Valeree Lane January 2020 The phrases “social determinants of health” and “equity lens” can seem like jargon that stands between people who work in the health care fields and those they serve. This report seeks to remove barriers to understanding and open a conversation about what influences the health and wellbeing (social determinants) of Klamath County residents, while working to meet people where they are and help them get to where they would like to be (equity). As with most work, it is a good idea to know a little history. Ar- cheologists have found evidence of early Klamath County resi- dents dating back at least 13,000 years, and these first citizens witnessed the eruption of Mount Mazama that would result in the formation of Crater Lake. One Klamath Nation leader and scholar has provided an insight into how to address current is- sues with an eye to the past. Thomas Ball, PhD, is a former Klamath Tribes Chairman who did his doctoral work around the generational trauma and post trau- matic stress experienced by the Tribes. The effort was not about making excuses, but creating a starting point for healing. A figure of his findings can be found on the next page. Social determinants of health Social determinants Klamath County County Klamath Creation 1870s-80s Reservation boundaries surveyed 13,200 years ago Fort Rock sandals 1880s Reservation divided into allotments, start of board- 10,000 Caumcam village site (King Salmon bones) ing schools 7,000 years ago Tumsumni (Mt. Mazama erupts) 1990s Agency/day schools start, early timber sales 1825 Hudson’s Bay trappers 1908 First elected Tribal official 1826 Peter Skeen Ogden 1910 Banished Modocs return 1835 French Canadian trappers 1912 Flu epidemic 1843 Fremont Expedition fires cannon across marsh 1914 World War II 1846 Second Fremont Expedition (Kit Carson massacre of 1918 First per capita distributions Klamath village) 1920s-30s Tuberculosis epidemics 1840s Applegates & Portland notables plot to take Kla- 1930-50 Klamath Cattle Program math land 1937 Vote to remove Superintendent Crawford 1846 Applegate Trail opens; Small Pox hits Modocs 1941 World War II 1846-60 Modocs defend territory, retaliate against wagon 1945 Senate Bill 1313 trains 1947 Senate Bill 122 1850s Expedition from Portland for Oregon Trail 1940s-50s Relocation programs 1852 Ben Wright massacre 1951 Korean War 1860s Ghost Dance, Earth Lodge Cult, Dream Dance, start 1953 House Resolution 108 Termination passed by Con- of Reservation Period, treaties with California Indian agent gress 1863 Fort Klamath built 1954 PL 587 Klamath Termination Act passed by Congress Mid-1860s Massacre of Klamath women and children near 1961 Termination in effect, Chiloquin “Murder Capital, Fort Klamath USA” 1864 Klamath Treaty, Tribal leaders intimidated and ma- 1971 Remaining members terminated nipulated, ceremonies banned 1977 Kimball v Callahan, Klamath hunting rights recog- 1865 Cremation ends nized, Edison Chiloquin chooses land instead of money 1869 Treaty terms altered by U.S., military road built 1986 Restoration of federal Klamath Tribal recognition 1871 Treaty ratified 1990 Tribes purchase health building 1873-74 Modoc War, four Modoc leaders hung and be- 1997 Kla-Mo-Ya Casino opens headed at Fort Klamath, War Modocs banished to Indian 2000 Administration buildings open Territory 20?? Tribal lands restored 1876 Williamson River Church Figure 1: Intergenerational trauma and unresolved grief, based on the doctoral work of Thomas Ball (Photo by Edward S. Curtis, Library of Congress) Trauma connects generations A thesis, analysis and moving forward Trauma lives in the human body and is passed from gen- There are some hard truths presented here. The purpose eration to generation through epigenetics, or genetic of this work is to clearly define where the county is and memory. There are outward signs of generational pov- what needs attention in order to further growth, health erty, but Ball was able to demonstrate that intergenera- and success. tional trauma is directly connected to current depres- Throughout this document there is descriptive analysis, sion, self-medicating behaviors and other poor health showing what has happened — or where we are now. A outcomes. diagnostic analysis has already been offered as the thesis Life in Klamath County has not seen a generation re- of this paper — generational trauma has influenced the moved from trauma, regardless of race or ethnicity. present as we know it. While the first Hudson Bay trappers came through the The question, “What is likely to happen?” is predictive area in 1825, Linkville – as Klamath Falls was first known analysis. In truth, without sound interventions Klamath – wasn’t established by George Nurse until 1867. The County’s future is not promising. Klamath Tribes had villages throughout the region. In the That leaves the final type of data analysis: prescriptive — forty years between first white contact and formal incor- or recommendation of what needs to be done. Stay with poration of a town, settlers established homesteads. this work to see that there are paths to improve the cur- Both peoples worked hard to provide for themselves in rent status. this rugged land and had encounters that left them scared of each other (traumatized). While the overall topic is Klamath County, each of the smaller towns are examined. Just like people are individ- Both communities experienced stress, which was height- uals, all of the towns and cities that create the whole of ened during the Modoc War. World War I – the first the county are unique. Wherever possible, information is mechanized war – and the Spanish Flu epidemic were provided at the town level. It helps clarify where work experienced by the children of those who participated in can be done to help improve the future. or witnessed the Modoc War. The following generation would see World War II, the internment of Japanese It all starts in childhood Americans near where the Modoc War was fought, nu- Kaiser Permanente did groundbreaking work in establish- clear bombs devastate Japan, and a riot in Klamath Falls ing the connection between adverse childhood events to remove Jehovah’s Witnesses here for a conference. (ACEs) and chronic health problems. Tribal termination would foment in the next generation, Acesconnection.com lists the ten questions that inform along with Vietnam and a perceived shift in cultural val- an individual’s ACE score. Prior to your 18th birthday: ues toward drug experimentation and free love. • Did a parent or other adult in the household Next would be the loss of the timber economy in the late often or very often… Swear at you, insult 1970s, followed by a water crisis in the early 2000s that you, put you down, or humiliate you? or Act devastated agricultural concerns. in a way that made you afraid that you might be physically hurt? There have been joyous occasions, too, but the point of • Did a parent or other adult in the household the previous paragraphs is that today’s conditions– eco- often or very often… Push, grab, slap, or nomic, physical, mental, social – all have a connection to throw something at you? or Ever hit you so the past. hard that you had marks or were injured? • Did an adult or person at least 5 years older Klamath County Social Determinants of Health | Page 3 than you ever… Touch or fondle you or have clothes, and had no one to protect you? or you touch their body in a sexual way? or Your parents were too drunk or high to take Attempt or actually have oral, anal, or vagi- care of you or take you to the doctor if you nal intercourse with you? needed it? • Did you often or very often feel that… No • Were your parents ever separated or di- one in your family loved you or thought you vorced? were important or special? or Your family • Was your mother or stepmother: Often or didn’t look out for each other, feel close to very often pushed, grabbed, slapped, or had each other, or support each other? something thrown at her? or Sometimes, • Did you often or very often feel that… You often, or very often kicked, bitten, hit with a didn’t have enough to eat, had to wear dirty fist, or hit with something hard? or Ever re- Figure 2: Types of ACES among adults aged 18 years or older, Oregon, 2017 (Source: Oregon Health Authority, Oregon Behavioral Risk Factor Surveillance System (BRSS) Figure 3: Number of ACEs among adults aged 18 years old or older, Oregon, 2017 (Source: Oregon Health Authority, Oregon Behav- ioral Risk Factor Surveillance System (BRFSS)) Klamath County Social Determinants of Health | Page 4 peatedly hit over at least a few minutes or In September 2019, the Oregon Health Authority re- threatened with a gun or knife? leased a report on the state’s ACE scores. The most com- • Did you live with anyone who was a problem monly reported types of adverse childhood experiences drinker or alcoholic, or who used street are emotional abuse (33.2%), household substance drugs? abuse (33.4%), and parental separation or divorce • Was a household member depressed or (33.2% ). mentally ill, or did a household member While there is not specific data concerning ACEs in Kla- attempt suicide? math County, it is informative to look at the responses • Did a household member go to prison? given by eighth graders and high school juniors here in A point is scored for each yes answer and the higher the the 2019 Oregon Healthy Teen Survey. score the more likely a person is to have chronic health issues in adulthood. Figure 4: High ACE score (4+) among adults aged 18 or older by race/ethnicity, Oregon,