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TITLE Comprehensive Program for American Indians & Alaska Natives. INSTITUTION Indian Health Service (PHS/HSA), Rockville, MD. PUB DATE 1994-00-00 NOTE 55p.; Photographs may not reproduce adequately. PUB TYPE Reports Descriptive (141) EDRS PRICE MF01/PC03 Plus Postage. DESCRIPTORS *Alaska Natives; *Allied Health Occupations Education; American Indian Reservations; *American Indians; Delivery Systems; Elementary Secondary Education; Federal Indian Relationship; Health Education; Health Occupations; *Health Programs; Health Services; Medical Education; Postsecondary Education; *Public Health; Special Health Problems; Technical Education; Tribes IDENTIFIERS *Indian Health Service

ABSTRACT This booklet summarizes programs of the Indian Health Service (IHS). The IHS was created in 1954 as part of the Public Health Service when responsibility for American Indian and Alaska Native health care was transferred from the Department of the Interior's Bureau of Indian Affairs to the Department of Health, Education, and Welfare. The goal of the IHS is to raise the health status of American Indians and Alaska Natives to the highest possible level. Since 1955 the average life expectancy for American Indians and Alaska Natives has risen 19%; mortality rate among Indians with tuberculosis has decreased 96%; and infant mortality rates have decreased 85%. These improved health numbers are the result of stronger central program supervision, more qualified staff, and an accelerated public health program, including establishment of public health clinics on all reservations. The booklet describes the following IHS programs:(1) health care programs (preventive health services, emergency medical services, environmental health and engineering services, pharmacy services, contract health services, health education program, community-based programs, alcoholism and substance abuse program, school-based programs, diabetes program, nutrition program, mental health program, community health representative program, dental program, laboratory program);(2) special health concerns and initiatives (AIDS, maternal and child health, otitis media, , aging, health care database management system, physician services); (3)IHS career opportunities and training programs (IHS manpower program, advanced professional and specialty training, Commissioned Officer Student Training and Extern Program); and (4) paraprofessional training (community health aide training, mental health worker training, nutrition and dietetics training, optometric assistant training, dental assistant training). The 12 Area Offices of the IHS health care delivery system are also described. Includes photographs and a national map of IHS health facilities. (TSP)

******************************************************************************** Reproductions supplied by EDRS are the best that can be made from the original document. ******************************************************************************** Comprehensive Health Care Program

For American Indians U.S. DEPARTMENT OF EDUCATION Office of Educational Research and Improvement EDUCATIONAL RESOURCES INFORMATION fV" ' CENTER (ERIC/ his document has been reproduced as received from the person or organization & Alaska Natives originating it. 0 Minor changes have been made to Improve reproduction quality.

Points of view or opinions stated in this docir ment do not necessarily represent official OERI position or policy.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Indian Health Service Washington, D.C. AVAEL131111 2-1 "Comprehensive Health Care Program for American Indians and Alaska Natives" was produced by the Communications Office of the Indian Health Service, and reviewed by: Richard Church, Pharm. D, Associate Director, Office of Information Resources Management; W. Craig Vanderwagen, M.D., Director, Division of Clinical & Preventive Services; J. T. Garrett, Ed.D., Chief, Health Care Administration Branch; Darrell Pratt, Chief, Health Professions Support Branch, Office of Human Resources; Steven Heath, M.D., Medical Consultant, Office of Health Programs. CONTENTS

Foreword 3 9

Preface 4

Mission Statement 5

Introduction 6

8 IHS Accomplishments 14

Brief Chronology of U.S. Indian Health Care 9

Indian Health Today 12

Health Care Programs 14 22 Special Health Concerns and Initiatives 22

IHS Career Opportunities and Training Programs 27

Paraprofessional Training Opportunities 30 27

Measuring Progress 32

IHS Health Care Delivery System 34

Summary 43 32

4 Foreword

Our goal at the Indian Health Service is to raise the health status of American Indians and Alaska Natives to the highest possible level. Since 1955, dedicated staff have been committed to working with federally recognized tribes to translate this broad idea into a reality.

As an organization, the IHS maintains a truly unique health delivery system that provides its customers with wide-ranging medical services. Those services respect and attempt to blend traditional healing beliefs with the latest advances in medical technology. The IHS employees work with more than 547 federally recognized tribes in the delivery of health care to communities that range from Point Barrow, Alaska, to Hollywood, Florida, and from Maine to California. Care is provided in some of the most remote and beautiful locations in the nation, as well as within the metropolitan areas of major cities. Dr. Michael H. Trujillo, Direct and contract patient care, although a Director, Indian Health Service mainstay of our community based primary care system, is only a part of the picture at the IHS. With Tribes have the option of providing all of their health tribal participation, we also provide environmental care, only a portion of it, or none at allelecting to planning and maintenance services, build and have the IHS remain their provider of choice. The maintain clean water treatment systems, carry out number of tribes choosing to deliver their own educational outreach and preventive health health care has steadily increased, reaching an programs, and assist in ground-breaking research unprecedented level. The unique and challenging and application of scientific information. This nature of this exciting endeavorefficiently moving combination of patient care and preventive health a large community-based primary health care activities has produced unequaled improvements in system into the 21st Century, while maintaining the health of American Indians and Alaska Natives. A accountability, integrity and customer focus is few examples of pioneering achievements include: unmatched in private sector health organizations. development and application of advanced life This change must be accomplished so that our support for trauma victims; development of a world customer, the American Indian and Alaska Native, model plague control program, and the introduction only notices improved quality of care. The needs of federal health care resource sharing programs. of our customers and communities are always paramount because they honor us when they come The unique nature of IHS programs and services to us for care. make it one of the most dynamic health care organizations anywhere. The IHS network of Employees of the IHS possess a wide array of programs and services is a good example of a expertise because of the community focus of our national health delivery system where our customers primary health care programs and methods we use participate and share in the development of in patient care, hospital administration, construction strategies to meet their unique health needs and to programs and administrative support. The collective respond to the new needs and new priorities of a and individual achievements of our employees are changing external environment. The result has been indicative of a successful health delivery system. the establishment of a partnership which is often used as a model by other health care organizations, The IHS seeks employees that will work hard, as both in the United States and abroad, and we are part of a team, to maintain and improve the quality proud to be seen as a leader in health care of care for our patients, customers and management. communities. We would like you to join us as we move forward. I am confident that each day will Direct tribal participation in strategic areas of bring you professional growth, personal satisfaction, decision-making has been facilitated and expanded and a chance to work with, learn from, and improve through legislative initiatives of Self-Determination. the quality of life for America's first citizens.

35 Preface spiritual levels; thus, individual wellness is considered as harmony and balance among mind, body, spirit, and the The traditional beliefs of American Indian environment. Medical treatment provided and Alaska Native people regarding to a person with this wellness belief wellness, sickness, and treatment are very system requires the consideration and different from the medical model or public integration of their belief with western health approach used in training health care medical practice. providers today. The beliefs, traditions, and customs handed down through many The "Circle of Life" or hoop is one of the generations played the principal role in the most meaningful symbols in American establishment of individual and collective Indian life. It symbolizes the continuing Indian identity. The effectiveness of any circle of life, which includes birth, health care approach is greatly affected by adolescence, adulthood, elder years, the the inherent beliefs of the patient. passing-on, and then rebirth. This concept is an integral part of the symbolism of the To many in the medical community, the Medicine Wheel, which shows the four methods and approaches of western cardinal directions and totality of creation, medicine conflict with the approaches used which dwells in those regions. The four by traditional Indian healers. As a result, in directions provide a road map for life using many American Indian and Alaska Native traditional Indian beliefs integrated into the communities, a dual health care system understanding and approach by the Indian exists, sometimes leading to confusion and Health Service (IHS) health care delivery unsatisfactory results. However, it has been system. The result is respect for a unique demonstrated that these two philosophies of cultural belief system in providing quality health care can be successfully integrated health care to Indian people. in a way that complement each other.

In order to appreciate the differences between western medicine and Indian healing practices, it is helpful to understand Indian culture and traditional ways of life. This consists of gift offerings and sharing one's self, time and energy with the family, clan and tribe. This concept is one of mutu- al interchange in a supportive environment with a commitment to the traditional beliefs of Indian culture.

American Indians and Alaska Natives strive for a close integration within the family, clan and tribe and live in harmony with their environment. This occurs simultaneously on physical, mental, and

4 Mission Statement training, technical assistance and human resource development; (2) facilitates and assists Indian tribes in coordinating health The IHS provides a comprehensive planning, in obtaining and utilizing health health services delivery system for resources available through federal, State American Indians and Alaska Natives with and local programs, in operating opportunity for maximum tribal involvement comprehensive health care services, and in in developing and managing programs to health program evaluation; (3) provides meet health needs. The goal of IHS is to comprehensive health care services, raise the health status of the American including hospital and ambulatory medical Indian and Alaska Native people to the care, preventive and rehabilitative services, highest possible level. and development of community sanitation facilities; and (4) serves as the principal To carry out its mission and to attain its federal advocate for Indians in the health goal, IHS: (1) assists Indian tribes in field to ensure comprehensive health developing their health programs through services for American Indian and Alaska activities such as health management Native people.

5 7 OntroducUon Congress and they are not eligible to participate in federal programs, such as those provided by the IHS. Before Europeans arrived in North America, the original inhabitants now The primary responsibility for known as American Indians and Alaska administering governmental services rests Natives enjoyed excellent health. It is with the IHS and the Bureau of Indian estimated that at least 10 million Indians Affairs (BIA). The IHS was part of the BIA once lived and flourished throughout what is from 1924 until 1955, when it was now the United States. transferred to the Department of Health, Education and Welfare (DHEW) which is Exposure to disease and ecological now known as the Department of Health changes introduced by European explorers and Human Services (DHHS). took a heavy toll on the Indian population. Despite these negative health changes, The IHS has a federal trust responsibility American Indians and Alaska Natives have to provide health care to members of survived, and are today rapidly growing in federally recognized American Indians and number, due in part to improvements in the Alaska Natives. The majority of these tribes health care they receive. The Indian Health are located in the lower 48 States on Indian Service is proud in its role as the major reservations and in small rural communities. federal health care provider to the American Indian and Alaska Native people. A large segment of the IHS client population resides in the State of Alaska in American Indians and Alaska Natives are 197 Alaska Native villages. Alaska Native is citizens of both their tribes and of the United a term used to describe people of the States. It is important to remember they Athabascan, Tsimpsian, Tlingit, Haida, have a unique relationship with the federal Eskimo and Aleut descent. government. This is based upon more than 350 treaties signed by the United States The 1990 census identified over 2 million and Indian tribes between 1784, when the people of Indian heritage. Approximately first treaty was signed with the Delaware 1.34 million of this group qualified for IHS Nation, and the late 1800s when the last and BIA services as federally recognized treaty was concluded with the Nez Perce American Indians and Alaska Natives. Tribe of Idaho. The majority of the Indian population are Based upon "treaty rights," the federal members of the more than 545 federally government has a special "trust recognized Indian tribes, bands, pueblos responsibility" that entitles Indian people to and villages. Most of these groups have participate in federal financial programs tribal governments organized under the and other services, such as education and Indian Reorganization act, Oklahoma Indian health care. Although all tribes were once Welfare Act and Alaska Native Act, and sovereign nations, some never signed have adopted written constitutions treaties with the United States. Therefore, approved by the Secretary of the Interior. not all tribes are federally recognized by

6 Many of these tribes also operate traditional Although significant gains have been governments based on tribal customs made, the health status of American Indians rather than written constitutions. and Alaska Natives is not equal with the general U.S. population. Poor nutrition In keeping with the concept of tribal coupled with unsafe water supplies, and sovereignty, the Indian Self-Determination inadequate waste disposal facilities have and Education Assistance Act (Public Law resulted in a greater incidence of illness in 93-638) of 1975, as amended, builds upon the Indian population. IHS policy by giving tribes the option of staffing and managing IHS programs in their Other major health concerns include communities, and provides for funding for maternal and child health needs, otitis improvement of tribal capability to contract media and problems associated with aging. under the Act. As a result, increasing Heart disease, alcoholism, mental health, numbers of American Indian and Alaska diabetes and accidents are also serious Native governments are exercising problems for American Indians and Alaska operational control of hospitals, outpatient Natives. facilities, and other health care programs. Many reservations and Indian The government-to-government communities are located in isolated areas relationships between American Indian where impassable roads and populations tribes and Alaska Natives and the IHS spread over many miles create additional requires open consultation, commitment, challenges to the IHS commitment to patience and financial support. The effort to provide quality health care. Transporting work together to develop regulations has Indian patients by airlifts to health care resulted in a level of communication and facilities is one way IHS meets the understanding between the IHS and tribes challenge of helping Alaska Natives. unparalleled In history.

79 IHS Accomplishments general population. Currently, the age-adjusted alcoholism death rate for In its relatively short history, the IHS has Indians is 440 percent higher than that for contributed to tremendous improvements in the general U.S. population; accidents is the health status of Indians residing in the 165 percent higher, diabetes mellitus is 154 IHS service areas. Since 1973, infant percent higher, homicide is 50 percent mortality has decreased by 54 percent, higher, and suicide is 43 percent higher. maternal mortality by 65 percent, Significant improvements have been made pneumonia and influenza mortality by 50 in all these areas, but there are still percent, tuberculosis mortality by 74 significant disparities with the general percent, and gastrointestinal mortality by population. 81 percent. There are obviously many reasons for these improvements. Notable The top two leading causes of death for are a dramatic increase in ambulatory the Indian population are greatly influenced medical care services (about a 1200 by personal behaviordiseases of the percent increase in ambulatory visits since heart and accidents. These are also the 1955), an extensive program of two leading causes of death for Indian constructing sanitation facilities, and the males. This contrasts with the leading development of a community-oriented care causes for both Indian females and the program. general population (both sexes) which are diseases of the heart and malignant Working Toward New Improvements neoplasms.

As Indian life expectancy increased (a 12.2-year increase since 1973), so did behavioral risks to health. This is reflected in relatively high mortality rates for the Indian population in comparison to the

Table 1 Comparison of Five Leading Causes of Death, Indians Residing in the IHS Service Area vs U.S. All Races Population (Both Sexes, All Ages)

IHS Service Area Indians (1989-91) U.S. All Races Population (1990)

1. Diseases of the Heart 1. Diseases of the Heart 2. Accidents and Adverse Effects 2. Malignant Neoplasms 3. Malignant Neoplasms 3. Cerebrovascular Diseases 4. Diabetes Mellitus 4. Accidents and Adverse Effects 5. Chronic Liver Disease and Cirrhosis 5. Chronic Obstructive Pulmonary Diseases

8 0 L

Brief Chronology of U.S. Interior in 1849, physician services were extended to Indians by the establishment of Indian Health Care a corps of civilian field employees. By 1875, almost half the Indian agencies had a physician and, by 1900, the Indian Federal health services for Indians began Medical Services employed 83 physicians. in the early 19th century when U.S. Army Nurses joined the staff in the 1890s and physicians took steps to curb smallpox and their numbers grew from 8 in 1895 to 25 in other contagious diseases among tribes 1900, with most assigned to Indian board- living in the vicinity of military posts. Many of ing schools. the early Indian treaties signed between tribes and the U.S. government imposed Beginning in 1891, field were time limits of 5 to 20 years on the provisions employed to give instruction in sanitation of health care. Subsequently, the federal and hygiene to provide government adopted a policy of continuing services and to prescribe medicine for minor services after the original benefit period illnesses. Public Health Service nurses expired. eventually took over these activities. When the BIA was transferred from the The first federal hospital built to care for War Department to the Department of the American Indian people was constructed in

9 t the 1880s in Oklahoma, representing a appointment of district medical directors. commitment to establish hospitals and By 1926, medical officers of the PHS were infirmaries on every reservation and at each detailed to positions in the Indian Health boarding school. This was a response to the Program. isolation in which Indians lived, the lack of nearby health care facilities, and home Thus, the Snyder Act ensured the conditions that made prescribing a course continuation and acceleration of of treatment outside a hospital often improvements that had been progressing ineffective and sometimes dangerous to the slowly for quite some time. patient. Transfer to PHS Professional medical supervision of health activities for Indians began in 1908 A milestone was reached in 1954 when with the establishment of the position of Congress passed Public Law 83-568, better chief medical supervisor. Congress made known as the Transfer Act. This law the first federal appropriation specifically for transferred responsibility for American health services to American Indians and Indian and Alaska Native health care from Alaska Natives in 1911, but made no the Department of the Interior's BIA to the provision for recurring appropriations for PHS within the Department of Health, that purpose. Individual disease control Education and Welfare, now known as the programs, such as for tuberculosis, and Department of Health and Human Services. health education activities to support these efforts were also introduced in the early The initial program priorities for the new 1900s'. Division of Health were: (1) to assemble a competent health staff; (2) to establish Dental services began in 1913 with adequate facilities where services could be the assignment of five dentists to visit provided; (3) to institute extensive curative reservations and schools. In 1920 the treatment for the many people who were Secretary of the Interior, himself a seriously ill; and (4) to develop and initiate a physician, successfully urged Congress to full scale preventive program aimed at legislate a requirement that a senior Public reducing the excessive rates of illness and Health Service (PHS) officer be detailed early deaths from preventable diseases from the PHS to the BIA to advise him on and conditions. health matters. Faced with the findings of repeated surveys on the alarming state of Indian Health Surveys and Reports the health of American Indians and Alaska Natives, Congress, in 1921, passed the Beginning in the early 1900s, the federal Snyder Act, which, for the first time, government and other research authorized regular appropriations of funds organizations began to conduct health for "the relief of distress and conservation of surveys of the American Indian and Alaska health" of American Indians and Alaska Native population. Such surveys prepared Natives. This landmark law resulted in the the way for future development of federal creation of the BIA Health Division and the health programs, and for the eventual

10 12 establishment of the IHS. Four such the historic Meriam Report of 1928, important surveys include the Trachoma which revealed mortality and disease Survey, the Meriam Report, the Public rates exceeding those for the general Health Service Survey and the Hoover population. Among the startling findings Commission Report. contained in the report was that one Indian person in 10 had either active or inactive Congress directed the Public Health tuberculosis; 29 percent of all American Service to conduct the first of these studies, Indian and Alaska Native deaths were from the Trachoma Survey of 1909, in response tuberculosis; and 37 percent of all to numerous reports of an unusually high American Indian deaths were children number of cases of blindness in the under 3 years of age. The report American Indian population. The survey recommended stronger central health contained the first comprehensive data on program supervision, more qualified staff, infectious diseases among American and an accelerated public health program, Indians and Alaska Natives, and confirmed including the establishment of public health a widespread trachoma epidemic and clinics on all reservations. found unusually high concentrations of other infectious diseases such as tubercu- losis. The survey report urged improvement of sanitary living conditions, expanded and improved health care, and specific infectious disease control measures.

In the 1920s, mounting concern over the conduct of Indian Affairs resulted in

1113 Dndan Ilea Dth Today about $13,700. Among the general population, the median family income was According to the 1990 U.S. Census $19,000 with only 12.4 percent of the Bureau, the American Indian and Alaska general population below the poverty level. Native population is young and growing rapidly. The median age for Indians in the The 34 States that contain Indian reservation states was 22.6 compared to reservations or Alaska Native entities are 30.0 for the general population. The IHS identified alphabetically in Table 2. service population reflects these trends with 32 percent of patients served under the age HIS Team Approach of 15 and the service population growing at the rate of 2.7 percent per year. Virtually every discipline involved in the provision of health care, social services and In addition, the 1990 U.S. Census Bureau environmental health is represented on the reports that reservation-based populations IHS team. The professionals providing care have fewer economic and educational in the many health facilities throughout the opportunities than the rest of U.S. society. country are supported by a wide variety of The median annual family income for IHS programs and special initiatives. Indians on reservations or tribal lands was

12 14 Tall 2 THE 34 RESERVATION STATES AS OF APRIL 1994

1.Alabama 12.Maine 23.North Dakota 2.Alaska 13.Massachusetts 24.Oklahoma 3.Arizona 14.Michigan 25.Oregon 4.California 15.Minnesota 26.Pennsylvania 5.Colorado 16.Mississippi 27.Rhode Island 6.Connecticut 17.Montana 28.South Carolina 7.Florida 18.Nebraska 29.South Dakota 8.Idaho 19.Nevada 30.Texas 9.Iowa 20.New Mexico 31.Utah 10.Kansas 21.New York 32.Washington 11.Louisiana 22.North Carolina 33.Wisconsin 34.Wyoming * A State is considered a "Reservation State" if IHS has responsibilities within the State.

The focus of the IHS program is on the reservations and in Indian and Alaska welfare of American Indian and Alaska Native communities includes 41 IHS Native communities. Paramount to the hospitals ranging in size from 11 to 170 success of this program is the active beds per hospital. This includes medical involvement of the community members centers in Phoenix, Arizona; Gallup, New themselves not only in terms of their Mexico; and Anchorage, Alaska. participation in preventive medicine programs, but also in terms of their role in In locations where the IHS does not have strengthening tribal management and its own facilities, or is not equipped to operation of health care programs. provide a needed service, the IHS contracts with local hospitals, State and local health To the extent of the resources available, agencies, tribal health institutions and American Indians and Alaska Natives individual health care providers. served by the IHS receive a full range of preventive, primary medical care (hospital The IHS Service Unit clinical staff and ambulatory care), community health, includes all major health disciplines such as alcoholism programs and rehabilitative physicians, dentists, nurses, pharmacists, services. Secondary medical care, highly therapists, dietitians, laboratory and specialized medical services, and other radiology technicians, and medical and rehabilitative care is provided either by IHS dental assistants. Community health medics staff or by non-IHS health providers under (IHS-trained physician assistants), nurse contract. practitioners and nurse-midwives complete this clinical health care team. A system of inpatient and ambulatory care facilities operating on Indian

13 15 Hee Oth Care Programs Emergency iViedical Services

Preventive Health Services Keyto the IHS emergency medical services is the "first responder' concept, Preventive services designed to improve which relies upon a trained individual such American Indian and Alaska Native health as a community health representative and reduce the need for acute medical care (CHR) or police officer who can respond to include prenatal, postnatal and well-baby a crisis within 15 minutes and communicate care, family planning, dental health, via a radio to the next level of medical care. nutrition, immunization, environmental Because of the remote locations common health and health education. These services on American Indian and Alaska Native are provided by clinical staff at IHS and reservations, ambulance response (ground tribal facilities and by community health to air) may take hours. Tribes have taken personnel working directly with the Indian the initiative in providing ambulance community. Others include preventive care services, with some 75 tribes operating 150 programs, community health nursing, vehicles and with more than 500 trained mental health, and medical social work. Emergency Medical Technicians staffing the vehicles.

14 8 Environmental Health and with the Environmental Protection Agency Engineering Services in such environmental health activities as training, emergency response, grants to Environmental health services are a tribes, and technical assistance in the critical part of IHS preventive care programs. administration of tribal sanitation facilities; These programs address environmental (7) assisting tribes in the development and conditions in American Indian and Alaska adoption of sanitary ordinances and codes; Native homes and communities that and (8) alleviating crowded, substandard contribute to high morbidity and mortality housing, unsafe water supplies and among the Indian people. The environment, inadequate waste disposal facilities. which includes the home, community, and workplace, as well as the natural Since 1959, IHS has initiated more than surroundings, is recognized as a vital factor 4,000 projects to provide sanitation facilities in a person's overall health and well-being. for American Indian and Alaska Native homes and communities. To date, 196,000 Activities include environmental planning, Indian residences have received running food protection, occupational health and water and a means for safe waste disposal. safety, injury prevention, pollution control, Much of this work has been done under control of insects and other transmitters of cooperative agreements with the BIA, the pathogens, and institutional environmental Department of Housing and Urban health in reservation areas. Staff members Development, Indian housing authorities include environmental engineers, and tribes. Other IHS projects in this sanitarians, environmental health and specialized service area include engineering technicians, and injury- prevention specialists. Typically, environmental health program activities include the following: (1) identifying and recommending remedies for the causes of injury; (2) evaluating changing environmental conditions and subsequent planning with tribal officials for the development of comprehensive environmental health programs; (3) investigating communicable disease outbreaks and initiating corrective environmental health control measures; (4) providing technical assistance and training to communities in the operation and 40 maintenance of water supply and waste I disposal facilities; (5) evaluating institutional facilities to make recommendations to the operators so that they may maintain healthful environments; (6) coordinating

1715 engineering surveys, emergency facilities CHS funds help pay for care when other construction, and technical assistance and sources of funding are not available, or training for tribal employees and individual supplements other alternate resources homeowners in the use, care and (such as private health insurance). In maintenance of these facilities. Indian general, the CHS program may pay for tribes have participated by contributing physician and other health professional labor, materials and funds. services, inpatient and outpatient hospital services, patient and escort travel, and Pharmacy Services other health care support services. However, IHS funds may not be available to Comprehensive and patient-oriented pay for all CHS referrals. American Indians pharmacy services are provided at both IHS and Alaska Natives are generally referred and tribally operated facilities. Pharmacists for CHS by the IHS physician, except when work closely with other health care extreme emergency treatment is required. providers in the selection, use and dosage Referrals for CHS are based on a system of of medications and in some instances, medical care priorities, and are available for provide primary care to outpatients. Patient only those patients who meet eligibility consultation programs developed in the IHS requirements for participation in CHS. are used throughout the profession. Health Education Program Computers are used in many pharmacy functions. Drug information and therapeutic The goal of the IHS Health Education drug monitoring services are provided in Program is to assist American Indian and both the inpatient and outpatient settings. Alaska Native people to adopt health- Inpatient services include the preparation of promoting lifestyles; to select and use intravenous additives, unit dose, pharmacokinetic and other clinical services. American Indians and Alaska Natives receive on-the-job pharmacy technician training to provide inpatient and outpatient assistance and also to serve as interpreters as needed. IHS pharmacists also train local I high school students and serve as wA .43 wD preceptors for pharmacy students and residents. 414 Contract Health Services

Besides the direct health services provided within IHS facilities, IHS also purchases Contract Health Services (CHS) from the private sector, such as in a physician's office or in a private hospital.

16 9s health care resources, products, and Alcoholism and Substance services wisely; to influence policy and Abuse Program planning on health care issues and larger environmental matters that affect health; TheIHS has identified alcohol and and to involve other agencies that have the substance abuse as the most significant potential to improve health. The program is health problem affecting American Indian designed to help the Indian community and Alaska Native communities. In addition better understand the nature of disease and to the cultural and social devastation it how lifestyles and behaviors can reduce causes, alcohol contributes to a number of diseases and injuries. These goals are physical disabilities treated by IHS that attained through community service, drain medical care resources. In response, school health services, patient and staff the IHS has initiated a number of programs support services, and tribal health program to provide treatment and prevention development. Other activities are provided services. It is widely believed that few by American Indian tribes and Alaska Indian families remain unaffected either Native corporations through contracts with directly or indirectly by alcohol abuse. the IHS. Current data indicates that 4 of the top 10 causes of death among Indians are Community-Based Programs alcohol-related: accidents, cirrhosis of the liver, suicide, and homicide. TheIHS health delivery system is designed around the principles of public Presently, the IHS is funding over 200 health combined with traditional medical American Indian and Alaska Native practice. This combination leads to a style alcoholism programs serving Indian of practice characterized as community- reservations and urban communities. oriented primary care (COPC), an approach Together with other federal entities, tribal that gives American Indians and Alaska communities and leadership, IHS is Natives direct access to primary care. It also developing an effective and permanent generates information useful to health care alcoholism/substance abuse prevention providers in determining which health program. Although alcoholism is a grave issues should be targeted. issue, Indian people are demonstrating their resolve to address the issue of alcohol The COPC mandates that primary care abuse in their communities. be tailored to the unique requirements of a demographically and geographically The Indian Alcohol and Substance Abuse defined community, and the provision of Prevention and Treatment Act of 1986 information and resources to communities authorized IHS to develop one youth so they can determine how resources are regional treatment center within each IHS allocated. IHS also is developing a national Area. These centers are major resources database that will be accessible to all tribes for youth in need of treatment of alcoholism and tribal communities. and other substance abuse.

1.9 17 School-Based Programs to relate to the cultural and linguistic needs of its patients. Schools attended by American Indian and Alaska Native children are important focal Nutrition Program points of the IHS, and for the Alcohol and Other Drug Abuse (AODA) prevention Nutritional factors contribute to some of strategies involving teachers, teachers' the leading causes of death of American aides, students, parents and counselors. Indians and Alaska Natives heart Student and parent school-based groups disease, cancer, cirrhosis, and diabetes add formed as a result of AODA prevention to the prevalence of obesity, hypertension programs include Students Against Drunk and dental problems. At greatest nutritional Driving, Chemical People, Mothers Against risk are infants, preschool children, Drunk Driving and peer counseling groups. adolescents, pregnant and lactating women, and the chronically ill. Nutritional They combine traditional counseling with care is an integral part of health service cultural support, Alcoholics Anonymous and delivery. IHS integrates its nutrition program Narcotics Anonymous groups, recreational into all preventive, therapeutic and and/or therapeutic activities, and family rehabilitative programs. IHS also conducts support. Each center works closely with its nutrition services research and coordinates community in planning for admission, with other social, educational and food- discharge and aftercare. assistance programs to ensure nutritional services are consistent with the cultural riabetes Program needs of American Indian and Alaska Native communities. Diabetes is a significant cause of death among adult patients at IHS facilities. IHS places emphasis on incorporating Throughout the IHS health care service nutrition education into every available areas, programs are being developed to health, social and education service and help patients better understand and deal food assistance program. with diabetes and to learn the special care and nutrition requirements of the disease. Mental Health Program The diabetes program staff coordinates the activities of 12 model centers of excellence Throughout our nation's history, around the country that develop American Indian and Alaska natives have educational approaches and recommend experienced conflicts between their improvements. Because diabetes is so traditional cultures and the demands of prevalent in American Indian and Alaska modern society. This struggle has Native communities, coordinators provide contributed greatly to an increase in mental surveillance and training in diabetes care health problems. Symptomatic of this for clinicians and evaluate control efforts struggle is an alarming increase in the from a public health perspective. Indian suicide rate, which is two to three times that health providers help patients make of the rest of U.S. society. Alcoholism, lifestyle changes to control diabetes. As violence, homicide and family distress are always, IHS works to adapt its health plan all side effects of the frustration, depression,

18 low self-esteem and feelings of the unique cultural and social aspects of hopelessness prevalent in many Indian their people's lives. communities. Deeply involved in promoting health and The IHS mental health program preventing disease within their own incorporates two important efforts: first, to communities, CHRs provide early understand Indian people and their way of intervention and case findings that result in life, ideas and language; and, second, to patients receiving care earlier in the course encourage the active involvement of Indian of their illnesses. In less serious cases, people in their health care program. direct primary care and follow-up services are provided by the CHR in the patients' The IHS and tribal mental health homes. The CHRs often work long hours programs are actively involved in providing and serve their communities on a 24-hour culturally relevant care for persons and basis. families experiencing emotional distress. Most persons are treated as outpatients. CHRs receive training in basic health Inpatient services are arranged by contract. skills, health and disease, home nursing, Prevention programs include working with emergency medical services, nutrition, communities to build mentally healthy environmental health and how to educate environments and combat individual self- others about health matters. Training destructive behaviors. As additional includes the principles of communication, resources become available, the mental group organization and planning. It is health program intends to intensify its child- conducted in classrooms and through field family-community treatment and prevention experience under the supervision of programs by working closely with other medical and health professionals. disciplines, improving recruitment and retention of mental health treatment staff, and increasing mental health training and research.

Community Health Representative Program

The community health representative (CHR) program, initiated by IHS in 1968, is a unique concept for providing health care, health promotion and disease prevention services. CHRs are American Indians and Alaska Natives specially trained through IHS, but employed and supervised by their tribes and communities. They are paraprofessional health care providers who are completely familiar with the dialects and

19 21 The CHR program often serves as the primary avenue through which American Indians and Alaska Natives gain access to the direct health care system provided by IHS. Perhaps more importantly, it is also an invaluable means through which health practitioners and others gain access to tribal communities.

Today, more than 1,400 CHRs are serving more than 250 tribes in more than 400 rural communities. These individual CHR programs are community-based with well trained, medically guided health care providers who are respected leaders in their communities.

What is perhaps most significant about the CHR programs is that they represent the first time in history that tribes have managed their own health programs, setting their own priorities through contractual locations within IHS and tribal hospitals, agreements with IHS. In 1988, the Indian health centers and other fixed facilities, as Health Care Improvement Act amendments well as at almost 200 field locations and in recognized the CHR program as an integral 26 mobile dental sites throughout the part of the IHS health care delivery system. United States. In isolated areas of Alaska, It remains a prime example of Indian IHS dental teams with portable equipment self-determination, embodying all the often travel by aircraft or boat. precepts and managerial goals of the self-determination principle. Effective cavity prevention measures, such as water fluoridation, are encouraged. Dental Program IHS dental health staff work closely with IHS environmental health personnel and tribal Dental disease is more prevalent among workers to ensure that fluoridation American Indians and Alaska Natives than equipment is installed in Indian community among the U.S. population as a whole. The water supplies. IHS dental program places priority on providing preventive and corrective dental Many tribes have set up injury prevention care to prevent disease and reduce tooth programs in which specially trained CHRs loss. It has evolved from an emergency take a leading role in reducing the causes of care program staffed by itinerant dentists injuries. Community alcoholism programs into an interdisciplinary community-oriented also play a role in calling attention to the program carried out in more than 250 high rate of injuries among American

20 0 Indians and Alaska Natives. The second Laboratory Program leading cause of death among American Indians and Alaska Natives is injuries due to The IHS operates fully accredited hospital accidents. In the 3-year period, 1986 to and clinic laboratories with state-of-the-art 1988, a total of 21,943 American Indians instruments and equipment staffed by and Alaska Natives died, with 3,533 (or 16.1 certified technologists and technicians. percent) from injury due to accidents and Advanced technologies and capabilities accidental poisonings. The 1988 have increased the IHS laboratory age-adjusted death rate for accidents from program's effectiveness in early diagnosis all causes and for motor vehicle accidents, and preventing secondary development of respectively, among American Indians and unrelated disease. IHS clinical laboratories Alaska Natives, was 2.3 times that for all perform approximately 15 million laboratory other U.S. races. Injuries are also the tests annually from simple screening tests second leading cause of hospitalization for to complex procedures for detecting and general medical and surgical patients in IHS monitoring such diseases as diabetes, heart and contract hospitals, accounting for disease and cancer. 50,000 hospital days and nearly 300,000 outpatient visits in FY 1988. To combat this In addition, the IHS laboratory program problem, IHS environmental health staff are provides the following: (1) home-testing working with other health disciplines and quality assurance programs; (2) health the tribes to develop community injury promotion/disease prevention health prevention and control teams to train and screening programs; (3) regional offer guidance on home and community consultants/international consultation safety. services; (4) reference laboratory services; and (5) proficiency testing programs.

2321 CumulativeGrowth of Al/ANAIDSCases Before 1984 through October1991 Total Al/AN Population1.9Million # of Cases 350 _

300 _

250 _

200 _

150 _

100_

50 _

0 _ ,, 1---1 ElR <1984 1984 1985 1986 1987 1988 1989 990 Oct. 1991 Source: CDC 10/31/91

Spec aD Fleallth Concerns and 11nMatives During FY 1988, specific AIDS prevention plans were developed for the 12 IHS areas Acquired Immune Deficiency with funding from the Centers for Disease Syndrome initiative Control (CDC) and from other IHS program resources. Additionally, IHS expanded train- IHS has developed a comprehensive ing of HIV patient educators and coun- acquired immune deficiency syndrome selors and started dozens of local health (AIDS) initiative in response to the potential facilities and community-based AIDS edu- risk of a human immunodeficiency virus cation and intervention programs. These (HIV) epidemic among American Indians included seminars designed to prepare joint and Alaska Natives. This initiative began in IHS-BIA teams to teach AIDS prevention to 1987 with the establishment of AIDS-related an estimated 40,000 school children. performance standards for resource identification, disease reporting, The IHS, along with CDC, also has begun seroprevalence testing, patient surveys, a national Blinded Seroprevalence Program public information, health education, risk to determine the extent of HIV infection in reduction, patient counseling and clinical American Indian and Alaska Native care. communities.

22 ?4 Maternal and Child Heath Otitis Media

The family is recognized as the traditional Otitis media is a disease of the middle ear and most important basic social unit in that may cause hearing loss and was once American Indian and Alaska Native even more of a health problem to Indian communities. The IHS is very sensitive to people than tuberculosis. However, as a the communities' family-oriented cultural result of otitis media programs the IHS beliefs and practices. established in 1971, the incidence of chronic otitis media has been reduced to a The IHS approach is to promote level equal to or fewer than the rate family-centered care in all IHS facilities observed in the U.S. non-Indian population. providing maternal and child health (MCH) This reduction resulted from expanded services. High rates of infant morbidity preventive efforts, increased case-finding and post-neonatal mortality are being met and treatment of acute cases, intensified with an emphasis on early and adequate treatment of chronic patients and expanded prenatal care for all pregnant women and rehabilitative measures. continued post-partum care and well-child care. Pre- and post-natal health education activities that assist the mother to develop good parenting skills are also provided during well-child and acute care visits to help parents better understand normal growth and development and to recognize and manage common childhood illnesses. Creative and collaborative MCH programs meet the unique health needs of American Indian and Alaska Native children and their families. Particular emphasis is focused on partnership efforts with tribal health organizations to provide accessible and acceptable MCH services to women of childbearing age and to infants and children. High teen pregnancy rates and mortality due to accidents are special challenges to IHS. Also, the complex needs of abused and neglected children demand increasing interagency cooperation. ,----'?'.)-'----;., In addition, MCH programs include comprehensive family planning services to protect the health of women and to promote a happy and healthy family environment, and programs for early detection of cervical and breast cancer.

23 25 At selected IHS facilities, communication planning in which a more comprehensive disorders such as speech and language assessment of client needs is made by the deficiencies are treated. Special clinics nurse with emphasis placed on treating the have been established to care for children whole person and being sensitive to the with disfigured faces, learning disabilities, needs and concerns of the family. Particular deafness and related health problems. A attention is paid to their need for medical program providing hearing aids has helped education and training associated with the patients of all ages regain lost particular condition of the patient. Continuity communication and social abilities. of care is accomplished by coordinating inpatient and community health programs Nursing with community resources for preventing illness and maintaining health. Nursing has been an integral part of IHS health care for more than a century, growing provides from a core of eight nurses in 1895 to 2,500 therapeutic, counseling, education and nurses today. Initially assigned solely to advocacy services. IHS public health nurses Indian boarding schools, IHS nurses today are involved in planning, implementing and represent the backbone of the IHS health coordinating community programs and care team. services. They assess health needs of the individual, the family and the community by The primary focus of inpatient nursing is evaluating health practices and providing the development and delivery of a system of primary health care. comprehensive nursing practice within the hospital setting. It is accomplished through Nurses also help prevent complications of the systematic application of the nursing pregnancy and improve the general health process; patient assessment establishing a status of expectant American Indian and ; developing and Alaska Native mothers and their infants by implementing a plan of care that encouraging and providing early prenatal coordinates and complements the medical care. They are responsible for reducing plan; and finally, evaluating the plan's morbidity and mortality of infants in high-risk effectiveness. Although each nurse is families by providing early visits to the well trained in medical procedures, just as newborns in their homes. important to the well-being of IHS patients is identifying and meeting the holistic needs IHS public health nurses also investigate of the client and family. the causes of communicable diseases through home visits. They strengthen health Ambulatory care nursing is one of the teaching in the home, the community and fastest growing services in IHS. The primary the clinical setting, provide counseling and focus of ambulatory care nursing is to guidance in healthy living to teenagers and provide both comprehensive care and young adults, and immunize infants and education to the client and family through a children against infectious diseases. system known as "industrial-strength triage." This is a system of advanced visit

24 26 IHS also provides a program that Health Care Database enables currently employed American Management System Indian and Alaska Native nurses to seek additional nursing education through the American Indian and Alaska Native Center for Indians (NECI). people are increasingly mobile, this makes American Indian and Alaska Native licensed the crucial job of accurate record keeping practical nurses can become registered especially difficult. While providing health nurses with an associate or baccalaureate care to American Indians and Alaska degree through NECI, and each year a Natives, it is possible to gather an exten- limited number of opportunities are sive health database on this diverse popu- available for graduate study. lation and to follow individual members' medical histories throughout the course of Aging their lives. Such a database has broad ramifications for improving individual day- As more Indians live longer, IHS has to-day health care and enables IHS and expanded services in areas of primary tribal health care administrators and plan- concern to the elderly, such as diabetes and ners to identify particular problems facing arthritis. The number of American Indians the service population. Once needs and and Alaska Natives 45 years and older has problems are identified, plans and actions increased during the last decade largely can be formulated and implemented. because of improved nutrition and health care and some lifestyle changes. This IHS has developed a state-of-the-art increase in the older population has created information system called the Resource and a greater demand for health and social Patient Management System (RPMS) in services for the ambulatory, home-bound which data are entered on computers and institutionalized aging Indian located at 200 IHS and tribal health facilities community. throughout the continental United States and Alaska. Statistical reports are generated at the IHS Data Center located in Albuquerque, New Mexico. A key element of the RPMS is the Patient Care Component (PCC), which provides for the confidential collection, storage and output of a broad range of health data resulting from inpatient, outpatient and field services. Among the applications authorized for use at IHS facilities are patient registration and administration, pharmacy, immunization tracking, dental services, clinic scheduling, contract health services and quality assurance. It is a major input point for data to support health care delivery, planning, management and research.

25 27 Physician Services of all ages. The specialty areas most often encountered in the IHS are family practice, Within the IHS, physicians have the internal medicine, pediatrics, obstetrics and opportunity to work in a variety of settings, gynecology, and general surgery. In larger from remote one-person stations to IHS facilities, one can also find ear, nose multi-disciplinary medical centers. Over 900 and throat specialists, orthopedic surgeons, medical and osteopathic IHS physicians are radiologists and ophthalmologists. The involved in providing direct care outpatient, majority of IHS physicians are board inpatient, and emergency room services to certified or board eligible. American Indian and Alaska Native patients The wide diversity of clinical practice experiences presents a unique challenge to the skills of any physician. In addition to providing direct patient care, IHS physicians have responsibilities in health care management, quality assurance, coordinating care, and hospital administration. There are numerous N, z_-,..., ""iilf- opportunities for community involvement.

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26 28 IIFIS Career OpportunMes and program management staff, and health Trakfing Programs service workers. The IHS offers a wide variety of career Recruitment and career development are opportunities under the federal Civil two means by which IHS brings into the Service and U.S. Public Health Service service the many skills needed to Commissioned Corps personnel system. accomplish its health care goals. Through Opportunities always exist for physicians, staff education, training and structured dentists, nurses and other health assignments, IHS employees improve professionals to select a location to professional management and develop skills to meet the special needs of the practice. Indian community. This also generates IHS success has come through the hard greater career potential for IHS employees work of many dedicated practitioners from and enhances their ability to promote Indian a variety of fields attracted by the participation in IHS health programs. opportunity to use their skills to make a Training is also available to American Indian profound difference in the lives of their and Alaska Native advisory board patients and the communities where their members, tribal and corporation health patients live.

2927 Attracting a new generation of health This program provides $13.0 million professionals (including doctors, nurses, annually to award scholarships that fund dentists, pharmacists, environmental health pre-professional and professional level specialists, and others) will be the keystone training to American Indian and Alaska to IHS success in the future. Crucial to this Native students seeking higher education effort is renewed outreach to the students in degrees in medicine, nursing, social work, the nation's health professional schools to pharmacy, medical technology, nutrition, acquaint them with the unique challenges medical records, health administration and and satisfactions inherent in serving with many other fields. Each year, more than IHS and continued effort to encourage entry 100 new scholarship recipients are selected of American Indian and Alaska Native for health profession training in this students into health care disciplines. competitive program. In FY 1990,105 students were funded under the authority A policy of Indian preference is followed of the Health Professions Preparatory in recruitment and career development Scholarship Program. In addition, 67 training. At present, more than half of the students were funded under the authority IHS staff is of American Indian or Alaska of the Health Professions Pre-graduate Native descent. Program. A total of 96 students graduated from health professions schools in 1990. OHS Manpower Program These students are now working for the IHS and continuing in post-graduate programs TitleI of the Indian Health Care or are working in other Indian health Improvement Act, Public Law 94-437, and programs. the amendments of 1980 and 1988 provide for the establishment of a health work force scholarship program designed to meet the health professional staffing needs of the IHS. Section 101 states the long range objective: The purpose of Title Iis to augment the inadequate number of health professionals serving Indians and remove the multiple barriers to the entrance of health professionals into the IHS.

28 30 Advanced Professional and training period, these health professionals Speciality Training staff positions at major IHS medical centers and Area Offices to direct the institutional Opportunities for training and career environmental health activities. development are numerous and include advanced training in public health for Commissioned Officer Student Training physicians, nurses, dentists and others; and Extern Program physician residency training in specialties needed by the IHS; a dental residency IHS offers medical students and residents program; a pharmacy residency program; the opportunity to perform clinical rotations internship; and training. at most facilities. Other health professional A special program provides training for students may participate in the American Indian and Alaska Native nurses Commissioned Officer Student Training to prepare them for advanced degree and Extern Program (COSTEP), the IHS studies. Extern Program, or other special student programs. COSTEP offers health IHS also provides considerable on-site profession students, including engineers continuing professional education. Many and sanitarians, an opportunity to gain professionals are able to attend continuing experience within the health program education courses away from their duty environment. Students are commissioned stations at IHS expense or while on official as reserve officers in the PHS leave. Limited long-term training Commissioned Corps and are called to opportunities are also available for those active duty during free periods in their who wish to pursue an advanced degree academic year. These officers may serve that would enhance their contribution to the in any of the IHS facilities or programs. IHS mission. Those selected as long-term Many students who participate in this trainees are assigned full-time as students program subsequently enter career service at an academic institution at full salary with in the PHS. all educational tuition and fees paid.

IHS sponsors a state-of-the-art Indian injury prevention specialist fellowship. Key IHS and tribal health professionals are given an intensive one-year accelerated training program in the causes of injury, preventive strategies and evaluation methodologies. Annual continuing education programs are offered to fellowship graduates. In addition, IHS sponsors an in-house institutional environmental health residency for a selected group of environmental health officers. After an extensive one-year

29 31 410

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Paraprofessional Training supervisor and nutrition aide. On-the-job Opportunities training is provided for nursing assistants, optometric assistants, pharmacy Allied and auxiliary health personnel of technicians, mental health workers, IHS, tribes and native corporations are medical social work associates, food vital resources in the provision of health service supervisors and nutrition aides. care for American Indians and Alaska On-the-job training is also provided for Natives. By supplementing the work of nursing assistants, food service workers health professionals, these paraprofessionals and medical records clerks. make health services more accessible and comprehensive, strengthen continuity Community Health Aide Training and increase American Indian and Alaska Native involvement in health activities. The Community Health Aide Training Among the careers for which training Program was developed in Alaska to train is available are community health selected village residents in primary health representative, community health aide, care. Remote villages depend on the health records technician, dental assistant, community health aide, or CHA, for first-line optometric assistant, mental health worker, primary health care and as the initial medical social work associate, food service responder for emergency care. A wide

30 32 range of preventive health services Optometric Assistant Training provided by the CHA are coordinated with native health corporations, the State and Training programs for vision IHS health care programs. Professional paraprofessionals range from three weeks support and collaboration are provided by to more than a year in duration and are the physicians in various Alaska Area available at many vocational, technical and Native Health Service Units and native community colleges. Optometric assistants corporation-administered hospitals. More deliver eye care at the IHS optometry and than 400 CHAs in 200 villages have been ophthalmology clinics and provide optical trained to provide these valuable health support and direct patient care assistance. care services. Where direct eye care is not available, individuals are trained as eye care Mental Health Worker Training coordinators who arrange for contract optician support for the tribe. The mental health worker is an essential member of the IHS health care team. These Dental Assistant Training paraprofessionals are American Indians and Alaska Natives knowledgeable of the A one-year program at Haskell Indian psychological and social aspects of the Junior College in Lawrence, Kansas, trains people they serve. Such workers are highly high school graduates to be dental sensitive to the needs of the communities in assistants. Students are trained in chairside which they work. They are instrumental in assisting, preventive services, and dental promoting understanding between the practice management. The training program American Indian or Alaska Native patient is accredited by the American Dental and the non-Indian medical provider and Association and graduates are eligible for in winning acceptance of mental health certification. American Indian and Alaska activities from the Indian community. Mental Native dental assistants increase IHS health workers are trained to assist dental services by more than 30 percent. psychiatrists, psychologists, psychiatric social workers and other mental health professionals in providing therapy services in the Indian community, schools, hospitals and health centers.

Nutrition and Dietetics Training

Nutrition and dietetics training is provided to American Indian and Alaska Native paraprofessionals by the IHS Nutrition and Dietetics Training Program located in Santa Fe, New Mexico. The aim of the training is to upgrade nutritional care provided by dietary personnel in IHS or tribally operated hospitals and facilities.

331 33 1111 Si Enna 1.7* re

Measuring Progress the health status of American Indians and Alaska Natives to the highest possible Over the years, many rewards have level, while empowering Indian people to resulted from IHS dedication to improving have greater control over their own destiny. the quality of life for American Indian and Whenever possible, IHS encourages and Alaska Native people through medical assists tribes and Alaska Native intervention and preventive measures. For corporations in assuming management example, the mortality rate among Indians of IHS health services. with tuberculosis has decreased by 96 percent and life expectancy has risen 19 Throughout the years, there has been a percent since 1955 to an average life marked increase in the determination of expectancy of 67.9 years for males and tribal leaders and their communities to build 75.1 years for females. on the foundation IHS has provided and to become partners in the health service Much remains to be done before Indians arena. Tribally established community realize health parity with other U.S. citizens. health boards, representing the tribes The IHS faces a future of challenges that served by IHS, have helped develop local require dedicated and accomplished health program policy, determine needs and care professionals. The IHS is committed to priorities and allocate resources. These working together with the tribes to elevate groups are represented by the National

32 34 Indian Health Board. Together with other planning and evaluation, construction and organizations such as the National Indian operation of health facilities in their areas Education Association, and the National of responsibility. Congress of American Indians, they work with the IHS at the national level. In response to concerns of the American Indian and Alaska Native governments, the Technical assistance is provided to tribes IHS has been working jointly with tribal and native corporations to strengthen representatives for several years to develop health boards and departments, and to train an improved mutual dialogue. An annual staff in administrative and management forum has taken shape in which Indian skills. Program activities managed by the and Alaska Native leaders are consulted tribes and native corporations include on ways to improve health care programs, community health, mental health, and on future IHS regulations, policies, alcoholism and injury control services. procedures, and special initiatives before These groups also oversee activities in they are formally proposed.

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HIS IleaNh Care The IHS delivery system for health neDvery System services is composed of 12 Administrative Area Offices, which oversee local Service From its headquarters in Rockville, Units at hospitals and clinics. Currently, the Maryland, the IHS oversees a wide variety IHS carries out its mission through the of health delivery activities, which include efforts of 14,500 employees. Besides the following: (1) providing technical facilities that are managed and operated assistance and monitoring area and field by the IHS, a number of programs are activities; (2) formulating statistical operated under contract by individual tribes information and budgets; (3) planning, under the authority of the Indian Self- implementing, managing and evaluating Determination Act, P.L. 93-638. operational programs and policies; (4) allocating financial, materiel and human Each Area Office has the responsibility resources to Area Offices; and (5) for operating the IHS program within a maintaining communications with the designated geographical area. Their Department of Health and Human Services administrative duties include budget; and the U.S. Congress. operation; personnel and property management; program planning and implementation; tribal affairs; community development; statistical monitoring; grants

36 34 and contracts management; and satellite facilities and field health stations. environmental health program direction. Health care is provided in the service units The 12 IHS Administrative Area Offices either directly through IHS, through tribally are shown in Table 3. operated facilities or through the contract health services program. The 12 Area Offices are divided into 127 basic administrative units, called Service Theberdeen Area Indian Health Service Units, which are usually defined by the Indian reservation(s) or tribe(s) they serve. The Aberdeen Area Office in Aberdeen, A Service Unit may include several smaller South Dakota, works in conjunction with its

Tablis 3 IHS Headquarters 5600 Fishers Lane Rockville, MD 20857 (301) 443-4242

Locations of 12 Indian Health Service Administrative Area Offices

Aberdeen Area IHS Billings Area IHS Phoenix Area IHS Federal Office Building P.O. Box 2143 3738 North 16th Street 115 4th Avenue, SE 711 Central Avenue Suite A Aberdeen, SD 57401 Billings, MT 59103 Phoenix, AZ 85016-5981 (605) 226-7581 (406) 657-6403 (602) 640-2070

Alaska Area Native California Area IHS Portland Area IHS Health Service 1825 Bell St., Suite 200 1220 Southwest 3rd Avenue Box 107741 Sacramento, CA 95825-1097 Room 476 250 Gambell Street (916) 566-7020 Portland, OR 97204-2892 Anchorage, AK 99501-7741 (503) 326-4998 (907) 257-1153 Navajo Area IHS P.O. Box 9020 Tucson Area IHS Albuquerque Area IHS Window Rock, AZ 86515 7900 S.J. Stock Road Western Bank Building (602) 871-5811 Tuscon, AZ 85746-9352 505 Marquette, N.W., (602) 295-2406 Suite 1502 Oklahoma City Area IHS Albuquerque, NM 87102-2163 5 Corporate Plaza Nashville Area IHS (505) 766-2151 3825 N.W 56th 711 Stewarts Ferry Pike Oklahoma City, OK 73112 Nashville, TN 37214-2634 Bemidji Area IHS (405) 945-6820 (615) 736-2400 127 Federal Building Bemidji, MN 56601 (216) 759-3375

e 35 37 13 Service Units to provide health care ambulatory health care centers are to approximately 94,000 Indians on located in Juneau, Ketchikan, Metlakatla, reservations located in North Dakota, Fairbanks, Tanana, Fort Yukon and St. Paul South Dakota, Nebraska and Iowa. The Island. Area includes nine hospitals, eight health centers, two school health stations and The principal provider of primary health several smaller health stations and satellite care in Alaskan villages is the Community clinics. Health Aide, who consults with physicians at field hospitals or clinics by telephone or Each facility incorporates a comprehensive radio. The CHA is trained to provide first health care delivery system. The hospitals, aid, examine patients and carry out health centers and satellite clinics provide treatment recommended by the consulting inpatient and outpatient care and conduct physician. Primary care is provided by preventive and curative clinics. The physicians and other health professionals Aberdeen Area also operates an active who periodically visit the villages. Patients research effort through its Area requiring hospitalization or speciality care Epidemiology Program. Research projects are evacuated by plane. The Alaska Native deal with diabetes, cardiovascular disease, Medical Center, a 170-bed general medical cancer, and the application of health risk and surgical hospital located in Anchorage, appraisals in all communities. is the referral center for the rural hospitals and clinics. Tribal involvement is a major objective of the program, and several tribes have The AANHS delivery system is linked assumed management for their own to the regional Native Alaskan health health care programs through contractual corporations, village corporations, and arrangements with the IHS. State and local agencies. In addition, AANHS has a close working relationship The Alaska Area Native Health Service with the State of Alaska's Department of Health and Social Services, with which it The Alaska Area Native Health Service shares resources. Other federal agencies, (AANHS) Office is located in Anchorage, such as the Arctic Investigations Laboratory Alaska. Eight service units in the Alaska of the Centers for Disease Control (CDC), Area provide comprehensive health also play a significant role in the delivery services to approximately 90,981 Alaska of health care. Native people, Eskimos, Aleuts and Indians, and also to non-natives living in remote areas who are charged for services on a fee-for-service basis.

Field hospitals are located in the five rural villages of Barrow, Bethel, Dillingham, Kotzebue and Sitka and are operated by Native Alaskan organizations. Seven

36 38 The Albuquerque Area Indian The Bemidji Area Indian Health Service Health Service The Bemidji Area IHS Office located The Albuquerque Area IHS, in Bemidji, Minnesota, oversees headquartered in Albuquerque, New comprehensive health care services to Mexico, provides comprehensive health approximately 117,711 Indian people. It services to approximately 64,242 Indian administers three Service Units and 29 people. A broad range of curative, federally recognized tribal programs. Five preventive, environmental and education urban programs also contract with the services are provided directly by 26 health Bemidji Area Office for the provision of care facilities. In addition, highly specialized health services to approximately 59,000 medical care is provided by other health Indian people in Minneapolis, Minnesota; care providers and facilities through Green Bay, Wisconsin; Milwaukee, contract funding. Professional consultation Wisconsin; Detroit, Michigan; and Chicago, services are provided from the Albuquerque Illinois. Area Office in each specialty program. The Bemidji Area includes Minnesota, The Albuquerque Area serves 27 tribes in Wisconsin, and Michigan. Although the the 4-State area of New Mexico, Colorado, primary population belongs to the Chippewa Utah and Texas. The health care delivery Tribe, members of the Sioux, Ottawa, system has 7 Service Units consisting of 5 Potawatomi, Menominee, Winnebago, hospitals, 10 health centers, 10 health Oneida and Stockbridge-Munsee Tribes stations and one special dental/clinic facility. are also served by the Area Office. Two health centers are operated by tribes under Public Law 93-638 contracts; the The Bemidji Area is unique in that 60 remaining facilities are operated by IHS. percent of its annual funding allocation is One Service Unit without facilities of its own distributed among the 29 tribes through currently provides total health care through contracts. Each tribe contracts with IHS for the contract health services program. health services ranging from outreach and contract health care to fully comprehensive In addition, Albuquerque Area IHS health delivery systems, including serves the Jicarilla and Mescalero Apaches environmental health services and and the Navajo communities of Alamo, sanitation facilities, and health facilities Canoncito and Ramah. The Albuquerque construction. The major role of the IHS Area IHS also provides health care to the Area Office staff and those located at field Southern Ute Tribe and Ute Mountain Ute offices in Rhinelander, Wisconsin, and Tribe located in southern Colorado and Kincheloe, Michigan, is to provide technical southern Utah. It also serves 19 pueblos assistance to IHS and tribal contractors. in the State of New Mexico. Both tribal and IHS locations use a health team approach for successful program design, implementation and evaluation. The growth of community-based services results from tribes becoming more involved

37 33 with the management of health care The emphasis on health promotion and delivery to their own people, and in disease prevention activities nationwide response to the need to get services into has led to the development of the reservation- the community, not from just providing based Community Fitness Centers. At least services at a central location. This is one program has been started on each particularly important in the Bemidji Area, reservation and they are well utilized. as many tribal members are geographically isolated from towns and community centers The California Area Indian where most health care is available. Health Service

TheWings Area Indian Health Service The California Area IHS Office in Sacramento oversees the delivery of health The Billings Area IHS Office in Billings, care to approximately 91,652 Indian Montana, oversees the provision of people. Because of the unique history of comprehensive health care services to the State and it relationship with its Indian approximately 52,013 Indian people on communities, California has been an seven reservations in the State of Montana active participant in developing health and one in the State of Wyoming. In care financing for Indians living on the Montana, there are Service Units on each of rancherias and reservations throughout the following reservations: Blackfeet, Crow, the State. All California Indian health Fort Belknap, Flathead, Fort Peck, Northern programs are managed by the Indian Cheyenne and Rocky Boys. In the State of people themselves, although engineering Wyoming, a Service Unit is located on the and sanitation facilities construction Wind River Reservation. The Indian Health services are still provided directly by Service also operates three hospitals on the IHS staff. Blackfeet, Crow and Fort Belknap Reservations. No service area program operates a hospital, nor does the IHS have any Like all of the IHS Area Offices, the hospitals in California. Some programs Billings Area makes widespread use of contract directly with the IHS and some are computerized patient information systems. subcontracted through tribal consortiums. This helps primary care providers give One of the major differences between the quality health care, because patient data traditional 1HS service unit and these is immediately available from computers California service areas is that the tribes at the health facility level. augment IHS funds with grants and contracts from other funding sources. Many of the health problems encountered The State of California is one such funding on a daily basis may be traced to poor source. socio-economic conditions that lead to unemployment and inadequate housing. State funding results in two unique Most of the health services in IHS clinics conditions: (1) patients may be charged address prenatal care, diabetes, fees for services, and (2) programs using hypertension, accidents and respiratory State funds must also serve non-Indians. infections. The California IHS Area Office also

38 4 0 contracts with urban Indian organizations in United States and has the largest eight major urban centers to provide health reservation, which encompasses more than care for Indian residents in cities. 25,516 square miles in northern Arizona, western New Mexico and southern Utah, The Nashville Area Ondian Health Service with three satellite communities in central New Mexico. (The Navajo Area coordinates The Nashville Area IHS Office in with both the Phoenix and Albuquerque IHS Nashville, Tennessee, oversees health care Area Offices for the delivery of health services to approximately 44,556 Indian services to the Navajo, Hopi and Zuni people in the Southern and Eastern United Reservations because these reservations States, including Massachusetts, Rhode are close to each other.) Island, Connecticut, Florida, New York, Tennessee, North Carolina, South Carolina, Comprehensive health care is provided Mississippi, Louisiana, Alabama, Maine, to the Navajo people through inpatient, Texas and Arkansas. The Nashville Area outpatient, contract and community health Office has expanded from six employees programs centered around 6 hospitals, 7 to a present staff of nearly 80. health centers and 12 health stations. School clinics and Navajo tribal health For most Indians within the Nashville programs also serve the community. The Area, the IHS is the only available source six 1-ospitals range in size from 39 beds of health care, although they are entitled in Crownpoint, New Mexico, to 112 beds at to participate in the full range of programs the Gallup Indian Medical Center in Gallup, open to them as residents of counties, New Mexico. Health centers operate full- States and local communities. Health care time clinics, some of which provide delivered in the Nashville Area offers a emergency services. Some smaller diversity of options. communities have health stations that operate only part time. The Cherokee Hospital, located in North Carolina, is the only IHS operated Service A major portion of the Navajo Nation Unit in the area. The Nashville Area Office health care delivery system is sponsored has contracts with 18 tribes and three urban by the Navajo Tribe itself, which operates Indian groups. More than 77 percent of the the Navajo Department of Health (NDOH). Nashville Area's annual health services The NDOH, created in 1977, has the mis- budget is contracted to tribal organizations. sion of ensuring that quality and culturally acceptable health care is available and The Nay* Area Ondian Health Service accessible to the Navajo people through coordination, regulation, and where The Navajo Area IHS Office, located in necessary, direct service delivery. The Window Rock, Arizona, administers NDOH also provides a variety of health- numerous clinics, health centers and related services in the areas of nutrition, hospitals, providing health care to 201,583 aging, substance abuse, community health members of the Navajo Nation. The Navajo representatives and emergency medical Nation is the largest Indian tribe in the services.

39 41 The Oklahoma City Area support needed to achieve observable Indian Health Service improvements in the health of people.

The Oklahoma City Area IHS Office in To provide health services to this Oklahoma City, Oklahoma, oversees the population, the Oklahoma City Area Office provision of health care to approximately has organized its system into the following 246,000 Indian people residing in eight Service Units: (1) Kansas, (2) Oklahoma and Kansas. This is the largest Shawnee, (3) Claremore, (4) Lawton, (5) IHS service population in the U.S., with the Tahlequah, (6) Clinton, (7) Pawnee and (8) majority of the service population living in Talihina. Of the 27 health centers, 15 are urban settings. Approximately 13,000 totally managed by tribes under contract admissions and 800,000 outpatient visits and 12 are operated directly by the IHS. are made annually at seven Indian hospitals and 26 outpatient health centers and clinics The Phoenix Area Indian Health Service located throughout Oklahoma and a small area of Northeastern Kansas. The Phoenix Area IHS Office in Phoenix, Arizona, oversees the delivery of health The Oklahoma City Area of the IHS care to approximately 105,000 Indian delivers over 3,800 babies a year, making people in the States of Arizona, Nevada it one of the largest delivery systems in the and Utah-from the small Cocopah Tribe in State. Over 70 percent of the obstetrical southwestern Arizona to the widely population lives below the state poverty dispersed Paiute Indians in Nevada and level. Applying standard perinatal criteria Utah. The Phoenix Area Office operates of the American College of Obstetrics and primarily as an administrative center for 10 Gynecology, the population contains a Service Units, which may include one or high risk mix, with Indian women being more health centers or hospitals. More than particularly susceptible to hypertensive 40 tribal groups reside within the Phoenix disease, gestational diabetes and Area IHS region. pre-eclampsia with liver and platelet involvement. Within the Phoenix Area are nine IHS hospitals, the largest of which is the A physician specialist within this Phoenix Indian Medical Center. Patients environment is the vital component in a are referred there for specialized care not comprehensive team approach to total available at the eight reservation hospitals health care. In addition to the advantage in the following communities: Fort Yuma, of state-of-the-art equipment and modern Owyhee, Keams Canyon, San Carlos, facilities, IHS doctors can draw on the White River, Parker, Sacaton and Shurz. assistance of an array of professional and In addition, IHS operates seven health paraprofessional specialists, all directing centers and six health stations. their efforts toward the common goals and problems. In short, the physician gets the

42 40 A growing number of health facilities The Portland Area IHS Office offers a throughout the Phoenix Area are tribally flexible health care system that invites the operated. As of January 1990, Indian tribes initiative of the northwest Indian tribes in operated four of these health centers and defining and meeting their own health two of these health stations. Service Units needs. in Schurz, Nevada, and Fort Duchesne Utah, operate both clinics and health As a result, an increasing number of centers. health facilities throughout the Portland Area are being operated by tribes. In Some clinics are staffed by one or more addition, local physicians and dentists IHS employees who are stationed in the often are under contract to the Indian local community. In addition, local Health Service. physicians and dentists are often under contract to the IHS. Other areas are The Tucson Area Indian Health Service served by traveling teams of IHS medical and OHPRD and allied health professionals. The Office of Health Program Research The Portland Area Indian Health Service and Development (OHPRD), located in Tucson, Arizona, is an IHS The Portland Area IHS Office in Portland, headquarters-level office with a dual role. Oregon, oversees the delivery of health It is the site of research and development care to approximately 120,000 Indian activities related to health care and human people who reside on 40 reservations in the resources for American Indian and Alaska States of Idaho, Oregon and Washington, Native health programs and staff, and it as well as in the Portland, Seattle and administers health services for more than Spokane urban areas. The Portland Area 20,000 American Indian people in the IHS operates 12 health centers and 4 Tucson Area. health stations, but there are no IHS or tribal hospitals located in the Area. The Within a single organizational element, Service Units are located within 100 miles OHPRD's administrative management must of Portland, Oregon; Seattle and Spokane, simultaneously balance headquarters, Area Washington; or Boise and Pocatello, Idaho. Office, Service Unit and tribal perspectives Only ambulatory care health centers are in its daily operations. available at the Service Units so patients are usually hospitalized at nearby OHPRD's functional objectives include: community hospitals. Many locations run (1) to develop and demonstrate methods specialty clinics staffed by private and techniques for improved operation and specialists to supplement the family practice management of American Indian and orientation of the IHS/tribal staff physicians. Alaska Native health programs; (2) to provide consultation and technical More than 300,000 direct ambulatory visits assistance to all operating and were provided by IHS, tribal and urban management levels of IHS and American clinics in the Portland Area in FY 1990. Indian tribes and Alaska Native villages

41 43 and corporations in the design and Native people; (4) to provide or develop implementation of health management and appropriate training courses, methods and service delivery systems; (3) to coordinate plans for human resource development; health research and development activities and (5) to provide direct and contracted within the IHS directed toward improving health services for the American Indian and the health of American Indian and Alaska Alaska Native people in the IHS Service Units under OHPRD's jurisdiction.

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42 44 Summary patients are now under the age of 15. So, In summary, the IHS has been proud our client population is both young and to have contributed to many improvements growing rapidly. in the delivery of quality health care to American Indian and Alaska Native people Further evidence of major improvements since 1955. Signs of progress include the in the quality of health care include the facts findings of the 1990 census which indicate that the average life expectancy has risen that the American Indian and Alaska Native by 19 percent from 1955 to an average life population is now 2.06 million strong and expectancy of 69.1 years for males and growing rapidly, at a rate of 2.7 percent per 77.5 for females, and the mortality rate year. In fact, the birth rate of our patient among Indians with tuberculosis has population was 78 percent higher than the decreased by 96 percent. In addition, the U.S. birth rate in 1987. The median age of maternal mortality rate for clients residing this population is nearly 8 years younger in the reservation states has decreased by than the general population, at 22.6 years 91 percent, while the infant mortality rate of age in reservations states, as compared during the same period decreased by 85 to 30.0 years of age in the general percent. population. Thirty-two percent of our American Indian and Alaska Native Among our major programs designed to

43 45 Among our major programs designed to alcoholism programs have been funded by reduce mortality and raise life expectancy IHS throughout the United States. are the Diabetes Program, the Nutrition Program, the Mental Health Program, the While we are proud of our past Community Health Representative accomplishments, the IHS accepts the Program, the Dental Program, the Accident serious challenges of the 1990s. During and Injury Reduction Program, the the next 10 years, we will focus our efforts Laboratory Program, and the Pharmacy on Preventive Health Services and Program. Environmental Health Services with the development of our new National Indian However, we also manage an Indian Health Service Database. It will be Health Service Career Opportunities and accessible to all tribes and tribal Training Program which was established to communities to assist with local attract energetic and capable health care community planning. providers to the IHS, and includes the IHS Manpower Program, the Specialty Training Despite our combined efforts, in several Program, the Advanced Professional areas American Indian and Alaska Native Training Program, the Commissioned people still experience far higher Officer Student Training and Extern occurrences of a number of debilitating Program, the Paraprofessional Training diseases than the general population of Program, the Community Health Aide Americans. Training Program, the Mental Health Worker Training Program, the Nutrition and The new challenges of the 1990s which Diabetes Training Program, the Dental we must face together are represented by Assistant Training Program, and our attention to threatening and potentially Optometric Assistant Training Program. devastating health crises, such as AIDS. Through our new "Indian Health Service Forty-one IHS hospitals are now in Initiatives," including the AIDS Initiative, operation in the United States, ranging in the Maternal and Child Health Initiative, size from 11 to 170 beds per hospital, and the Otitis Media Initiative, the Aging several new facilities are being planned. Initiative, and the Nursing Initiative, the Research and training facilities are located IHS will continue to strive for improved today in Phoenix, Arizona; Gallup, New health of American Indians and Alaska Mexico; and Anchorage, Alaska, as well as Natives. through IHS contracts with local hospitals, State and local health care agencies, tribal health institutions, and individual health care providers. Progressive and comprehensive patient-oriented Pharmacy Services are now being provided throughout the United States. Two hundred American Indian and Alaska Native

44 46 1/6117239 240 4-(-44%, 235 9243'234',. 4.`k 0 HEADQUARTERS Legend 2422410 14W-232,--k21 a: A81 0AU HEALTHHOSPITALSAREA OFFICE CENTERS HEADQUARTERS, WEST 23801''0-, 88Indian Heal 94* 87 A83 89 86 * URBAN PROGRAMS G 96 95* Billings Area 93* 92*111 Billings A82 84 105104 i 19 CA 112 90 121103 106 W 098 OO 11109 117 91 1(1 128 115 1.241N 129 sacrament° 120 HI _OS2/ 99 102 0101 *124 116 California Area gam 107 *123 125 114 108 208 ' *217 ** 4 ea 110 122127 113 97 A198 Phcl20.1;* 207 A29" BEST COPY AVAILABLE A Q 44 4 4 4 4 4 4 191 195 173 4 4 Oklahoma City *19192175 162 187179 185 * 190 A165 4 172 176 194 166 182 1 131 Philadelphia, NIS 177 132135134133 BigPouchBrighton.Hollywood. Cypress. Creek. FL Fl. FL ALHEALTH CENTERS 220219 Lapwai,For Hall. ID ID HEALTH CENTERS PORTLAND AREA 250 Sells. AZ HOSPITALS TUCSON AREA 13913S137136 PeterCoushatta,Nliccosukee.Indian Dana Island. LAPoint. FL ME ME 159158157 TeecTohatchi.Dzilth Nos Na Pos, NM0 Dith AZ Hle, NM 181180179178 Watonga,Ardmore.PoncaBroken City. Bow, OK OK OK 202201200 199Sacaton.KearnsPhoenix. Fort Canyon. Yuma. AZAZ AZAZ 225224223222221 ChernawaWarmPendletonLununi.Colville, Springs. WAWA (Salem).(Yellowhawk). OR OR OR 253252251 SantaSanYaqui. Xavier Rosa. AZ (Tucson) AZ AZHEALTH CENTERS 143142141140 Steanthurg,Cuneraugus.PleasantHogansburg, Point. NY NYNY ME 160* URBAN Tucson, PROGRAMS AZ 184183182 183Hugo.Eufau,McAlister. Salina. OKOK OK 205204203 SanOwyhee.Whiteriver, Carlos. NV AZAZ 229228227226 YakimaTaholah,NeallWellpinit, Bay, (Toppenish), WA WA WA WA 4 * URBAN144 Alabaina-Coushatta. PROGRAMS TX HOSPITALS OKLAHOMA AREA . 188187 186Sapulpa,Stilwell, Salisaw. OKOK OK 207206 Cibecue,Bylas, AZ AZ HEALTH CENTERS 23223123(1 MucklcshootInchelium,Coeur d'Alene WA (Auburn), (Plummer). WA WA 4 145 Boston,46 New MA York. NY 165164163162161 Tahlequah,Claremore,Ada,Lawton,Clinton, OK OKOK OK 189 192191190Tishomingo, Okemah,Jay.Nowata. OK OK OK 211210209208 PeachFonSaltElko. Duchesnc.River. NV Springs. AZ AZUT 236235234233 Siletz.SwinomishPuyallupTulalip OR (Marysville). (Tacoma), (La Conner.) WA WA WA A HOSPITALS148147 ChinFort Defiance,Ie, AZ AZ NAVAJO AREA 167166 Okemah,Talihina, OKOK HEALTH CENTERS 195194193 Stroud,Tulsa.Oklahoma OK OK City. OK 215214213212 Reno-Sparks,PyramidGarnerville,Fallon, NV Lake. NV NV NV 240239238237 GrandLowerChehalis.Quileute, Ronde.Elusha, WA OR WA 4 152151ISO149 Shiprock,Gallup,TubaCrownpoint, City. NM NM AZ NM 171170169168 Carnegie,LawrenceAnadarko,Holton. KS OK(Haskell) OK KS * URBAN197196195193 Tulsa,Dallas,Wichita,Oklahoma PROGRAMS OK TX KS City. OK 217216 201*Schurz.Flagstaff, URBAN Phoenix, NV PROGRAMSAZ AZ 244243242241 UpperNooksack.SquaxinNisqually. Skagit, Island. WA WA \VA 153134 InscriptionKayenta, AZ House, AZHEALTH CENTERS 172 175174173El Reno, Pawnee,Pawhuska,Miami. OK OK OK OK PHOENIX AREA 218215 Reno-Sparks.Salt Lake City. NV UT 246*245 URBAN Gresham.Burns. PROGRAMS OR OR 155156 TsaiWinslow. le. AZ AZ 49 177176 Shawnee.Wewoka. OK 198 Parker, AZ HOSPITALS 249248247 Spokane.Portland.Scuttle. WA ORWA 50 Tucson Area A199 A202 --"' 206 39 38 Navajo154 Area 153 158 A152 0 HEADQUARTERS ADMINISTRATIVEINDIAN HEALTH OFFICES SERVICE * HEADQUARTERS, WEST A 149 - ' 155 157 ABERDEEN AREA - Aberdeen,AREARockville, OFFICES South Dakota Maryland Albuquerque, New Mexico }47A 148 159 A ISO ALBUQUERQUEALASKACALIFORNIABILLINGSBEMIDJI AREA AREA AREA -AREA AREA Anchorage,- -Bemidji, Billings, -- Sacramento,Albuquerque, Minnesota Montana Alaska California New Mexico 156 # Window Rock A 151 TUCSONPORTLANDPHOENIXOKLAHOMANAVAJONASHVILLE AREA AREA AREA AREA CITY - -Tucson, WindowPhoenix, -AREA- Portland, Nashville, Arizona -Rock,Arizona Oklahoma Oregon Tennessee Arizona City, Oklahoma HOSPITALS ABERDEEN AREA 28272625 Mt.Kotzebue,Nome,Dillingham. Edgecombe, AK AK AK AK 56555453 SantaTaos,Alamo,Pinc Hill. ClaraNM NM NM (Espanola), NM 807978 GreenChicago.Milwaukee. Bay, IL WI\VI 104103102101 Hoopa,CampCovelo.Clovis, Antelope, CA CA CA 432 I EagleWinnebago,Ft.Belcoun, Yates, Butte. NDND NESD 29 Ketchikan, AKHEALTH CENTERS * URBAN PROGRAMS5857 Denver.El Paso, COTX BILLINGS AREA 107106105 LoneKaruk,lake Pon,Pine, CA CACA 765 Rapid City. SD Rosebud.Pinc Ridge. SD SD 33323130 Juneau.Fairbanks.Dena'Ft. Yukon, ina AK (Kenaitze) AK AK 42 Albuquerque. NM A HOSPITALS838281 CrowHarkin, Agency. MT MT Browning, MT 110109108 PaumaOroviIIe.Morongo, Valley. CA CA CA Portersville, CA 98 HEALTH CENTERSSisseton, SD 363534 Metlakatla.McGrath.Kodiak. AK AK AK HOSPITALS BEMIDJI AREA 84 Lame Deer. MTHEALTH CENTERS 114113112III SanRedding, Manuel,Jacinto. CA CA 1211Ili Wagner.Ft.Minne-tohe,M. Thompson,Totten, SD NI) NI) SD 40393%37 Tanana,St.NorthSi. Paul.George, Star, AK AkAK 6059 CassRed Lake, Lake,HEALTH MN MN CENTERS )0{878685 LadgeRockyRipka. Grass, !toys,NIT MTMT St. Ignatius, MT 118117116115 SantaSycuan,Susanville, Rosa,Ynet, CA CA CA 16151413 Wanblee,McLaughlin,LowerKyle, SD Brute, SD SDSD ALBUQUERQUE AREA 64636261 Ponemah,Cloquet.BlackWhite RiverEarth, MN MN Falls. MN \VI 919089 Arapahoe,FortWolf Washakie, Point, WY MT WY 122121120119 Riverside,Ukiah,Tuolumne,Tsurai, CACA CA CA 191817 MesquakieCarlTrenton-Williston, T. Curtis Clinic (Macy), (Tama) ND NE IA 4241 Albuquerque,San43 Mescalero, Fidel, NM NM NMHOSPITALS 68676665 SaultOnamia,NettBowler, Lake. Ste. WIMN Marie, MN MI * URBAN949392 PROGRAMSGreatButte,Billings. Falls.MT MT MT 124123* URBAN Fresno,Bakersfield, PROGRAMS CA CA 2120* URBAN PROGRAMS Linclon,Pierre, SD NE 45 Zuni,44 Santa NM Fe.HEALTH NM CENTERS 72717069 Oneida,LacKashena,Hayward, du Flambeau, WI WI WI 9695 Missoula.Helena. MT MT 128127126125 SanSacramento,Los Angeles,Francisco,Diego, CA CACA CA HOSPITALS ALASKA AREA 49484746 Towaoe.Canoncito,Ignacio.Duke, NM COCO NM * URBAN PROGRAMS757473 St.Mt.Duluth, Ignace,Pleasant, MN MI MI 97 Alpine, CAHEALTH CENTERS CALIFORNIA AREA 129 San Jose, CA NASHVILLE AREA 242322 Bethel.Anchorage,Barrow, AK AK AM 1 525150 Jemez,Laguna,Isleta, NM NM NM 7776 Minneapolis. 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