PRESENTED AT THE 15TH NATIONAL CONFERENCE ON PRIMARY HEALTH CARE ACCESS
CAPT Charles Q. North, MD, MS
Chief Clinical Consultant for Family Practice
Indian Health Service
Dr North: I am greatly honored to present the Rodos Lecture this morning not only because it honors such a great leader, mentor and philosopher as J. Jerry Rodos, but because you in the audience embody many of the outstanding qualities and values exemplified by Jerry Rodos. As national leaders in the development of an ongoing movement to meet the primary health care needs of our nation, I salute you this morning.
I would like to recognize the past Rodos Lecturers some of whom are with us today: Sandral Hullett, David Sundwall, Hector Flores, Count Gibson, Tom Allen, Marc Babitz, Ken Moritsugu and Gary LeRoy. When Bill asked me to present this year’s lecture, he said that past themes have included the Public Health Service, rural and inner city health, community health centers, cultural sensitivity and community oriented primary care. He asked me to call him if I planned to stray from public health topics such as “trends in plastic surgery”.
I always enjoy surprising Bill so today’s talk is entitled “Trends in Plastic Surgery: Extreme Makeovers: Esthetic Leadership or Pure Greed?” Although some of us may benefit from an extreme makeover I sense that our specialties of primary and community oriented care need to get back to the basics rather than superficially changed in appearance.
Last year I spoke to this group about the Bush Administration initiative to increase funding for community health centers, a proven program to meet the needs of underserved populations. This year I would like to cover three broad themes.
First is an update on the plans of the Bush Administration to enhance the Commissioned Officer Corps of the United States Public Health Service. Second, I would like to speak about the state of IHS and new initiatives in Indian Health. And finally, I would like to focus on what we have learned in managing our practice in Albuquerque and how it can help us approach America’s greatest health care challenges in this new millennium.
On February 10, 2003 the Bush Administration announced plans to seek the largest expansion ever of the PHS in order to recruit thousands of doctors, nurses, and health officers to respond to potential national health emergencies, such as bioterrorism threats and new strains of infectious diseases. The plan would increase the current PHS force of 6,000 uniformed officers by more than 1,000 annually for an unspecified number of years and creates a reserve of health care professionals who could be called into service at times of crisis. A major goal is to transform the federal agency from mainly a provider of medical care to the underprivileged into a front line defender against threats to the nation’s health.
Surgeon General Richard H. Carmona said, “We as a country have to come to grips with the fact that we have underfunded public health, chronically, for decades.” Trying to catch up from a half a century of neglect, federal expenditures on public health preparedness increased from $305 million in 2001 to $4.4 billion in 2003.
The proposed expansion would be the largest since the PHS was established in 1889 to replace the Marine Health service, which had been created nearly a century earlier to care for sick sailors. The administration proposal calls for creating scholarships to recruit 1,000 nurses and 100 doctors per year.
Through the Office of the Surgeon General, the PHS now has a formal process in place to mobilize professionals willing to serve in emergencies. This force is called the Commissioned Corps Readiness Force, or CCRF. 44% of all Corps officers are in CCRF rosters. Members of the Force are available for a month long rotational call twice a year for rapid response deployment to a manpower shortage area or crisis location. In 2003, 8% of IHS officers were deployed through CCRF.
Since HHS plans for all Commissioned Officers to be deployable in a few years, the CCRF is an intermediate stage in mobilizing the entire Corps. Secretary Thompson plans to increase the number of officers who remain clinically active by working on Indian reservations and providing care to underserved communities through the National Health Service Corps in community health centers, and rural and migrant clinics.
Promotion in rank is now dependent on deployment through one’s duty station, membership in CCRF and responding to CCRF calls. Officers stationed at IHS defined Isolated Hardship sites are considered already deployed for promotion purposes. Deployments for those in sites not considered isolated or hardship could be to an “incident command center” at the Super Bowl, Olympics, national political convention or other potential terrorist target.
The Federal Emergency Management Agency calls the PHS first for medical needs now that CCRF is operational. IHS leadership uses CCRF to provide professionals for manpower shortages in isolated hardship sites. CCRF has recently responded to an epidemic of premature births in Guam, an earthquake disaster in Iran and a shortage of pharmacists in Bethel and Kotzebue, Alaska. Deployments last year included Iraq; hurricane, tornado and wildfire disaster sites; and the HHS Secretary’s command center in Washington.
A family physician in the IHS national epidemiology office in Albuquerque went to Ground Zero in NYC shortly after 911 to provide primary care to fire fighters; and a public health nurse and a pharmacist from our Albuquerque clinic responded to Washington’s anthrax attack. This spring two physicians CO’s from our clinic are spending May and June in Kabul, Afghanistan teaching in a large maternity hospital. Another is on call to assist a Native Alaska family practice clinic on Kodiak Island unable to fill a physician position.
When there is a national or natural disaster that overwhelms local medical resources, our nation is now better prepared to respond rapidly with a force of health professionals specifically oriented and trained in disaster medicine. And our Indian patients are more likely to see experienced PHS officers on rotational call who are familiar with indigenous health instead of a locum tenens professional who may not be familiar with our system. I am gratified to see the Commissioned Corps become organized to fulfill its obligation to mobilize and respond to national and international medical needs.
To meet this expanded mission HHS Secretary Thompson has directed a 12% increase in Commissioned Officers assigned to the IHS; a total of 236 more officers are needed in the professional categories nursing, pharmacy, engineering, and medical. Nationwide IHS had 2066 officers as of October 2003, an increase of 39 over last fiscal year. In Albuquerque, one of the 12 administrative regions of the IHS, the target force is 190 CO’s.
We need an additional 28, most of whom will be nurses recruited through such student programs offering early benefits, i.e. JR and SR COSTEP. I expect that most of our new physician CO’s will come directly from residencies. Centralized programs to speed and smooth the hiring process are under development.
The transformation of the Corps into a more mobile force is an exciting development for young doctors who are mission oriented and want to play a larger role in national and international public health while still maintaining a practice base with an underserved population. Providing direct care to fireman at the World Trade Center or preventing maternal deaths in Kabul can be a life transforming experience. Indian Country, communities served by the NHSC and all Americans gain by strengthening and enlarging the role and mission of our nation’s public health workforce.
Though the process is referred to as the “transformation of the Commissioned Corps,” it formalizes the continuing fundamental mission of a national public health service corps of elite professionals who can rapidly respond to the nation’s health needs.
The IHS loan repayment program can provide a strong incentive to an indebted residency graduate. We have a $17 million federal appropriation budget to guarantee supplemental loan repayment to attract and retain health professionals.
New this year, local hospitals and clinics can contribute up to $10 million more to improve recruitment and retention with the understanding that they will not be reimbursed from a headquarters fund. Some local units have been advocating for this policy; while they have the money to hire, they haven’t been able to attract health professionals. So if you have the money locally, you can use it more effectively to meet your mission by using loan repayment to recruit and retain nurses, optometrists, pharmacists, dentists, physicians and other health professionals as the need arises.
What is the today’s IHS after 59 years as a federal agency? As an operating division of the HHS, we serve 1.6 million native people with a network of 49 hospitals and 550 other health care facilities, half of which are operated by tribes or native corporations. Our operating budget is close to $3 billion including construction, sanitation and environmental engineering programs. In the 25 years, 1974-1999, American Indians and Alaska Natives have seen the following reductions: maternal mortality down 79%, TB mortality down 86%, GI mortality down 72%, infant mortality down 65%, and unintentional injury mortality down 54%.
These outcomes are more significant when you consider that we did this despite having lower per capita funding than Medicaid; higher costs for health care due to increased disease burden; and reduced access due to geography and culture. Low funding levels and provider recruitment and retention problems have limited the number of physicians and nurses per capita to half as many as the general population. Facilities are lacking or inadequate in numerous locations: the average age of facilities is 32 years compared to 9 years in the private sector.
The population served suffers from high unemployment, poverty, lack of education, substandard housing and other social determinants of health leading to poor health status. The program success of IHS suggests that even a poorly funded public program based on community oriented primary care could serve as a model for a national health program, at least for indigenous, rural, frontier and underserved urban populations. Are we as a nation bold enough to fund the program adequately and use the model for other populations as part of a national health program?
What are today’s health related priorities in Indian Country? Our Director, Charles Grim, is a dentist from Oklahoma with an appealing style reminiscent of Will Rogers. Chuck has emphasized mental health, disease prevention and health promotion in his speeches to tribal groups and IHS professionals.
To this end, IHS has established ten successful regional treatment centers for youth with alcohol and substance abuse problems. We have given tribes more direct monetary and administrative control to develop culturally appropriate local programs. At tribal requests, we have supported tribes with funding for an improved national data collection and electronic record system in behavioral health.
One of the secrets of our success has been to follow the principle of COPC by developing strong local tribal consumer health boards which provide us with community input for hospital and clinic management, public health program administration and community based research efforts.
IHS Headquarters has recently signed an agreement with the Nike Corporation to promote healthy lifestyles and choices. The goal of the partnership is to help communities gain a better understanding of the importance of exercise at any age, particularly for those with diabetes.
The initiative Just Move It is based on national fitness experts training local fitness coordinators across Indian Country. Similarly the NFL has partnered with the center for Native American Health at Johns Hopkins to operate summer youth camps in reservation communities in the West, which emphasize physical fitness, athletic participation and healthy choices. We are pleased that Santa Ana Pueblo in the Albuquerque Area will be participating this summer.
IHS headquarters has created new positions for health promotion disease prevention officers in each of our administrative regions. They are charged with coordinating physical activity promotion and funded by special appropriations to the national diabetes program.
In the annual evaluation of federal programs mandated by the Government Performance, Results and Accountability Act (GPRA), the IHS was ranked one of the top 20 federal programs, second in all of HHS.
We were highly commended for our Resource and Patient Management System, which is now under intense development and being deployed nationally as a model electronic health record. Designed by clinicians for medical care rather than for billing and financial management, it merges databases from public health records, medical records and financial records.
IHS has been very successful reducing leading causes of mortality and meeting tribal and consumer driven health needs as discussed earlier. I love my patient care and leadership roles. I plan on signing another three-year contract when I get home despite reaching my full retirement benefits two years ago.
So, if it is such a great program, why isn’t it better funded? One reason is that it is a program for a neglected and forgotten American population living at the freeway exits most politicians and voters don’t even consider taking. In addition, much of the public erroneously perceives that Indian tribes are wealthy because of gaming revenues.
However, only a fraction of tribes allow gaming and successful gaming operations benefit few individual Indian families. In fact most of the largest tribes do not allow gaming and would be too remote to benefit from it. A third reason for inadequate funding is that the IHS is often viewed as a Great Society War on Poverty program for poor people.
IHS predates the Great Society programs by ten years. It is a unique federal government to native government obligation for health care which was part of a settlement of the most significant land dispute in our nation’s history. Many native groups have expressed a willingness to forgo all federal benefits for a return of their homeland.
Congress appropriates only 60% of the funds needed to provide basic health care for people already in the Indian Health system. There is proposal before Congress spearheaded by Senator Daschle to double the IHS budget using system called “level of need funding”. Daschle has asked the GAO to document the deficiencies in Indian health care to bolster his proposal and a report is expected soon.
If the IHS were ever fully funded, we could meet many of the needs we are now unable to address and serve as an attractive model for a national health program for other non-Native populations in the US and in developing countries. Not by coincidence did Tommy Thompson ask our Chief Medical Officer, Craig Vanderwagen, a family physician from New Mexico; to serve a four-month tour as director of health programs for liberated Iraq.
On a more positive funding note, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 includes several items important to Indian Health:
• Increased reimbursement rates for rural ambulance services
• Provided undocumented alien reimbursement for emergency services
• Assured Medicare as payment in full by contracting private hospitals
• Improved reimbursement rates for part B, critical Access Hospitals and disproportionate shares
• Provided reimbursement for initial assessments and screening for diabetes and heart disease in the Medicare age group.
Even with improvements in Medicare IHS does not meet all of the needs of Native Americans and Alaska Natives. In a recent article in the American Journal of Public Health, Zuckerman and Haley of the Urban Institute and Roubideaux from University of Arizona, concluded:
Documented disparities in health coverage and care show that native people continue to be at a disadvantage in the US health system. They lack insurance coverage at much higher rates than whites and efforts are needed to reduce these disparities. IHS provides a valuable source of basic health care for some natives who lack coverage but there are clearly gaps in preventive care that need to be addressed.
Just under half of low-income uninsured natives reported having access to the IHS, due principally to the fact that half live in urban areas where the government has failed to fund Indian programs. Many urban dwellers are left to fend for themselves and compete for scarce resources in the urban safety net programs.
Urban Native American rates of medical indigence are higher than in African Americans and comparable to Hispanics. In the Albuquerque Service Unit, 75% of our patients lack health insurance whereas in the nearby community health centers and reservation communities 25-30%, lack third party coverage.
Our local Albuquerque tribes, with federal acquiescence decided that all of the local IHS budget could be directed to their 10,000 members leaving 23,000 urban Indians without a funding base. Clearly there is much more to be done to reduce disparities in health care to our nation’s first citizens.
I would like to change focus now to the greatest public health needs of our nation in 2004 and how we, as leaders, educators and clinicians, can best meet them. A new theme is emerging in public health that affects us all. The actual causes of death statistic, popularized by Dr. William Foege of the Carter Institute and the former director of the CDC has obesity leading tobacco for the first time as the number one cause of death in the US.
Working with Southwestern Indians who rarely become dependent on tobacco, we have seen a change in actual causes of death from infectious diseases to obesity complications in the past 60 years, bypassing the tobacco phenomenon almost completely. This epidemiological transition has occurred during my career with striking speed.
In the January 26 Wall Street Journal Report entitled “Breakthrough! Ten major medical advances you’re likely to see in the coming year,” all of the advances were related to obesity and the cardiovascular and cancer consequences. The one exception was the trend to supply over-the-counter emergency contraception and birth control pills, more of a political than a public health trend.
A Rand report published in the current issue of Health Affairs notes that if obesity rates and disability trends continue they could wipe out recent improvements in functional status of older Americans.
“If current trends in obesity continue, disability rates will increase by one percent per year more in the 50-69 age group than if there were no further weight gain. But as obesity becomes more and more prevalent among the elderly, it will be more and more difficult for other social trends to counter its adverse health effects. Unless the factors underlying past trends toward better health become even stronger, Americans who will be ages 50-69 in 2020 may not have better health and functioning than this age group has now.”
In February 2003 we searched our electronic records for the service population of about 32,000 in and around Albuquerque and found about 900 people with weights recorded over 300 pounds. This winter we searched for patients with BMI over 40. We found over 800 patients meeting this definition of extreme or morbid obesity. With one out of 40 patients suffering from morbid obesity we may well be ahead of the national trend. Some already have the complications of diabetes, heart failure, obstructive sleep apnea, knee arthritis, infections and higher cancer rates.
Our obese patients also suffer from higher rates of gestational diabetes, menstrual problems and infertility, psychological problems, chronic pain, substance abuse, mobility problems and disability. While these data are discouraging, even if weight gain were arrested for all age groups today we face a tsunami of medical complications just due to aging as the Rand report suggests. Clearly we need to develop new approaches to the prevention and treatment of obesity.
One practical solution to the immediate problem is to develop a disease management model for morbid obesity much like we have for diabetes and heart failure. Health Partners and Kaiser have been in the news for their fledgling effort but very little is happening in most health plans.
A year ago we integrated a clinical social worker into our practice in Albuquerque. She is actively managing medical and community based resources for our highest BMI patients. She is still contacting those with BMI over 60, so we are hoping for an accelerating effect if we have some early successes with our toughest patients. An effective intervention could rapidly gain acceptance with this population. If an evidence based therapy for morbid obesity is ever developed, we will be ready to implement it.
How did we get from under nutrition and malnutrition to over nutrition in one century, or maybe just the last 50 years? Why were infectious diseases, vitamin deficiencies and starvation more of a problem than diabetes 30 years ago on the Navajo reservation? We’ve all read about how sedentary we have become, how our suburbs are not designed for walking, how portions are super sized and fast food is too dense in calories, but what else is going on? What can we do in our practices and teaching programs? I would like to offer an explanatory model found in Indian Country for the rising rates of obesity and a few suggestions about how we can approach it in the family practice setting.
One attractive hypothesis is that we have responded to historical trauma, in the case of Native Americans and holocaust survivors, by secreting stress hormones, which lead to cushingoid fat distribution and a propensity to diabetes. Some would postulate that posttraumatic historical stress could account for higher diabetes rates in Indians and perhaps any group subject to the stress of war and racial prejudice.
An intriguing bit of evidence comes from the Pima Indians in the Diabetes Prevention Study. You may recall that the study concluded that intensive diet and exercise was more effective than Metformin in preventing progression from impaired glucose tolerance to overt type 2 diabetes.
There were three Pima groups: experimental drug; experimental intensive diet and exercise; and a control group. All three groups met regularly but the control group had no predetermined agenda. They had to meet regularly so decided to pass the time learning more about their tribal heritage. Guess which group had the least progression to overt diabetes? The control group, who didn’t take Metformin, diet or exercise. This suggests at least for traditionally oppressed groups, that identity support may have powerful therapeutic effects. I look forward to studies testing this hypothesis which, if true, could empower community groups to improve many chronic conditions.
Looking at an entirely different population from San Diego Kaiser, Vincent Felitti has demonstrated a relationship between adverse childhood experiences and chronic disease in adulthood in the Adverse Childhood Experiences Study. Two publications most cited are in JAMA and the American Journal of Preventive Medicine although, as of a year ago, 40 publications were cited from the original ACE database.
These data suggest that childhood stress can lead to adult obesity, physical inactivity, alcoholism, drug abuse, depression, suicide and poor self-rated health status. In fact the number of categories of adverse childhood exposures showed a graded relationship to the presence of adult diseases including ischemic heart disease, cancer, chronic lung disease, skeletal fractures and liver disease.
The seven categories of adverse childhood experiences were strongly interrelated and persons with multiple categories of childhood exposures were likely to have multiple health risk factors later in life.
In a Graham Center One Pager quoting Dovey, Larry Green, Barbara Yawn, David Lanier from AHRQ and others published an article in a 2003 Pediatrics entitled: “The Ecology of Medical Care for Children in the US”. The authors found that a significantly smaller proportion of children were seen in physicians offices if they were the same in all regards except: they were black, Hispanic, uninsured or living in families where the head of household had not graduated from high school, and if they did not have a usual source of care.
The authors conclude that health insurance and access to a usual source of care for all children are feasible strategies that could be achieved in the US to help ensure that all children receive appropriate health care. Children who are stressed by poverty seem to have some of the same problems in adulthood as those populations who suffer posttraumatic historical stress. Maybe the same mechanism is at work? Felitti says our society is “Turning gold into lead”. Maybe we are missing a golden opportunity in primary care?
It appears that we need to reach children in our primary care practices and be prepared to identify and prevent adverse childhood experiences. Who is going to do this? Family physicians, pediatricians and behavioral health specialists need to have the support systems in place to be successful in this task. We need to build a better system to intervene. Sounds to me like the community mental health movement all over again.
Primary medical care is the de facto mental health system in this country. Half of all formal mental health care is delivered solely by the general medical practitioner. While almost half of all individuals with a diagnosable mental disorder seek no mental health care from any professional, 80% will visit their primary care provider at least once a year. Therefore, we need to integrate behavioral health specialists of many types directly into our family practice clinics. Not an extreme makeover, just getting back to basics that were developed in the early years of community health and model family practice clinics.
In the past year we have a full time child and adolescent psychiatrist fully integrated into our Albuquerque IHS clinic. He is scheduled in the primary care exam room area and available for a “warm hand-off” or a curbside consult. The patient never has to walk through the “mental health door”, so little stigma is attached to the visit. We also may bring a medical social worker or a pharmacist into the exam room.
We therefore can bring services from several disciplines to intervene early in behavioral problems and thereby prevent or lessen the effect of some adverse childhood experiences. At the very least, we are more likely to catch problems early and interrupt the intergenerational cycle that leads to chronic problems in adulthood.
This practice style is called the Open Door System and is being advocated around the country in community health centers by Eric Strosahl and others on contract with HRSA. So far studies of the model have shown that it improves both patient and provider satisfaction and patient outcomes and decreases health care costs. We expect that integrating behavioral health providers into the primary care settings will result in:
• Improved recognition of behavioral health needs
• Improved collaborative care and management of patients with psychosocial issues in primary care
• Creation of an internal resource for primary care providers to help address a patient’s psychosocial concerns or behavioral health issues, reducing the need for referrals to a specialty mental health clinic (should one even exist)
• Improved patient access to mental and behavioral health services through rapid access to behavioral health consultants and rapid feedback from consultants to primary care providers
• Improved fit between what patients seek in primary care and the services offered
• Prevention of more serious mental disorders through early recognition and intervention
• Triage into more intensive specialty mental health care by a behavioral health consultant
• Increased job satisfaction among primary care medical providers and behavioral health providers
• Provision of behavioral health services to a larger proportion of the population in need of those services.
Just as prenatal and post-partum visits by public health nurses have been shown to lead to better adult health status, prevention and early intervention with children in primary medical care settings may lead to healthier adult populations. So what I am proposing is a primary health system that integrates the skills of medical social workers, disease management experts and public health nurses.
Integrating behavioral health specialists from the fields of substance abuse, clinical psychology and psychiatry could have an even more powerful effect on the health status of a population in the era of chronic disease.
In summary, we have discussed some exciting developments in public health and primary care practice accessible to the nation’s family physicians.
• The PHS Commissioned Corps is poised for an expansion to provide for a better public health infrastructure and exciting job opportunities for clinicians and other health professionals who want to serve traditionally underserved populations and their nation
• The IHS has been a successful example of a federal medical program based on an integration of public health, primary care and behavioral health that could make greater strides fulfilling the nation’s promise to indigenous people as well as provide a model national health program. Stay tuned to see if our political leaders have the will to fully fund the program.
• By focusing on the prevention of adverse childhood experiences, we could prevent or ameliorate the impact of the leading chronic adult conditions including obesity, substance abuse, cardiovascular disease and cancer. A national strategy to reduce the impact of the obesity epidemic without addressing adverse childhood experiences will not be completely successful.
• Integrating behavioral health clinicians into our primary care practices may provide a method to improve satisfaction in patients and professionals and be a more effective model for dealing with the behavioral basis of the leading actual causes of death in our nation: tobacco dependence and obesity.
Thank you for listening to my attempt to honor one of our leading philosophers and teachers, J. Jerry Rodos. I would be happy to open up the floor for discussion and comments.