Indigenous cultures have long struggled obtaining and accessing quality health care in the United States. Yet there is much that healthcare professionals can learn from indigenous peoples, if we listen carefully.
For the past 17 years, James Tiesinga, MD, a trained pathologist, has worked closely with the indigenous population in Alaska, as Laboratory Medical Director of the Alaska Native Medical Center, which is owned by the Alaska Native Tribal Health Consortium. In recognition of Indigenous People’s Day on October 10, Critical Values spoke with Dr. Tiesinga about barriers that prevent Alaska Native people from accessing care and the work that he has done to address this issue. Based in Anchorage, Alaska, Dr. Tiesinga also shares his insights on how the medical laboratory can help improve care delivery for this population.
Critical Values (CV): What are some of the health and wellbeing issues that affect indigenous peoples?
James Tiesinga, MD (JT): Cancer, heart disease, trauma (unintentional injury), and suicide are major causes of death among Alaskan Native people. They have higher occurrence and death rates from certain cancers—lung, colorectal, stomach, kidney and liver cancers—when compared to non-Hispanic White people in the U.S. A number of factors contribute to these higher rates.
Nutrition is one factor, and it is related to the high cost of food, particularly in rural villages. The nutritional value of the produce also tends to be quite poor, as fruits and vegetables are mainly shipped from long distances. Many Alaska Native people rely on subsistence hunting, fishing, and gathering of berries for their food. It is a traditional way of life, and the food is far healthier and more nutritious than processed food purchased in the local store. However, over time, there have been major threats to this lifestyle, such as federal and state regulations that impose limitations, and overharvesting by commercial fishing that impacts fishing in rural interior communities.
Subsistence is also a physically intense and time-consuming way of life. For example, whaling is a very important part of the Inupiaq culture. It is cost effective and provides a highly nutritious food source to Arctic communities. But, during whaling seasons in the spring and summer, whalers will prioritize providing food to their communities and families over their own personal healthcare, such as getting screened for things like diabetes and cancer. At the end of the summer whaling season, the town of Utqiagvik throws a big Whaling Festival that attracts people from all over the North Slope of Alaska. There are traditional songs and dances, including a blanket toss, where a dancer is tossed high in the air from a blanket made of seal skins. Knowing that this festival draws a large crowd from the local and nearby communities, Arctic Slope Native Association, the tribal health organization in that area, sets up a health fair at the festival and also schedules many people to come into the clinic at that time for wellness checks and other healthcare needs.
CV: What barriers prevent Indigenous peoples from accessing quality diagnostic testing and care?
JT: Geography is a huge barrier. Alaska is an enormous state with mountainous or other inaccessible terrain. About 100,000 of Alaska’s 700,000 residents are indigenous, or Alaska Native, and many live in extremely remote areas. The majority of Alaska’s native villages can only be accessed by small plane or, in some interior or coastal communities, by boat. There is no road network in most of Alaska. This can make access to care very challenging.
Additionally, there are tribal communities in Alaska that, to this day, do not have adequate water and sewer systems. Many homes in these communities do not have indoor plumbing. These conditions affect the health and hygiene of the community. While a lot of progress has been made to address these conditions, funding for these projects is diminishing.
Another barrier pertains to historical trauma. Multiple generations of Alaska Native people have experienced having their land taken away or rendered unusable to them. Whole families and communities have been wiped out by the introduction of diseases brought in by outsiders. There have been coercive migrations and disruptive federal work programs. Children have been removed from their families and sent to government-run boarding schools or placed in non-native custodial care. Historical trauma, and the events leading to historical trauma, are not just limited to things that happened 100 or 200 years ago. Many people my age (57) have experienced this in their own lifetimes.
CV: What impact does historical trauma have on access to care?
JT: It undermines confidence in the U.S. healthcare system. This is why, during the 1990s, Alaska Native people worked to gain control of their own healthcare system, which was being run by the U.S. government. Alaska tribal leadership petitioned the federal government to transition ownership and oversight of this healthcare from the U.S. government to Alaska Native people. This transition occurred in or around 1997. Since then, the Alaska Tribal Health System has been owned and operated by Alaska Native people through tribal health organizations established by local communities.
Since the transition, traditional values of the Alaska Native people have been incorporated into their healthcare system. For example, many tribally owned healthcare facilities now serve indigenous foods in their cafeterias and to their patients. Tribal health organizations have also hired indigenous people to work in their facilities, ideally hiring local people to work in local clinics as they understand the culture and can speak in culturally sensitive ways. These efforts have restored the confidence of Alaska Native people in their healthcare system, which, after all, they own.
CV: Tell us more about these tribal clinics and how they operate.
JT: The Alaska Tribal Health System operates on a hub-and-spoke model. According to this model, tribal health starts at the community level with many small village clinics that feed into larger regional hospitals and, in some cases, large outpatient facilities. The Alaska Native Medical Center, or ANMC, serves as the tertiary hospital for this system. ANMC is the largest tribal hospital in the U.S. with approximately 250 beds. It is a Level II trauma center and offers a full range of specialty and laboratory services. ANMC partners with our local tribal health organization, Southcentral Foundation, which provides primary care and has a vast network of primary care clinics across southcentral Alaska. ANMC is overseen by a Board of Directors comprised of tribal leaders from all regions of Alaska.
An objective of mine, which is shared by tribal leadership, is to bring basic healthcare and laboratory services to the local level, to improve access. As a practical matter, that means finding ways to establish waived testing platforms in the majority of small village clinics and to develop logistics that allow these clinics to send specimens to ANMC or other reference laboratories as needed. For larger tribal clinics in bigger communities, we also include some moderate complexity tests such as Troponin. And, for the regional hospitals, our laboratory services include high complexity testing such as blood banking and microbiology. These services all work together to improve access to care for people living in remote areas. What is particularly interesting to me is the fact that many non-Native people also live in the same rural communities that are served by the Alaska Tribal Health System. Alaska is a very integrated population. The primary mode of health care for many Native and non-Native peoples in Alaska is the tribal health system.
CV: How can the medical laboratory play a role in designing appropriate healthcare systems for this population?
JT: During my 17 years here, I have implemented laboratories in village clinics, hospitals, and outpatient settings. It is essential to maintain a dialogue with people who live in these communities and who best understand the healthcare needs for their community. Community feedback influences the direction these laboratories will take. That means setting up as many of these tests as we can, within the limitations that we face. We all know laboratories are highly regulated, but to the extent we can establish access to basic and necessary laboratory services, based on community feedback, that is what we strive for in Alaska. As one example, when it comes to obstetric services, it the goal of the Alaska Tribal Health System to support women in their birthing choices, whether that means working with a traditional midwife, or using a nurse midwife, or coming into ANMC for prenatal care and delivery. Our local and regional laboratories work together to give midwives and other healthcare providers access to basic hematology and chemistry results, perform workups for group B strep and other infectious agents, provide access to Rhogam and blood products as needed, and all other testing that is essential to ensuring a good outcome for Mom and baby. Of course, not every test can be performed locally, but by setting up a process to refer samples to a regional hub or to ANMC and setting up moderate and high complexity testing platforms within the regional hubs, we can achieve very good turn-around times and overall access to essential laboratory services.
Laboratorians understand—particularly during this time of national staffing shortages—that qualified personnel with appropriate training and education are required to perform moderate and high complexity testing. And we all know there are all sorts of regulations we must follow to ensure the accuracy of test results. Maintaining adequate staffing and meeting all the regulatory requirements become even more challenging to manage in a rural environment. For that reason, laboratorians like me must make frequent trips to remote areas to train staff, coordinate services with providers and community leaders, and take the necessary quality assurance steps to keep the lab running smoothly and ensure the accuracy and timeliness of test results.
High complexity testing in remote areas also comes with some unique challenges and must be performed exclusively at regional hospitals within our hub-and-spoke model. High complexity testing includes services like transfusion medicine, microbiology, and abnormal blood smear interpretation – services for which a pathologist is generally required to oversee the testing. But even though this testing cannot be performed locally in most cases, that does not mean these services are not incredibly important to the well-being of people living in smaller communities. For example, trauma is one of the leading causes of death among Alaska Native people. This is related to harsh environmental conditions, the demands of subsistence living, modes of transportation, and other factors. High complexity laboratories in the regional hubs play a huge role in responding to traumas by providing safe and reliable blood products via air medical transport to remote areas where accidents occur, and by following up with lifesaving test results shortly after blood samples are received back into the labs.
How did the Alaska Tribal Health System Deal with COVID-19?
JT: Let’s take a step back for a moment. A primary cause of hospitalizations among Alaska Native people is respiratory infection. In October 2019 (the start of our fiscal 2020 year), I initiated a strategic plan to bring molecular testing to rural communities across Alaska. Going into fiscal year 2020, it was my goal to implement up to 30 analyzers to test for respiratory illnesses such as FLU A&B and RSV in these communities, using the more accurate molecular platforms. Consequently, as part of this strategic plan, the Alaska Native Tribal Health Consortium had already begun to work with vendors to acquire molecular platforms when, in December 2019, we heard about the spread of SARS-CoV-2 in China. Recalling the dire impact of the H1N1 virus on many Alaska Native communities some years before, we became alarmed that SARS-CoV-2 would hit here.
And so, as early as December 2019, I directed my lab staff to order the supplies and equipment we might need, such as collection swabs and viral transport media, in the event SARS-CoV-2 became an issue for us. By March 2020, when the U.S. government declared a national emergency, we had already arranged (as part of this earlier strategic objective) for vendors to bring molecular analyzers and testing supplies to Alaska Native communities to fight COVID-19. Subsequently, on April 5, we rolled out over 100 of these analyzers across Alaska, along with the requisite supplies and reagents, and implemented strategies for training staff to perform COVID-19 testing. For those communities that could not perform this testing locally, we developed pathways to bring specimens to the regional hubs and to ANMC for testing. Through all of this, we helped many vulnerable communities establish testing mandates for travel; we assisted public health services implement disease tracking, effective quarantine, and lifesaving interventions; and we kept many Anchorage-area operating rooms and surgery centers, tribal and non-tribal alike, in business by helping them meet pre-procedure testing mandates. In fact, for most of 2020 and 2021, the ANMC Laboratory was performing around 2,500 COVID-19 tests daily from samples received from all over Alaska.
It is truly amazing what we accomplished at ANMC and what our tribal partners accomplished across the state, and it is an enormous testament to the role of the Alaska Tribal Health System in combatting the virus throughout Alaska, for all Alaskans.
CV: In closing, what do pathologists and medical laboratory professionals need to consider most when working with patients of indigenous cultures?
JT: There is much for us to learn. Alaska Native people want to participate in their own healthcare. That is very important to them and, I think, important to most other people. Participation means allowing people to understand and collaborate with their healthcare providers, allowing them to take part in decisions, and respecting their traditional beliefs and values as part of the decision-making process. For all these things to happen, it is important that healthcare providers listen to and respect what people are telling them. In populations where English may not be the first language, as is the case for many Alaska Native people, it is especially important to make the effort to understand and listen patiently, and give people the opportunity to tell their stories. Listening to people in an environment where they feel safe and valued is an essential step toward improving their access to care. It allows people to participate in their own healthcare on a very fundamental level. For pathologists and medical laboratory professionals who may not have direct access to patients, there are other ways we can empower patients. Some ways include giving patients access to their lab results through an electronic portal and adding comments to certain tests that help patients understand the results in a way that is meaningful to them. Another way that I believe shows great promise is to include laboratorians in hospital rounds. I think this is a great way for us to interact with our patients and other members of the team; it gives us an opportunity to listen to and address patient concerns directly and provide useful feedback in culturally sensitive ways. Ultimately, when we pay attention to what our patients are telling us, it improves their access, it improves their health, and it improves their sense of well-being.
Read more on the connection between indigenous people and the laboratory here.