This interview with Sarah Stern, a Health Educator at John Hopkins American Indian Health (JHCAIH), was conducted and condensed by franknews.
frank | Native American populations have been disproportionately impacted by COVID. I am curious about what the current reality of tribal healthcare infrastructure looks like and the history that has played a role in shaping it?
Sarah Stern | The reality is that tribal healthcare infrastructure has been and remains underfunded and understaffed.
The Indian Health Services (IHS) has been vastly underfunded since it’s creation in 1955. The Snyder Act of 1921 was the first federal agreement to even allow Native people to receive medical care. We see facets of American history that are not even 100 years old. I stress this as a reminder that while Native people have always existed in the United States, there are far more years of physical and cultural genocide against Native people within American history than years of serving, protecting, and advocating for Native lives.
IHS remains the last in line to receive federal funding to aid the health and wellbeing of Native people. The National Indian Health Board (NIHB) released tribal budget recommendations showing that the IHS spends on average only $3,332 per capita on each patient, compared to a national average of $9,207. In comparison to the Veterans Administration (VA), which is also underfunded, the VA remains about 14 times as funded than the IHS. Highlighting these gaps creates dialogue for both Native people and allies to engage in political pressure to increase funding for healthcare and save lives.
From my understanding there was a "Self-determination Era," which came about in the 1960s, giving tribal governments greater control over local government operations, including healthcare and health clinics. Can you go into the history of that era?
The “Self-Determination Era” allowed Native people to use federal funds as they wanted, but the caveat was (and remains today) that Native people had to report how they wanted to use funds and keep records of the cash flows using systems developed by non-Native people. This created a newer opportunity to add in ‘western’, or non-Native educational programs. School-based teachings of Native cultural values or language were not allowed until 1975, which is less than 100 years ago. Public services, workforce creation, and health care facilities were more developed as Native people were granted the federal ability to allocate funds into these things, alongside education.
It is important to recognize Native people have always utilized the act of self-determination to keep community members, especially children and elders, safe from harm’s way, even before the “Self-Determination Era”. We have worked persistently to protect our land, people, and allies since time immemorial. As Native people proved in many ways to survive physical and cultural genocide, the United States eventually allowed Native people to use federal funding as they saw fit, which was not the case before the 1960s. Basically, the onslaught of Native people cost the United States so much time, money, and non-Native causalities that they eventually folded and decided to stop murdering on stolen land.
Native people also began to have more rights for self-governance, which allowed for leadership among the facets the people wanted funding applied to.
As we see in successful public health initiatives today, when communities have voices at the table representing what the needs and realities are, more positive opportunities take place.
Without Native leadership, the “Self-Determination Era” would not have been as successful nor propelled us to where Native communities are presently.
How can the federal government effectively help in this crisis while also ensuring levels of continued self-determination?”
The federal government can listen to Native leadership directly. Native community leaders have the means to communicate what their people need during this time. This is the most direct way for the federal government to help.
Another way that the federal government can help is to increase public health funding to health programs and educational opportunities. JHCAIH is committed to providing national leadership in training Indigenous scholars in health care and public health science. JHCAIH has awarded over 1,500 scholarships to people representing 45 tribal communities around the nation. Linked below is more information on the public health training programs and online application for scholarships.
Is there a specific piece of that history and its effects that you are thinking about most right now?
Treaty rights, and the broken treaties this country participates in.
Broken treaties impact all aspects of Native American communities. Broken treaties account for the fact that some Native people are not federally or state recognized, which in turn impacts the ability to apply for education, housing, health, and infrastructure assistance. Broken treaties have taken away Native lands and water rights.
Broken treaties have created health disparities we see across Indian Country.
Broken treaties have fueled stereotypes against Native people and treaties continue to be broken to this day. For example, in February, the current administration demolished Tohono O'odham Nation’s sacred burial lands without consulting the tribe. Members of the Mashpee Wampanoag community are currently battling the federal administration for seizure of land granted by a federal trust. Land has life. Land connects to Native creation stories, it holds memories, it gives protection, and when land is seized, people hurt. I encourage you to find out what Native land you live on, who the Native people are in your area historically and presently, and how you can show allyship to Native people during this time. Allyship can help combat broken treaties.
How do the economic crisis and health care crisis particularly feed off of each other?
Both crises increase panic. Health care requires money. Lack of economic opportunities diminishes ability to pay for health care costs and decreases the ability to fund health care initiatives.
Collapse of economic ventures impacts everyone, regardless of whether the business is run by Native people or not. This will vary by community, but Native leadership works diligently to ensure that community members have the means to purchase essentials, like food and water, and as they are able, they create plans for how business can run with social distancing procedures at the foreground. Protecting the health and lives of people is the best practice to begin re-opening businesses during the pandemic.
This interview with LaShyra Nolen, Harvard medical student, and the first Black woman to become class president, was conducted and condensed by franknews.
frank | You've written and spoken about your experience within a dual reality – of being both a medical student at Harvard, and a person committed to your own identity and equity.
LN | The dual reality is you're training at the best medical school in the world, but there is so much suffering going on in your community. And whatever knowledge you gain still isn't going to necessarily translate to the improvement of the condition of Black people. For example, I could go on to become the best surgeon in the world. I could save the life of a Black patient. But they can go outside, drive home, get stopped by a police officer, move too fast, and get killed.
That is the dual reality. You're learning, but you're not necessarily getting to the root cause of the suffering of your people.
You always have to think about it from both of those perspectives, that of a student and that of a Black person in America.
In addition, you go into class and you are expected to maintain professionalism. You are expected to just talk about the science and to talk about the assignment at hand – when that same morning you watched yet another police lynching of a Black man. You're trying to deal with those emotions, and you have no idea how it's going to be taken if you say, "Hey guys, I'm really not doing that well. Another Black man was killed. Racism is pervasive in our country and we're all complicit in it." It is a challenge that all Black professionals have. You have to walk in and put on this face, even though internally you are dealing with the turmoil and hurt of your community.
What does this moment feel like at Harvard, as a student?
As a medical student, I feel like I can speak out more than my mentors or faculty members who are more ingrained into the system of medicine. Academic medicine is very hierarchical. The higher up you go, the more you have your hands tied, and you can't speak as much truth because you're trying to move up to an associate professor position so that you can finally start to use your voice. I know that there's a risk that comes with speaking up, but I, personally, can no longer just pretend like everything's okay, and allow people to continue to suffer in silence. Even the most brilliant people have been complicit in racism, and some of them genuinely have never even thought about it.
They've grown up in a bubble, their entire lives, and all this is happening and they're just like,
"Oh my gosh, I'm a good person. I'm not racist." And you kind of have to be like, "No, but you really are though."
These brilliant people who are excellent in their field, are just now realizing they're complicit in this system.
Again, I am happy that's occurring, but I'm always just like, look how much it took for us to get here. NASCAR is just now removing the Confederate flag. Suddenly now I have Juneteenth popping up on my Google calendar. I'm like, what?
My classmates and professors have really been amazing actually. We are all from different backgrounds. Some are fourth-generation physicians, and some grew up on reservations and are bringing medicine to indigenous folks. All of them realize that the system needs to change, and they have been so supportive. Beyond just talking the talk and posting the black box on Instagram, they've been reaching out to me saying, “Here are the notes from class today. I got this recording for you because I know you've been putting in work on the advocacy front.” That's true allyship to me. I've really been pleasantly surprised and happy to see the support that I've gotten from my classmates.
There has been a widespread acknowledgment that COVID is affecting communities and people of color at much higher rates. I am curious if you think there has been an appropriate conversation around why that’s the case?
I think that in order to understand that we have to look at our history, and at policy. The original ill was, of course, chattel slavery. This country has not valued Black lives. The policy reflects that, and policy ties into our healthcare. That history of systemic discrimination is important to look at to examine the current landscape of COVID-19.
Redlining decided where people live in this country, and which communities our government and our local city councils were going to invest in. Black communities were not invested in. As a result, Black communities have not had access to the basic resources that they need to survive and thrive. They don't have access to healthy food. They don't have access to safe places to exercise. They are exposed to environmental pollution. They have less access to education. I mean, then you look at who is more likely to be an essential worker - Black people are overrepresented.
It doesn't end there. Once people get into the clinic, they have to deal with the biases and systemic racism in the hospital system. There are studies that have shown there are medical students and residents who still think that Black people have a higher pain tolerance.
We can take maternal mortality as an example of treatment differences. Black women, at all income levels, are dying disproportionately compared to white women. When they get to the hospital, doctors don’t believe their pain. I mean, it happened to Serena Williams. It is safer for Black women to not engage with the healthcare system because of the violence and harm it causes.
How do you think mistrust of the medical system compounded the COVID crisis?
I think it all comes back to this conversation of access, right? When COVID-19 first hit, the testing centers were predominantly located in affluent communities, and a lot of Black communities were left without access to testing. The lack of Black physicians and Black health care professionals means that when Black patients come in and say they have COVID-19 symptoms, they are less likely to get treatment compared to white people.
If you know there are no testing centers in your neighborhood, you know there is no representation in the hospital, and you know that you are going to be discriminated against once you walk in that door, you know your life is being devalued. That knowledge prevents Black people from seeking care from our healthcare system. With anecdotes of horror coming from your community, of course you are going to be nervous to trust the healthcare system.
What does a better understanding of investment into public health look like to you?
I think we need to turn all of the conversations that we've been having into public health initiatives. Racism was declared a public health emergency in Boston. That is the direction I think we should be moving in.
We need to move beyond equality to think about equity. We need to recognize that not everyone is on the same playing field. We need to truly make sure everyone's specific situation is taken into consideration. We do that by investing in those communities, and by looking at how we make sure they have access to good education, access to health care, access to housing, access to good food. Improving the conditions where people live, work, pray, play will improve their healthcare outcomes and our healthcare system.
Of course, we need things like the physical exam, but often patients go into that physical exam with preexisting chronic diseases caused by disparate suffering. Going as upstream as possible will lead to better healthcare outcomes and in the long run, improve healthcare costs. Even if investing in public health didn't improve healthcare costs, I still think that it's the moral thing to do. I think we're too driven by what's going to save money in our country. We need to do what's right.
Everyone deserves to have the basic resources they need to live out a viable, joyous life. Right now we are doing nothing to guarantee that.
Someone said to me once, we’re too focused on raising the ceiling and not at all focused on raising the floor in the American healthcare system. Do you feel like this starts as a medical student?
I can definitely speak to that culture. As a medical student, I'm really passionate about community activism. I am passionate about making sure that everyone has access to healthcare, and ensuring that we're teaching medical students anti-racism so that they don't go out and further harm communities. I can spend two years doing that – serving on committees, writing up reports, and changing curriculum at my institution. But my peers who are spending the same time publishing papers on very specific proteins and disease processes might have a better chance at residency.
In medicine, you're not incentivized to do work that you don't get credit for. You always want to be able to publish, and activism isn't always publishable.
It has been the responsibility of Black students, students of color, and indigenous folks to improve their institution. They do the work so that they can thrive and survive, and so the next generation can do the same. But at the same time, they still have to do everything they have to do as a medical student to get to the next level. I'm literally trying to improve the very environment that I'm suffocating in, while also trying to handle everything else that medical students are expected to.
There was a letter early on from public health officials advocating for protest as it’s needed to fight racism within the healthcare system. Does that feel new or was it already a part of the conversation?
I think it's always been a part of the conversation for those who have been oppressed.
But that is what is special about this moment. We literally had a global pandemic that exposed the disparate suffering of Black people across the country, across the globe. And then on top of that, you have back to back to back killings of Black people. It's heartbreaking that it took this much for us to start having these conversations, but we are having them, and people can’t run away from them.
There are no distractions. We're not going to get anywhere if people don't name systemic racism for what it is.
We need to say Ahmaud Arbery. We need to say Breonna Taylor. We need to say their names, and we need to name the issue at large.
Big-name organizations are just finally starting to realize that this is something that they need to get on board with. It’s hard to know if it's really genuine or not. I think that people don't want to be on the wrong side of history. Regardless, learning is still happening. I'm very happy that anti-racism is becoming the status quo and that we are having these conversations. We need to continue to push the envelope to get people things they need to live a good life.