CDC Telebriefing Transcript

CDC News Conference: Health Disparities Experienced
by American Indians and Alaska Natives

July 31, 2003

MS. HUNTER: Good afternoon, and welcome to this week's MMWR press briefing. My name is Karen Hunter. I'm a senior press officer in the Media Relations Office. At the end of this briefing I will be giving the phone number to both CDC's press office, as well as the press office number for Indian Health Service, for any reporters who have follow-up questions or wish to speak to some of the authors of the other articles.

This week's MMWR is a special dedicated issue looking at health disparities experienced by American Indians and Alaska Natives. We will have two speakers during this briefing. We will open with Dr. W. Craig Vanderwagen, who is the Acting Chief Medical Officer of HHS's Indian Health Service. He will give a brief overview of the whole health disparity issue in this population, and he will also briefly discuss one of the articles looking at diabetes prevalence among American Indians and Alaska Native children.

We're also going to be hearing from Christine Branche, Ph.D., with CDC's Injury Center, and she will be talking about one of the other articles at MMWR, looking at injury mortality among American Indian and Alaska Native children and youth in the U.S. from 1989 to 1998.

Let's begin now with Dr. Vanderwagen, and I am going to spell his name for you. It's W. Craig, C-r-a-i-g, Vanderwagen, V-a-n-d-e-r-w-a-g-e-n. And again, he is the Acting Chief Medical Officer with Indian Health Service.

Dr. Vanderwagen?

DR. VANDERWAGEN: Good morning, Karen, and thank you so much for the opportunity to be part of this process.

Today we are going to talk a little bit about disparities in American Indian and Alaska Native communities, and I want to say first of all, we want to express great thanks to the CDC staff who have dedicated time and effort in doing this analysis.

As many of you may know, the Indian Health Service really is a service organization providing clinical and community-based care, and we rely extensively on our colleagues at CDC to assist us in this kind of data capture and analysis. Based on this kind of analysis, we're able to target more effectively the kind of program interventions that we plan and implement. So thanks to CDC for this effort.

Contextually, I would like to point out that American Indians and Alaska Natives, at least since the turn of the 20th century have experienced great disparities in health. When the Indian Health Service was transferred to then HEW from the Department of the Interior, significant progress began to be made as we applied public health principles in addressing some of those disparities.

When I was a child growing up in Zuni, New Mexico on the reservation in the '50s, infant mortality was in the range of 60 per 1,000 live births. Tuberculosis killed a significant number of people before the age of 40. Many of those issues have been addressed effectively by the agency, and in fact, infant mortality now is very close to the general U.S. population, and in some communities in fact it's below or better than the general U.S. population.

Having solved those particular health problems, however, exposes other health issues that need to be addressed, and in fact, may be more refractory to medical interventions. And today you will hear some discussion of data related to a variety of chronic disease and some acute issues that will require a broader public health and community-based set of interventions that work in partnership with Indian trial governments in Indian communities if we are going to make the next step in significant improvements in Indian health.

Specifically today, we'll talk a little bit about diabetes injuries in its many forms, and I'm going to comment for just a moment about diabetes as a phenomenon in Indian communities. Again, I'll relate back to my experience 50 years ago, growing up on the reservation, when people were tubercular, and you were seldom saw anyone who approached anywhere near something we might call fat or obese. Diabetes was not an issue.

But in the last 20 years, we've seen an increasing rate of obesity, not only nationwide in the general population, but a rate of obesity that has increased very dramatically in Indian communities.

As most of you are aware, obesity is linked significantly with the development of diabetes and cardiovascular disease. So we've seen a large increase in diabetes over the last ten to fifteen years, and in fact this article will provide some specific figures for the period of the 1990's up to contemporary time.

We believe that medical intervention in the form of early diagnosis and intervention with medications or nutrition and exercise programs will have significant benefit, and there may be some preliminary data, in just the last year, that there might be a slight decline in diabetes-related deaths, which may be attributable to the kind of clinical interventions that we've exploited, I think very effectively, in Indian communities in the end of the last decade and over the last three years of this century.

Evidence for that also is found in the fact that we've been able to document a decline in hemoglobin A1c's, a full percentage point in those people who are known diabetics in our system. This indicates sound clinical management but that may be insufficient and we hope that this article will begin to expose some of the factors that we need to contend with, including nutrition and exercise interventions and other public health-oriented interventions that go beyond medical treatment of diabetes per se.

Karen, I'll hand it back to you because I think we have other comments to be made here before we answer some questions.

CDC MODERATOR: Thank you, Dr. Vanderwagen.

Now we're going to hear from Christine Branche, PhD, who is director of the Division of Unintentional Injury Prevention at CDC's Injury Center. I'm going to spell her name.

First name is Christine, C-h-r-i-s-t-i-n-e, last name Branche, B-r-a-n-c-h-e, and now we'll hear from Dr. Branche.

DR. BRANCHE: Good afternoon.

I'm going to be providing a brief overview of the MMWR article that dealt with the burden of injury and the issue of preventing them.

I'll be referring to Native Americans and that, in the article is referred--we use the term American Indian and Alaska Native.

I'll take your questions after my brief overview.

While Native American death rates for motor vehicle crashes, pedestrian events, drowning and fire, have decreased over the ten year period that we studied, we found that overall, injury disparity compared to white Americans continues to exist.

I would like to present key findings from our study to illustrate the gap in injury prevention facing Native Americans today.

From age one through 19 years, Native Americans are at greater risk of preventable injury-related death compared to other children and youth in the United States.

Injuries and violence account for 75 percent of all deaths among children and youths ages one to 19 years in this population.

The risk of injury-related death is about twice that of all children and youth in the U.S. and the risk for Native Americans varies from one region of the country to the other.

CDC researchers found that more than 3,300 Native American children and youth living on or near reservations died as a result of injuries or violence between 1989 and 1998.

While injury death rates declined for motor vehicle crashes by 14 percent, and please note that this is a change from the press summary that you received--it's 14 percent--other declines were in drowning, fire and pedestrian incidents. Rates increased for firearm-related deaths and homicide.

Disparities in injury and violence rates vary widely by region of the country and by cause.

For example, Native Americans who live in Alaska and the Dakotas have an increased risk of suicide and fire-related death that is 5 to 7 times greater than for all children in the United States.

In looking at firearm-related deaths, our study included all deaths from suicide, homicide, unintentional and undetermined intent.

However, this study did not look at why there have been increased in homicides and firearm-related deaths. More needs to be learned about how to apply advances that have been made in youth violence prevention to youth and Native American communities.

The Billings and Aberdeen regions had motor vehicle-related death rates more than three times higher than national motor vehicle-related death rates. Eight of the twelve regions had motor vehicle-related death rates higher than 95 percent of all U.S. state rates.

Each Native American community is unique. We believe that by addressing local practices and cultures, each of us can help to develop future prevention measures to narrow the injury disparity gaps that I've briefly outlined.

Several promising prevention strategies include Alaska's promotion of float coats and personal flotation devices.

Sleep Safe is a smoke alarm distribution and education program for Native American Head Start schools, that is working to alleviate residential fire-related deaths.

CDC, this fall, is going to fund tribes to implement injury prevention strategies to reduce motor vehicle-related injuries.

I'll be glad to take your questions now. Thank you.

CDC MODERATOR: I think we're ready to open it up for reporter questions.

AT&T MODERATOR: And ladies and gentlemen on the phone, once again, if you do have a question please press star and then one. One moment, please, for the first question.

And our first question's from the line of Anita Manning with USA Today. Please go ahead.

QUESTION: Hello. I'm trying to get sort of a broad sense of where we're going with Native American health. It looks to me as if things have always been pretty bad in terms of public health on the reservation. When I say "always," I mean back to '89, and I'm trying to get a sense of whether what you're presenting today is a snapshot or any trend. Where do you see us going?

And the second part of that is the report says that Native Americans have a 26 percent poverty rate, which is twice the national rate, and I'm wondering if anything is changing there. I mean, we've heard about all these casinos and money being made from casinos. Has that had any effect on the overall health? And I'll stop now but I will have more questions later. Thanks.

CDC MODERATOR: Thank you. Dr. Vanderwagen, would you like to address that question.

DR. VANDERWAGEN: Sure. Let me start with the second question first, and the fact of the matter is that the impact of Indian gaming, in general, appears to be positive in those communities where gaming has been a productive economic engine, but I will remind you that about 75 to 80 percent of the overall profits in Indian gaming are really focused in a limited number of Indian communities, and so those communities have shown tremendous improvement, and I will give you an anecdotal example here in a moment.

But other communities, there has been less impact or in fact they do not have gaming. Where I grew up in Zuni [ph], there is no gaming.

An example I want to give you is the director of the World Health Organization visited in Phoenix, recently, and we visited a reservation, the Salt River Reservation, and the tribal chairperson there, Ms. Ramos [ph], toured us around a little bit, and in fact you could see where investments were being made significantly in housing, schools, and other infrastructure on the part of the community, and I think the director-general was quite impressed with the impact of economics, and when he inquired of the tribal chair what she saw in the next 30 to 50 years, she noted that the economic impact of that was going to allow them to deal with the wide variety of social and cultural issues that had been problematic for the tribe, not the least of which was preservation of language, as well as education of their children in how to succeed in a western society.

To go to the trends issue, at least our perception in Indian health is that we're seeing the increasing impact of behaviors that affect health, and in fact, addictions that undermine health, whether that addiction is to foods or to alcohol, and in the injury article I think there are clear linkages between alcohol and many of the injuries that we see, and so we see the impact of these behaviors influencing the health status of people in Indian country, particularly young people. The rise of gangs in Indian country has been a real concern to tribal leaders and tribal officials, and the Department of Justice informs us that there are no less than 300 youth gangs on reservation environments.

We also have evidence that young people who lose their cultural connection have extreme difficulties. In one of our regional youth alcohol treatment programs, even though the surrounding reservation had 75 percent of the people able to speak the language and knew the culture, only 15 percent of the kids in that treatment center could speak the language and fully understood the culture.

So we think there has been a real fragmentation of the community and family support structures, and this is reflected in behaviors that really influence people's health, both very immediately in the case of youths who are involved in accidents, of suicide, and in the longer haul for adults who have eating behaviors that affect their health adversely.

MS. HUNTER: Thank you. And I believe Dr. Branche also had a comment.

DR. BRANCHE: Simply that the reporter asked about a trend, and our study did cover a 10-year period, and even though Native Americans do have a 75 percent higher profile in their injury issues for ages 1 to 19 years, we did see a decline in their overall injury picture for the 10-year period that we covered.

MS. HUNTER: Do we have additional questions?

OPERATOR: Ms. Manning, go ahead with any further question.

QUESTION: Thank you. This is great. So you saw a decline in the injuries between '89 and '98, and to what do you attribute that?

DR. BRANCHE: Well, actually, this was a review of death rates for the American Indian and Alaska Native populations over the 10-year period, and we were simply trying to get a better idea of the causes of injury. We don't explore as much the reasons why the decline occurs. We do know, however, that the Indian Health Service has implemented funding for tribes, those tribes that do work with them, to be able to build capacity to first understand and then try to implement interventions for their injury problems. And we also know that tribes have implemented a number of steps to try to alleviate their injury problems.

And one example that comes to mind is that some tribes have implemented zero tolerance policies for drinking and driving. There is also in Alaska, for their drowning problem, the Float Coat and personal flotation device intervention programs, and then a number of states have worked with both the Indian Health Service and the U.S. Fire Administration to deal with their fire-related injury problem by both distributing smoke alarms and giving fire safety education through Head Start programs.

DR. VANDERWAGEN: Could I add to Dr. Branche's comment? That she alluded to building capacity at the community level to analyze and then develop intervention, and I think the biggest improvement for us has been the Injury Prevention Fellows, where we bring community-based folks with an interest in some expertise together with Johns Hopkins and CDC, and we provide training. And over the last 10 years I think we've produced about 120 to 140 individuals with those skills at the community level.

And the highway safety factors have improved, whether it was seat belt use, and some of this is enumerated in the article, as well as roadside safety, installation of lights at places where pedestrians were at high risk after dark. So there have been a variety of interventions at the community level to address many of those issues.

MS. HUNTER: Thank you, Dr. Vanderwagen.

Next question, please?

OPERATOR: That's from the line of Betsy McKay with the Wall Street Journal. Please go ahead.

QUESTION: Hi. Thanks very much. I wanted to ask about diabetes and the fact that--ask a general question about the fact that diabetes affects American Indians and Alaska Natives so disproportionately, compared with the overall population. I know there have been various theories about why this is, and I am just wondering if you could expand on this a bit and just say, just, you know, give your thoughts on what is causing this? You know, how much--to what extent is diet, to what extent is lack of exercise, or the "thrifty gene." I know there have been various theories out there. Thanks.

MS. HUNTER: Dr. Vanderwagen?

DR. VANDERWAGEN: This is Vanderwagen. Well, the thrifty gene theory has not been demonstrated completely as yet, although I will note that two tribes in Arizona have--and these are gaming tribes--have invested 10 million with the Genome Research Institute, based in Phoenix, to study this and other genetic concerns in more detail, so we may learn more about that in the near future.

Clearly, as a clinician, anecdotally, 20 years ago we recognized that nutrition and diet were major concerns, and where we were able to implement dietary change and fitness activities, we were able to manage people who had been diagnosed as diabetics without medical intervention. And this was reinforced with a more scientific base in the diabetes prevention project that was funded and completed by the National Institutes of Diabetes, Digestive and Kidney Disease. And that was released I think about a year ago.

Clearly, those factors of diet and exercise are probably the most significant issues that predispose this population if one discounts any concern at this point about a genetic difference, and there's no evidence to support that there is necessarily a genetic difference. And consequently, tribal programs that manage commodities, foods, for instance, have changed their ordering practices, and moved towards lower-fat meats like skinless chicken, more frozen vegetables, fruits in natural juice as opposed to heavy syrup. And we know that for people who are dependent on those commodities programs, there appear to be positive effects in their rates of diabetes, at least in terms of the management of their diabetes as clinicians perceive it in those communities.

This is another area where more detailed science would be useful to understand, if in fact that social intervention has the kind of effect that our clinicians believe that it does.

CDC MODERATOR: Thank you. Next question, please.

AT&T MODERATOR: And that's from the line of Brian Bole [ph] with South Dakota Public Radio. Please go ahead. Mr. Bole, your line is open. Please go ahead. We will move on.

We'll go to the line of Maura Lennar [ph] with the Minneapolis Star-Tribune. Please go ahead.

QUESTION: Yes; hi. Thank you.

I have a question about the cancer mortality rate. I notice that overall, the cancer mortality rate is lower than the national average.

I wonder if you could just address, in general, why you think that is. But then specifically why up here, in the Northern Plains, they see quite the opposite, that the rate is actually higher than the national average.

CDC MODERATOR: I'm going to see if Dr. Vanderwagen would like to address this.

What you might need to do is call our press office after this briefing and we can put you in touch with the lead author of that particular article. That person is not here for the telebriefing.

Dr. Vanderwagen, did you have any comment that you wanted to make regarding the cancer article?

DR. VANDERWAGEN: Well, just two that are sort of more common sensical than science-based at this point. One is that population, is only in the last generation, started to live long enough to experience the cancers that generally prevail in the general U.S. population.

So it may be that we are just behind the curve, because the percentage of our population over the age of 65 is still half of what it is for the general population.

On the other side of that, the question of exposures and toxic exposures in farm environments, and work environment is an open question that we think needs some research, particularly in the Great Plains, because in fact we don't see the same kinds of cancer rates as you've noted in the Southwest, and that in fact may be related to exposure.

But I will say that it should be noted that the rates of tobacco use in the Great Plains and in Alaska are significantly higher than they are in the Southwest and so the cancer that we are most concerned about at this point is the rising rates of lung cancer, particularly in Indian women.

In the past, we were quite concerned about cervical cancer because it was one of the few cancers where the rates were higher for American Indians than they were for the general population.

But with interventions around women's health clinics and assuring that the screening was done in an effective and patient-acceptable manner, we've been able to reduce the cervical cancer rates very effectively, and what we've seen is that in Alaska, and I think in a couple of states in the Great Plains, lung cancer in fact is now the leading cause of cancer-related deaths for American Indian and Alaska native women.

So we believe that tobacco abuse and use, if you will, in the Great Plains, may be the most significant variable that is something we can intervene on if we're going to try and change those cancer rates.

CDC MODERATOR: Thank you, and again, caller, I will give the press office number following the briefing, at the end of the briefing, and you can call and we can put you in touch with one of the authors of that particular article.

Next question, please.

AT&T MODERATOR: And that's from the line of Casia Doyle [ph] with Indians.com. Please go ahead.

QUESTION: The majority of American Indians and Alaska natives live off reservation. Is there a difference in their rates of disparity, between urban natives and reservation natives?

Have there been any studies along those lines?

DR. VANDERWAGEN: In fact the majority of Indians do live in standard metropolitan statistical areas that are urban in nature. I'll note that a number of reservations, in the last 20 years, have now become overtaken by the cities that surround them, including Phoenix, Albuquerque, Seattle, and others, and so that even now, many of the reservation environments have become increasingly urban in character and in influence.

As to the specific question of folks who live exclusively in urban environments unrelated t other tribal traditional lands, the statistical information regarding that population is very thin.

We've recently funded an epidemiology research center to begin to get a better picture of what those issues are. In fact the local studies that we've done in selected urban environments reveals that the health status of Indians living in urban environments unrelated to their tribal lands are probably at least as bad as the disparities that we observed in folks living in reservation-based environments.

CDC MODERATOR: Thank you. Next question, please.

AT&T MODERATOR: And Ms. Hunter, there are no further questions. Please continue.

CDC MODERATOR: Great. Let me give some phone numbers.

The CDC press office number, for anyone who needs follow-up information, is [404] 639-3286.

The Indian Health Service press office number is [301] 443-3593.

And lastly, I'd just like to direct your attention to an electronic press kit that is on the media site, if you go to www.cdc.gov, click on In The News, that will take you to our newsroom site, and we have a number of links with more detailed information.

So that will conclude this MMWR press briefing and thank you all for joining us.

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