COLLEAGUE INTERVIEW

Colleague Interview: A Conversation with Mary J. Owen, MD

Mary Owen, MD is a member of the Tlingit nation. She graduated from the University of Minnesota Medical School and North Memorial Family Practice Residency Program before returning home to work for her tribal community in Juneau, Alaska. After 11 years of full-scope family medicine, she returned to the University of Minnesota Medical School, Duluth Campus in 2014 as the Director of the Center of American Indian and Minority Health (CAIMH). Her work includes developing and managing programs to increase the numbers of American Indian and Alaska Native (AI/AN) students entering medical careers, reaching out to local and national Native leaders to ensure University of Minnesota Medical School remains in tune with AI/AN healthcare and education needs, developing an AI/AN track for all students interested in providing health care to AI/AN communities and developing research efforts to address AI/AN health disparities. She continues to provide clinical care at the Center of American Indian Resources in Duluth and is the current President of the Association of American Indian Physicians.

American Indian/Alaska Native, Native American, Indigenous—what’s the difference in the terms and how should those terms be used?

All these terms can be used interchangeably. That said, many Native people prefer to be referred to by their Tribal identity. Additionally, each person is different. For instance, when I use the term, American Indian, one of my aunties corrects me and says, “Native American.” The only term that I recommend against by people who are not part of the Native community, either by birth or acceptance, is “Indian.” Native people often use it themselves, but I recommend people use the terms American Indian (AI), Alaska Native (AN), Native American (NA) or Indigenous.

How does historical and intergenerational trauma express itself in the lives of the Indigenous peoples of Minnesota?

Historical and intergenerational trauma is expressed in part through the persistent health, education, and economic disparities of Native people in Minnesota and the United States. I will give an example of historical and generational trauma playing out in Native communities: by 1920, up to 80% of Native children were in boarding schools—institutions that have been revealed to have been created to assimilate Native people by disallowing their language and culture to be practiced. Once children graduated from or left the boarding schools, they returned to broken communities now dependent on government support because the traditional practices and ways of survival that Native Americans had practiced for centuries could no longer support them. Family and community structures were in flux, if not destroyed by the imposition of western ways. Young people, now speaking a different language, struggled to communicate with their families when they returned. The youth returning from boarding schools far away from their communities were not raised with common teachings such as how to raise children and families. As young people do, they got together and had children. Without those critical family and societal lessons on how to raise children, how to support your family and how to interact with your traditional community members, dysfunction naturally ensued. Because over half of Native children were sent to boarding schools, which were open through the 1970s, the impact was and is massive. In her book, An Indigenous Peoples’ History of the United States, Roxanne Dunbar-Ortiz expertly describes the “narrative of dysfunction” in our communities. She cites the teaching of Vine Deloria and other activists who state that “there is a direct link between the suppression of Indigenous sovereignty and the powerlessness manifest in depressed social conditions.”

How do you blend traditional health practices of American Indian tribes with allopathic “Western” medicine?

Native ways of knowing, including health practices were in place for centuries before Europeans came to this continent. As in western medicine, many of our patients are interested in healing

practices outside of what physicians prescribe. Thankfully, many Tribal and Indian Health Service (IHS) facilities are incorporating traditional healing by employing traditional healers. I often ask about and encourage my patients to participate in culture, including healing practices, as cultural engagement has been shown by Dr. Melissa Walls’ and others’ work to improve health outcomes.

Reparations are a topic discussed mostly around the African Descendants of Slaves (ADOS). How should we think of reparations with Native communities?

Land Back is likely the movement that is closest to the reparations movement. The United States promised health care, education, and social services for Native people in perpetuity in exchange for millions of acres of land. The US has yet to pay its bill. Additionally, it has been made clear through history that Indigenous people are better stewards of land than non-Indigenous people. The Land Back movement is not only about the US government giving back some of the land it stole, but more importantly, about allowing Indigenous people to have a say in how traditional Indigenous land is managed. It is also about recognizing Tribal sovereignty. For more information on the movement see: https:// bit.ly/LandBackMovement.

What is your assessment of the effectiveness of the Indian Health Service in Minnesota and elsewhere in terms of protecting and improving the health of AI/AN?

It is important to recognize that the effectiveness of the Indian Health Service and Tribal health facilities throughout the United States is significantly impacted by factors outside the institution’s control. The IHS is funded at a fraction of what is necessary to provide health care for Native people. Consequences of underfunding are many, but include outdated buildings and supplies, high staff (including physicians) turnover, triaging of referrals, and limited monies for ongoing continuing medical education for all staff. All efforts by Minnesota IHS and Tribal health facilities are hindered by underfunding. Another key factor in providing care for Native patients is that the Indian Health Service and Tribal health facilities still battle the issue of mistrust created by centuries of misdeeds by the US government and its institutions. Even as Native practitioners within our own Tribal facilities, many of us have encountered mistrust and assumptions that the care we provide is subpar to what a patient might receive in a non-Native facility. Despite these factors, the IHS and Tribal health facilities have been very effective in many ways in providing for the health and well-being of Native people. An example of this success has been the IHS and Tribal health role in Native American communities having some of the highest rates of COVID-19 vaccinations. Another example is the success achieved by tribally managed diabetes programs on lowering the rates of end-stage kidney disease in Native people. There are so many amazing people working for IHS and Tribal health—people who dedicate their lives to improving health outcomes in our communities, but they face persistent funding and mistrust that make this work a constant uphill battle. I think it’s also important to remember that it has only been since 1975 with the passing of the Indian Self-Determination and Education Assistance Act that Native Americans have really begun to gain control of our health care through the Indian Health Service. Fifty years is not a long time to repair and make up for the impacts of centuries of genocidal acts against a population. Over 60% of Tribes now manage their own healthcare facilities. With appropriate funding and time, I believe that the Indian Health Service and Tribal healthcare facilities will continue to have significant impacts on the health of Native people. Importantly, however, we all know from our growing recognition of the impact of social determinants of health, that improving the health of a Native people will require the concerted efforts of many institutions outside of medicine. In this article, Dr. David Jones nicely summarizes the history of and the tremendous efforts necessary to improve Native American health outcomes: https:// bit.ly/DavidJonesInterview.

The numbers of AI/AN are small compared to some other racial groups so they often get overlooked in statistics that are presented to the public and policy makers. How can we do a better job of collecting and reporting data on Native peoples?

This is such an important question. An excellent example of the problem occurred at the beginning of the pandemic. News outlets were quickly reporting on the impact of COVID-19 on different populations and though Native Americans were hit immediately and possibly the worst, we were usually in the small “other” category on graphs and charts. Policymakers can’t be expected to fix a problem they don’t see. The National Congress of American Indians has been addressing our small numbers problem for many years. As they point out, disaggregation of data is critical not only for Native American populations but for subsets of many populations. For more information see: https://bit.ly/NCAIdata.

What incentives are available to get more Native American medical student applicants?

Since its founding in 1972, the University of Minnesota Medical School, Duluth Campus (UMMSD) has been attracting and retaining Native American medical school students. Dr. Gerald Hill and Dr. Joy Dorscher, former Directors of the Center of American Indian and Minority Health (CAIMH), implemented most of the support and retention activities that exist today for Native medical students attending UMMSD. A commonly cited struggle for Native students is being far away from their Tribal communities. Most of the work we do at CAIMH revolves around the creation and support of community for Native medical students. Retention begins as soon as students arrive for interviews.

They are invited to meet for dinner with other Native students to welcome them to the community. For many, this meeting forms friendships and support lasting long after medical school. Within the CAIMH space Native students at UMMSD have a safe space to gather for studying and meeting. In a normal year, without the isolating effects of a pandemic, students will gather at my house for celebrations and to welcome interviewees. Throughout the year students meet with Native alumni and community elders. CAIMH hosts and co-hosts events such as ribbon skirt making and a community sugar bush (maple syrup making). Another important incentive for Native students has been the required curriculum in Native health introduced six years ago by Dr. Melissa Lewis and supported by Drs. Ruth Westra and Alan Johns. These are just some of the supports available for Native American medical students considering school at the University of Minnesota Medical School.

How are NA medical students encouraged to serve NA communities?

UMMSD selects students based on their commitment to serving Native American communities. That said, service can come in many different forms. Because we are short of Native physicians in every specialty, we do not discourage students from choosing specialties outside of Family Medicine. Dr. Luke John Day, who works for the University of California, San Francisco, is one of possibly three Native gastroenterologists in the nation. He serves Native communities by providing specialty care for a local Native clinic and by his active involvement in Native healthcare equity as the President-elect of the Association of American Physicians. Dr. Tiffany Beckman, perhaps the only Native endocrinologist in the nation, is a researcher at the University of Minnesota who has also provided health care for a Minnesota Tribe. Dr. Amy Delong, a UMMSD graduate and family physician, is the Medical Director for her own Tribal health organization in Wisconsin.

What are/please describe some AI/AN teaching-training examples that should be incorporated into the current Medical School curriculum, especially those that might apply to all medical students.

All people in this country should have a basic understanding of the people who lived in the Americas before Europeans arrived. They should be aware that Native civilizations maintained functional governments and ways of providing for the education and health care of its members for centuries before Europeans arrived. They should understand the history of colonization and its impact on Native Americans—a history that has not been told in US textbooks. All people should be aware that Native Americans were promised health care, education, and social services in exchange for millions of acres of land. The US government has yet to fulfill its obligations, with severe underfunding of the Indian Health Services, Indian education, and social services for Native people. Because US citizens do not know this history, Native Americans live with stereotypes and the false perception that we receive free health care, education, and many other benefits from the US government. Stereotypes and the lack of our history being told contributes to Native people being treated as second-class citizens on their own land. These are just some of the lessons taught at the University of Minnesota Medical School, Duluth Campus. Students learn that there are 11 Tribal nations in Minnesota, four Dakota and seven Anishinaabe. Students also learn of the impacts of historical and intergenerational trauma, how social determinants of health play out in Native communities and about trauma-informed care. They also learn about some common Native American values such as reverence for elders, the importance of humility, and a common belief that all things are connected. Again, much of this is knowledge that all US citizens should have, but at the very least, people who provide health care and education for Native people have an obligation to know these basics. I am working now with other Native American medical scholars to develop Native healthcare proficiencies (competencies) and an Indigenous health curriculum that will be available to all United States medical schools. It will be most important to see these or similar curriculums in place in schools that exist in states like Minnesota with large Native American populations.

Are there plans to expand the Native American teachings at the UMN Medical School, Duluth Campus to the whole UMN system?

As we move to one curriculum for both campuses, I will advocate for required lessons in Native and rural health for students on both campuses. Anyone practicing in the state of Minnesota will at some time be caring for Native and rural patients. It is essential that they have a base of understanding of rural and Native cultures which are both different in many ways from urban, non-Native cultures. Additionally, services available in rural and Native American communities are often limited. Physicians transferring their patients back to rural and Native communities should have basic knowledge of available services and ideas on how to ensure appropriate longitudinal care. I am also working with Dr. Michael Sundberg to develop a Native American track for students interested in serving Native patients. We hope to use the already developed Seminars in Native American Health to supplement required Native American health curriculum. We will add requirements for rotations at IHS and/ or Tribal health facilities as well as a research project on a Native health topic. Dr. Sundberg and I hope to develop an Urban Indian Health arm to the track with rotations at Urban Indian Health facilities. The bottom line is that there is tremendous need for additional physicians who are well-trained and committed to Native American health. The University of Minnesota, with its long history of educating Native physicians and others about Native American communities and their health, is well poised for this next step in the journey to improving the health of Native people.