegeorhasagreataccomplishment,hegivesthemspecialgifts.Hedanceswithallthegiftshereceivesandoneofhismostprizedgiftsisaheadpiecemadefromporcupineneedles.Thewomanwhogaveittohimhandsewedeachneedleintotheheadpieceindividually.

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HeritageCenter:BeforeheadingoutforDuluth,westoppedbytheBoisFortemuseumtolearnmoreaboutthereservationandtheOjibweculture.ThemuseumtookusthroughthefirstOjibwepeopletoliveatNettLake.Themuseummovedthroughhistoryandtaughtusmoreaboutcolonization,thefurtrade,andtheboardingschoolsinthearea.Whilethispartofhistorybecomestragic,attheendofthemuseumisafeelingofhopeandresilienceisclear.Todaythecommunityisworkinghardtobuildbackitscultureandlanguage.

CassLake(Jacob,Maggie,Angela,Thomas)AfterinformativesessionsinMinneapolis,ourcrewheadedtoCassLake.CassLakeislocatedapproximately200milestothenorthwestofMinneapolis,afourhourdrivebyrentedcar.Thetripconsistedofrollinghills,occasionalfarms,andafewcows.ThefirstpersonwemetinBemidji,theurbanareanearCassLake,wasanemergencyroomphysician,Dr.MicahTreuer,whowasraisedinCassLake.WewereluckytoreceiveageneraloverviewofthecommunityandofhealthcarefromDr.TreueroverpizzasandsaladsatDave’srestaurant.Afterwards,wefoundwhatwouldbeourhomeforthenextseveralnights:thePalaceCasino.

OnourfirstdayinCassLake,MaggieandAngelajoinednursesfromtheLeechLakeTribalHealthClinicforpatienthomevisits.ThisamazingexperiencegaveMaggieandAngelaaninsideviewtothepatients’lives,andgavegreaterunderstandingtohowthepatientslivedandwhattheirpersonalsituationswerelike.Giventhatmanyofthepatientslivedinremoteareas,wesawthetremendousimpactthatthesenurseshadonthelivesofthesepatients.Onthesameday,JacobandThomaswenttoaTribalHealthClinic(outpatient)atBemidji.AttheClinic,ThomasandJacobworkedwithanoccupationaltherapistandanursethroughouttheday.TheylearnedaboutthefinancialworkingsoftheIndianHealthService(IHS),aswellaschallengesthatbothpractitionersandpatientsfaceinregardstohealthcarereimbursements.JacobandThomasalsometwithShawnO’LearyandfourIHSadministratorsforlunch,duringwhichmorewasexplainedaboutthedifferentwaysthatNativeAmericansreceive

fundingforhealthcare.AsasurprisetobothJacobandThomas,onlyaboutonethirdofhealthcarereimbursementforIndianinstitutionsisderivedfromIHSfederalfunding,withtheremaindercomingfromthirdpartybillingsuchasMedicareandMedicaid.Thatevening,allfourofusmetupwithresidentsofLeech

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Lake,nursesfromIndianHealthClinicsandHospitals,aswellasclassmatesthatwerevisitingthenearbyRedLakeReservationandhadacommunitydinnertogether.

Duringthemorningofthesecondday,weallshadowedprovidersattheCassLakeIndianHealthServiceshospital.Atthisfacility,whichhadabrandnewadditionthatdoubleditssize,weshadowedapediatrician,afamilypracticedoctor,andtwonursepractitioners.Wejoinedtheprovidersintheexaminationroomsandmetnumerouspatients,gaininguniqueinsightintosomeofthedifferenthealthchallengesthatfacemuchofthe

Nativepopulationsuchasuncontrolleddiabetes,obesity,cardiovasculardisease,andopiateaddiction.Thatafternoon,wetravelledtotheBug-O-Nay-Ge-Shigschoolandgaveapresentationtomiddleandhighschoolstudents.Attherequestoftheschooladministration,wepresentedmaterialandhaddiscussionsonhearthealth,diabetes,druguse,andsafesexpractices.Jay,theguidancecounselorattheschool,alsogaveusatouroftheschool.TheschooloffersauniqueeducationtoNativestudentsbyemphasizingthetraditionsandcustomsoftheOjibwepeople.Welearnedoftheschool’scurriculum,bothclassroomandfield-tripbased,thatfocusedaroundteachingandreintegratingthesecustomsintothelivesoftheyoungstudents.Wewereexcitedtohearthattheschoolwasrecentlyawardeda$12milliongranttorefurbishpartsoftheschool!Welookforwardtoseeinghowtheschoolcontinuestocreateapositiveimpactonthestudentsandsurroundingcommunity.Thethirddaybeganwithsomeexcitement:oneofourgroupmembersunfortunatelycamedownwithanastysicknessandhadtogototheemergencyroomtogettreated!Thus,first-handexperienceintothehealthcaresystemoftheCassLakeandBemidjiareawasacquiredbythegroup.Thisgroupmemberthankfullymadeasteadyrecoverythroughouttherestofthetrip.Fortheremainderofthatday,ThomasandJacobwereluckytoparticipateonhomevisitswithnursesfromtheLeechLakeTribalHealthClinic(asMaggieandAngelahad

onthefirstday),andoneofusreturnedtotheIHSclinicinCassLaketoshadowthefamilypracticedoctor,Dr.Ankney.WesawalotofpatientsthroughoutthedayandcontinuedtolearnalotaboutthehealthchallengesthatNativepopulationsface,andhowthecommunityconfrontsthesechallenges.Onourlastday,wevisitedtheLeechLakeTribalCollege.AmarinChanthorn,theDirectorofInstitutionalAdvancement,graciouslygaveusatouroftheschool.Theschoolhasbeautifulmodernfacilitiesandiscontinuallyexpandingtheircampus.ThecollegehasafocusonconnectingNativeculturewithmanyofthestudiesandhasaparticularemphasisonscience,technology,engineeringandmatheducation.

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ForourfinalafternooninLeechLake,weparticipatedinacommunityhealthfairthatwasoccurringinthetownofOnigum(locatedclosetoWalkerinthemapabove).VinceRockandtheLeechLakeTribalHealthClinichadorganizedthecommunityeventanditservedasanopportunityforthepublictoreceivefreehealthcareexaminations,particularlyforpediatricpatients,andeducationalmaterialsonhealthyliving.Thefourofusdecidedtotaketheopportunitytosetupabloodpressurechecktable.Wecheckedeveryoneattheevent’sbloodpressureandofferedtipsonhowtoreducetheirbloodpressureifitwasfoundtobeelevated.ThateveningwereunitedwithourclassmatesinDuluth,MN,sharingstories--andlessonslearned--fromeachofourrespectivedaysindifferentreservations.Insummary,thefourofus--Angela,Maggie,Thomas,andJacob--hadanamazingtimeexploringandlearningaboutvariousaspectsoftheOjibwecultureinCassLakeandLeechLake.WelearnedatremendousamountaboutthehealthchallengesfacingtheObjibwetribeandthereservationcommunities.Itwasanexperiencethatwewillneverforget,andanexperiencethatwearesogratefultohavebeenofferedbytheOjibwecommunity.Webelievethatweeachlearnedsomethingthatwillserveuswelloverourcareersasphysicians,regardlessofwhetheritisinaNativecommunityornot.Gigawabamen!

FondduLac(Nayan,Josh,Tommy,Meghan,Simrun)ozhiitaa-“prepare,getready”IntryingtofollowthecorrectprotocolforapproachingAnishinaabehealers,wepreparedatraditionalOjibwe“tobacco”fromthedriedinnerbarkofMiskwaabiimizh,RedOsierDogwooda.k.a.RedWillow(Cornussericea).ItiscustomaryforthosewishingtoconsultahealertopresentthehealerwithRedWillow.ItwasourhopethatbringingRedWillowthatwehadharvestedinNewHampshireinagoodway(byofferingtheplantstobaccoandaskingtheirpermission)andscrapedandpreparedourselveswouldcommunicatealevelofrespectfor,familiaritywith,andadmirationoftheculture.

Otherplantmaterialsusedforofferingsorforsmokinginaritual,ceremonial,orsacredcontextinclude:

• Asemaaorwildtobacco(Nicotianarustica),nottobeconfusedwithcultivatedorcommercialtobacco(Nicotianatabacum).Cancontainupto9timesasmuchnicotineasN.tabacum.Somehealersprefercommercialpipetobacco,likethePrinceAlbertbrand,totrueAsemaa.

• Apaakozigan,amixtureofAsemaaanddriedinnerbarkofMiskwaabiimizh.• Kinnikinnick,or“mixture”,ablendcontainingMakwa-miskominorBearberry(Arctostaphylosuva-ursi)

(thetermKinnikinnickcanbeusedtorefertothisplantalone),Nookomis-gizhikorCedar(Thujaoccidentalis),andanynumberofaromaticplantsaccordingtotheoccasionorpersonalpreference.

Therefore,culturally-competenttobaccopreventionandcessationeffortslikethe“KeepTobaccoSacred”eventweattendedfindthemselvesintheinterestingparadoxoftryingtostigmatizetheuseofcommercialtobaccoproductsmadefromNicotianatabacumwhilenotdemonizing(andactually,encouraging)thetraditionaluseofNicotianarustica,Cornussericea,andtheactofritualsmoking.

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endaad-“home,house”

Ourbeautifulaccommodations!MiigwetchtoShawnO’Leary’sfather,William“Grampies”O’Learyforgenerouslyallowingustostayinhishome!

odish-“visit,reach,comeuptowherepeopleare”

Simrun:“IhadtheopportunitytoparticipateinhomevisitsaroundtheFondduLacreservationwithanurse,M.,whohasbeenworkingatFondduLacforseveralyearsaftermakingacareertransitionfrombanking.Shelovesherworkasahomehealthnursebecauseitinvolvesdeeplyreconnectingwithhercommunity-seeingmanyoftheadultsthatsheknewasachildandmakingadifferenceintheirlives.

Duringmyvisit,westartedourdaybymeetingwithapatientattheAssistedLivingResidence.Althoughthevisitwasforanuncomplicatedmedicationmanagementconcern,itwasinterestingtoobservetheverystreamlinedinterprofessionalcommunication.Upontakingthepatient’sINR,thenurseimmediatelyphonedthepharmacy,wheresheandthepatientbothspoke(viaspeakerphone)withthepharmacistdirectlyabouttheresultsofthevisitandnextstepsformedication.Agreatexampleofteamworkwiththepatientasacareteammember!WethendrovearoundthereservationinsnowyMinnesotaweather,visitingdifferentcommunitymembers

andultimatelyvisitingtheElderComplex.WhatIenjoyedmostaboutthehomevisitswashavingtheopportunitytoseehowhealthcareisdeliveredoutsideaclinic,intheveryplaces(homes)wheremostofpeople’sactualday-to-dayhealthdecisionsaremade.Itwasinterestingtoseesomeofthebarriersexperiencedaswellasthecreativewayssolutionsarecultivatedwithanunderstandingofthecommunity.Forinstance,manypatientsonthereservationdonothavephoneservice,whichmakesitdifficulttoestablishcommunicationwiththeclinic;however,bycreatingaschedulewiththeprovider,visitingnursesareabletosurmountthisobstacle.Ialsohadawonderfultimeseeinghownursesprovideeducationtopatientsandfamilymembers.Itwasfascinatingtoexplorehowhomehealthnursesareincrediblycommittedtocreating/maintainingtherelationshipbetweenpatientsandthemedicalestablishment.Thisrelationshiptheniscrucialforproviderstoassistpatientsinmakingmedicaldecisionsandunderstandingtheirhealthneedsandvalues.”

nanda-gikendan-“seektoknowit,seektolearnit”

Josh:IreallyenjoyedthespringbreaktriptoMinnesotaofferedthroughtheDartmouthGeiselSchoolofMedicine.Throughoutmostofmy25yearsasaUnitedStatescitizen,Iwasonlyexposedtoonenarrative(thecolonizationnarrative)regardingtheinteractionsbetweenEuropeansettlersinAmericaandtheNativepeople

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whowerealreadylivinghere.DuringourIndianHealthServiceandOutreachelectivethispastterm,andespeciallyduringourtrip,Iwasabletoheartheothersideofthestory--thestoryoftheindigenouscommunitieswhoseliveswereforeverchangedafterLeifEricsonand,later,ChristopherColumbus"discovered"alandthathadbeeninhabitedbypeopleforthousandsofyears.InadditiontotherichhistoryoftheOjibwe,itwasenlighteningtowitnessthepatientinteractions(clinicalmedicine)andthecommunity'sapproach(populationhealth)tomeetingthehealthcareneedsofthoseenrolledwiththeFondduLacreservation.Iwasveryimpressedbythepre-diabetesprogramofferedbytheclinic,includingthemulti-disciplinaryworkshopwewereabletojoinonthelinkbetweendiabetesanddepressionthatwasgiventopatientswithelevatedbloodglucoselevels.Furthermore,thenursinghomebuiltonthereservationforthecommunity'selderswasperhapsthenicesteldercarefacilityIhadeverseen.Lastly,mygroupandIwereexposedtomanyofthetraditionalNativehealingpractices,anditwasaprivilegetobeabletospeakwithmultipletribalhealers(or"medicinemen"),aprofessionwithanunfortunatelydwindlingsupplyofcapableproviders.Afterbeingexposedtothecost-andproductivity-drivenmodelofhealthcareintheUSthroughoutourfirstfewmonthsofmedicalschool,itwasrefreshingtomeetwiththesehealerswhoviewedtheircallingassimplytoservetheircommunity.Theytreatedthesickwhocametoseethemandexpectedalmostnothinginreturn;asaresult,thosewhocouldaffordtopaygavemoneyorfoodwhilethosewhocouldnotwerestillgiventhecarethattheyneeded.

ThursdayMarch17th

Thursdaynightwerejoinedasalargegroupandhaddinner,wherewedebriefedwitheachotheraboutthepastweek.Thistimeallowedustosharewhatwehadlearnedandreflectonwhatwehadexperienced.

FridayMarch18th

Fridaymorning,wemetDr.ErdrichatPowWowGroundsCoffeeShopinMinneapolis.Therewasanartgalleryattachedtothecoffeeshop,whichwegotatourof.Aspartofthetour,welearnedabouttheIndianCorridorandanumberofprogramsthatwereinexistencegearedatupholdingtraditionalnativepracticesintheurbanenvironment.WethenaccompaniedDr.ErdrichtoherofficeattheIndianHealthBoard.Shehadset-uplunchforuswithDonaldRichardWright,amidwifeandtwonurses.Duringlunch,wehadinformalconversationsandalsoheardaboutworkthemidwifewasdoingtoaddressthelargeopioidepidemicthatshesayworkingwithpregnantwomen.Next,wegotatouroftheCommunityCenterandheardaboutinitiativesthatwerebeingtakentheretogetpeopleactiveandlivinghealthierlives.Theyalsotalkedtousaboutdifferentwaysthatthenativeculturewaskeptvibrantevenintheurbansetting.WeendedourdayattheWomen’sResourceCenter,whereweheardaboutdifferentobstaclesthathomelessnativeindividualsface.WealsolearnedaboutprogramsthattheWomen’sResourceCenterhadinplacetoaddressthesocialdisparitiesthatthenativepopulationfaced,rangingfromsextraffickingtoopioidaddiction.Wealsobrokeintosmallgroupsanddidsmallserviceprojectsattheresourcecenter.

SaturdayMarch19thWeleftinthemorningforourflightsbacktoBoston.