Editor’s note: This is the first in a series of posts by Dr. Ken Bernard on his experience with the Indian Health Service.
Boozhoo, or, “Hello.” I start in the language of my ancestors, the Anishinaabe, which means “Original People.” This summer I will be starting my career as an emergency physician and returning to the “rez” (reservation) after a thirteen year hiatus in the Northeast completing college, medical school, and an emergency medicine residency. What is bringing me back? To answer that, I must start at the beginning.
My life, like many here in the U.S., began with a series of numbers: APGARS of 9 and 9, weight 8 lbs. 3 oz., length 24 inches. There is also a curious ⅜. This last fraction is unique to the roughly five million American Indians and Alaskan Natives (AIAN) from over 566 federally recognized tribes that currently live in the U.S. This amount is recorded on my Certificate of Degree of Indian or Alaskan Native Blood. It is conferred by the Bureau of Indian Affairs and grants my enrollment in the Turtle Mountain Band of Chippewa Indians. Essentially, it is recognition by the federal government of my lineage and the degree of my “Indianness,” so to speak.
However, this little fraction has huge political, socioeconomic, historical, and cultural implications for Native populations. We are the only race whose membership is defined, regulated, and granted by the federal government. Personally, this number has been somewhat confusing. Nationally I am American, culturally I am Native, and ethnically I am a hodgepodge of Turtle Mountain Chippewa and European ancestry. Many consider me to look ethnically ambiguous — my patients often ask if I am Latino, Italian, or Greek. Furthermore, this number, which ties me to my home and heritage, took me farther away from both than I could have ever imagined to gain the knowledge and skills needed to fulfill my dream of becoming a physician. But I want to move away from the discussion of blood quantum for a moment to discuss a few other unsettling numbers that have been looming in my mind over the past few years.
As a researcher of health disparities and quality care, I have run into figures such as: 200%, 300% and 50%, which are the likelihoods that AIAN people are to be impoverished, unemployed, or obtain a college degree, respectively, when compared with the rest of the U.S. population. Forty-three percent represents the annual budget shortfall, and $3,348 is the per capita health expenditure, of the Indian Health Service (IHS), which is less than any other federally funded program including the federal prison system.
Or how about 20%? This is the annual physician vacancy rate within the IHS, which persists despite generous scholarship and loan repayment programs like the one I was grateful to earn. Inequities in social determinants of health and health care access, in addition to generational trauma, cultural erosion, and racial discrimination, have contributed to other disturbing facts. AIAN adults can expect to die five years earlier than their fellow U.S. citizens and have a 50% higher age-adjusted mortality rate from all causes. And AIAN neonatal mortality and death of young AIAN adults from intentional and unintentional injuries is 200% higher than their U.S. counterparts.
So now back to my “3/8thness” and my calling to serve Native people through the IHS. What do I do with the other 5/8ths or the leftovers? Why doesn’t anyone feel the need to define the 5/8ths of me that have been deemed “not Indian”? Well, that is easy. One dinner with my family and me would demonstrate to anyone observing that I am all in, 100% Indian, with no proportion of me that has ever wanted to be anything but a physician who serves Native people.
Our dinner ritual has been practiced for generations. The adolescents and healthy adults prepare and serve the food, first to elders, then the ill or frail followed by expectant mothers or moms with infants, and honored guests.
Next, the food is laid out on the table and a line naturally forms with the youngest first. The prep and service team eats last, once all others are comfortable and full. This small, quiet ritual is an important expression of our dedication to one another. It is a sign of respect and gratitude to those elders who have worked so hard in making sure we have had a chance to thrive. It is recognition that we are only as strong as our weakest members who deserve our compassion, love, and care.
So really, my call to service had nothing to do with fractions or percentages, but with values that lead most of us to medicine such as: service, compassion, justice, altruism, community, dedication, and love. As a researcher and physician I have come to appreciate that we need to look past numbers to understand the context and experience of individual patients. As a person and proud member of the Turtle Mountain Band of Chippewa I have never paid much attention to this notion of 3/8ths, but instead look to the foundation of cultural values and beliefs taught to me by elders and my community, which have brought me back to serve the Navajo and Hopi Nations at the Tuba City Regional Health Center in Northern Arizona.
I am excited to be able to share my experiences during this journey. I hope to not only raise awareness about the challenges on the front lines of medicine in Indian Country, but also encourage others to follow their passion and calling.