Over its 23 year history, the Commonwealth Fund Fellowship, along with California Endowment Scholars program and Joseph Henry Oral Health Fellowship, has a proven track record of creating physician/other health professional leaders; the Alumni Spotlight interviews showcase the expertise and dedication to care for vulnerable populations as a testament of that success. Interviews have been edited for length and clarity.
Director, Indians Into Medicine (INMED) Program, Director, Public Health Program, Associate Dean, Diversity, Equity and Inclusion, University of North Dakota School of Medicine and Health Sciences, Grand Forks, ND
Q. Describe your current role in your organization and your journey to that role.
A. At the University of North Dakota School of Medicine and Health Sciences, I'm Associate Dean for Diversity, Equity, and Inclusion; Director of the Indians into Medicine (INMED) Program; and Director of the Public Health Program, which offers a Master of Public Health with three specializations (including Indigenous Health), as well as a new PhD in Indigenous Health. I'm also Professor of Family Medicine. My path to the work I’m doing now hasn't been a straight line from when I did the fellowship. I think that's probably a common experience for many of the alums—we don't necessarily know at that time exactly what we will be doing in the future, and opportunities arise or we identify areas of need that we should be pursuing. So, it's ultimately kind of a circuitous route.
In terms of my own path since the fellowship, I had been working for National Institutes of Health as a staff clinician doing intramural diabetes research. Then I had the opportunity to join faculty at Arizona State University (ASU). They have a very good Indian Legal Program at the Sandra Day O'Connor College of Law at ASU. I taught American Indian health law and policy to law students, business students, and public health students. Then, I also had an opportunity to become the Health Policy Research Director for the Inter Tribal Council of Arizona, which represents all the tribes in the state of Arizona—that’s twenty or twenty-one tribes depending on how you count them. That was a wonderful experience, too, doing community-based health policy work: things like developing a sample Tribal Health Code and doing health policy research related to tribal management of Indian Health Service facilities.
I'm originally from South Dakota and I had been wanting to go back there for years when, in 2008, I had the opportunity to become Executive Director of the Great Plains Tribal Leaders Health Board, which is a consortium of nineteen tribes across North Dakota, South Dakota, Nebraska, and Iowa. It’s a nonprofit organization, and the board of directors is comprised of the tribal leaders—the highest elected officials—of those nineteen tribes. We do regional advocacy and regional public health programming. In that setting I worked with a multitude of US Department of Health and Human Services agencies—many of whom I’d been connected to through the fellowship. I actually got to “re-meet” some people in a different capacity.
In recent years, I moved back to academics. I had an opportunity to become the inaugural Master of Public Health program director at North Dakota State University (NDSU), so I continued moving north and lived in Fargo for about seven years. We initiated the MPH program there and established the world’s first American Indian Public Health MPH specialization. About three years ago, I moved into my current role at the medical school in North Dakota, which is at a sister university, the University of North Dakota.
The fellowship offered excellent training in thinking critically and systemically, and in asking what “health equity” is, how it might mean different things to different populations, and what the higher-level policy and programming solutions to address those challenges might be. Also, in a very practical way, just having those connections to leaders within HHS and other organizations was of great value.
Q. Could you say a little more about the definition of “health equity” as you see it?
A. I look at the differences between equality and equity. Quite often, when we think about equality in healthcare or equality in public health, we tend to take a one-size-fits-all approach to all populations. Even the whole idea of “evidence-based practice” is skewed toward the populations that get studied—towards the populations that have the resources to generate data and evidence in the first place. So, every time someone says “evidence-based practice,” my first question is: whose evidence is it?
We tend to take this one-size-fits-all approach to health services, whether it's public health or medical care. But something that works effectively in Boston or Atlanta is not necessarily going to work effectively in a rural reservation community. And there are also other cultural considerations. So, when I think of equality, it’s: everyone gets the same services, everyone gets the same curriculum, everyone gets the same programming. That’s equality, but it’s not equity. From my perspective, equity is about outcomes. We’re not just interested in the process by which an agency provides services; we want to see equitable outcomes in terms of who is getting optimal health. The fellowship prepares people very effectively to recognize that there's such a diversity across minority and underserved populations, and that we have to think systematically.
Q. Can you tell us about your leadership style?
A. I think that to be effective leaders, we need to have flexibility and we need to recognize that different circumstances will require different strategies. And, again, that's kind of the “equity” approach. Let’s look at the outcomes — even if the pathway to get there might be a little bit different, ultimately what we want is better outcomes. There are contexts where I’m working with groups that are not diverse, that are kind of the old-school, good-old-boys’ network, and the strategies I use might be very different from what I would do if I was working with a tribal community. So, I think one of the requirements for an effective leader is to recognize the circumstances in which you’re working. I do like the idea of transformational leadership, in which you have a vision. We have to know what is it we want to see in the world, for our program or agency. If you always have that vision-and mission-driven approach, then the particular steps to get there can vary depending on the circumstances.
But one thing I try to build in any setting is consensus. No matter what setting you’re in, if you take the approach, “I am the leader and you're the follower—do what I say,” no one responds well to that. And I’ve certainly seen examples of that throughout my career. But I think when we can be open, honest, and forthright, when we communicate our vision and mission effectively, when we can say, “these are the steps that we need to take to get there” and build consensus around that idea, then there’s much more buy-in. People work harder when they feel like there’s a higher mission and purpose and we have more effective teams and better outcomes. It’s the role of the leader to ensure that we're always mission driven.
Q. Can you tell us about your career goals at this stage of your career, and how they may have changed since the time you were in the fellowship?
A. When I first started my medical career, I thought that I would spend my entire career as a primary care doctor working with tribal communities – working with the Indian Health Service (IHS) or working for a tribe. But my big frustration in medicine was that almost everything I was dealing with was preventable – Type 2 diabetes, smoking-related challenges, nutrition-related challenges that lead to chronic disease. So, very quickly, I recognized we're not going to prevent diabetes in the hospital; that has to be done in public health. And in starting some initial work in public health, I recognized that everything we do in public health is related to policy. Policies determine our priorities. And with tribal communities, it's very complex—there are multiple levels of policymaking. We deal with the federal government regarding IHS and the Centers for Medicare & Medicaid Services (CMS), with state governments when it comes to Medicaid programming and state health department programming, and with tribal governments and tribal leaders, as well. And health policy is also made in the private sector. How do we connect with private-sector hospitals or even the pharmaceutical industry about how we can provide care?
After the fellowship, identifying areas of need directed my next steps. I knew that we needed training in American Indian health policy for public health professionals, lawyers, and people working in health services administration. That's why I joined the faculty at Arizona State and developed the American Indian Health Law and Policy course—the first of its kind. But I still wanted more direct experience, and I wanted to be working with the community, so I went back to South Dakota and became Executive Director of the Tribal Chairman's Health Board. So, I didn’t start out with a long-term plan that’s been playing out ever since. It has been evolving.
I’d say in terms of moving forward, I do see still a couple of areas with a significant lack of representation. We have a lot of medical schools across the country, but there are zero deans who are American Indian at US medical schools. Zero. That's pathetic! In the year 2021 to have no medical school deans who are American Indian is unacceptable, and if I were to move on from what I’m doing now, it would be for a role like that. And when we look at associate deans across the country, there are only two of us who are American Indian. So, I'm fifty percent of the medical school associate deans who are American Indian—and that's not a pat on the back, that's an indictment of the field. That tells us that leadership development, particularly in academic medicine, has been non-existent for American Indians, and that needs to change. So rather than complaining about it, we're establishing new leadership development programs and fellowships. But I'm also very, very happy with what I'm doing now. I love directing the programs that I do. Being an associate dean, I still have a lot of influence on university-wide, as well as medical-school-specific, policy and curriculum development. So, I'm happy with what I'm doing now, but I do recognize that there's no American Indian medical school dean, and that needs to change.
Q. In situations when stakeholders don’t share the same values as you—whether it's dealing with policymakers or academic institutions or health systems—what have been some of your strategies to try and move the needle?
A. Yeah, that happens almost every day. For example, in North Dakota, the state legislature is very conservative and there's even pushback against things like higher education itself in some sectors. Training related to social justice and diversity can have its own detractors, including among high-level policymakers and lawmakers. This is a big challenge, and we have to recognize is that not everyone shares our same values. We have to go into these situations with that deep-rooted understanding that what's important to me is not going to be important to all of the stakeholders. What we need to do then is identify common areas of interest. For example, I might be interested in promoting health equity for American Indians because I want my people to live optimally healthy and happy lives. That's important to me. Quite frankly, amongst some lawmakers, that's not important; but something that is important to them is saving money. And if we invest in public health and we decrease chronic disease, then that's going to save their Medicaid dollars in the future. So, when I’m talking about health programming, of course I'll say, “this is the right thing to do, because it's going to promote health in the population,” but I also am very clear to say, “and it's also going to save X amount of dollars over the next ten years if we’re successful.”
But sometimes there just is no commonality. I think we have to go into this work recognizing that we're not always going to win. We're going to face very disappointing and discouraging losses. I've seen some people almost give up, but we need to transform that energy related to disappointment into positive action. We need to build our stakeholders, collaborators, and champions across multiple disciplines. One area where I’ve done that is in serving on the national board of multiple organizations where I'm the only American Indian in the room: the National Board of Directors for the American Cancer Society, the National Board of Directors of the Public Health Foundation, the National Board of Trustees for March of Dimes. What I’ve seen is that these organizations have good intentions, but they don't always know the issues around Indigenous populations. So, we need more of our people at the table. As American Indians, we don't have the numbers or the political clout or the money to have as much influence as larger national organizations will have. So, we need champions from existing advocacy organizations on board. Our role is to build those champions. Because when we're dealing with lawmakers who might have different values, they still do recognize the power of larger organizations, and we need to be a part of that.
Q. What are the challenges in addressing health equity and health policy affecting vulnerable populations? And what are the strategies to address these barriers and challenges?
A. Typically, the populations that are marginalized or underserved are also impoverished populations. The communities that have the resources to influence political decisions have their needs met, and the communities that aren’t having their needs met, due to poverty and related challenges, don't have the influence on politics that the more affluent communities do. It's a vicious cycle, where the rich get richer and the poor get poorer—not just financially, but even in terms of health status, where we see these widening gaps. To me, the biggest overall challenge is that the way our current political system works and, of course, one of the classes we take in the fellowship (at least we did twenty years ago) is about, “well, what is politics?” The political arena is where we determine how we divide resources and distribute resources. The marginalized get less services, and the sick get sicker, and the populations that are impoverished die younger. And we make that decision as a society.
I think for American Indians in particular, again, one of our big challenges is that not only are we marginalized and underserved and impoverished, but we also have very small numbers of people. If we look at voting blocs, in some states it's relevant, but there are only seven states that have at least three percent American Indian/Alaska Native population: Alaska, Montana, North Dakota, South Dakota, Arizona, New Mexico, and Oklahoma. And for the most part, those are very conservative states. So, our voting influence is not as powerful as I wish it were, although we're seeing some changes, particularly in Arizona and New Mexico, where we're seeing some positive outcomes. In terms of minority health policy, American Indians are the minority of the minority populations. We are also the most underserved of the underserved populations. And the most underrepresented of the underrepresented. There’s not just a lack of American Indian medical school deans and professors, but physicians in general. We're about one to two percent of the overall population, but we're about 0.3 percent of physicians. That's kind of a big-picture issue, but it’s also what I deal with on a daily basis.
Q. Turning to back to your own journey, could you tell us about how your personal narrative and your past experiences have influenced the progression of your career?
A. I am originally from Kyle, South Dakota, on the Pine Ridge Indian Reservation, and that's where my family has been from for a thousand generations. I was very fortunate to grow up in a family with a lot of traditional healers and medicine men. When I was growing up, I learned a lot about traditional culture, language, healing practices, and ceremonies from my uncles. And for me it wasn't unusual or special, it was just my life. These were my uncles, and this is what I was exposed to. But I was very, very fortunate, because as I was growing up, without really knowing it, I was serving a kind of apprenticeship. And you know, it's never called an “apprenticeship.” There's no “medicine man school” or anything, but through that experience, I was able to learn a lot about traditional culture, perspectives, and holism related to health—the role of spirituality and ceremony in health. That was just a part of my upbringing, so it was really my foundation.
Later, in college at ASU, I was doing well in my science courses, and at that time there just happened to be a premed advisor who wanted to diversify the pre-meds at ASU. He knew that I
was doing well in biology and physiology, and he asked if I'd ever thought about becoming a pre-med. And my first question literally was, “are there any American Indian doctors?” Because I had never met one. I was nineteen or twenty at the time, and I had never met an American Indian physician. I look back on that now, and I think about the power of role models. For people who are from the majority society, if all the doctors they’ve seen or all their teachers and principals or all the professionals they encounter are from their race or ethnicity, then anything seems possible. But if you never see people who are from your community in those roles, it doesn't really seem possible. Just in my own experience, I mean, I knew it wasn't illegal for an American Indian to become a doctor, but it never seemed real until I met one. Fortunately, my mom was a nurse working in the Indian Health Service, and she knew of one American Indian physician. So, we set up an appointment, so that I could meet him. And that, for me, was life changing. It finally seemed real, and I said, “you know, I really could do this.”
So, I was mid-way through my undergraduate career before I actually became a pre-med, and as I was doing that, every summer I was going back to Pine Ridge, South Dakota, meeting with my uncles, and participating in ceremony. I was actually worried that that they would be disappointed in me for going into medical school—for going to the “Dark Side.” Because, quite frankly, modern medicine has been very disrespectful of traditional forms of medicine, like American Indian medicine (and we still see that today). I was worried that my uncles would be disappointed, but actually the opposite happened, and one of my uncles in particular said, “I think this is a good idea, but if you go to medical school and you become a doctor, never forget where you come from and never forget your responsibilities as a Lakota man.”
And I’ve taken that to heart, and I’ve never forgotten where I’m from or what my responsibilities are. And from that cultural perspective, the core value is humility—none of this work is about me as an individual. It's about our people, and it's about a higher purpose of community benefit. And honestly if I were to just focus on myself, it would all fall apart. Because it's about all of us collectively, and that's been an important component of my own journey. The other thing that my uncle told me at that time was, “if you do this, go to their best schools, learn their way of medicine, know it better than they do—because that's the only way you will be taken seriously as a Lakota man.” And I took that to heart, too. He wasn't saying the word “credentials,” but he meant, make sure you get good credentials, make sure you're well trained, and if you're going to do it, put everything you have into it. I was very fortunate to go to Stanford for medical school and Harvard for the MPH, but that advice opened doors as well. So, I think that I would not have gone on this path if it weren’t for that one pre-med advisor who cared about diversity and for my uncles—who supported this decision, but who also made sure that I held on to the traditional values that were important to all of us.
Q. In moving through the world of medicine and health care, are there aspects of the professional culture that make it challenging to hold on to that focus on the collective?
A. For me, the starkest example of a clash of cultures and values was in medical school. I had been taught that we do this for our people, that the role of the medicine man is to sacrifice and to ensure that we're promoting community benefit. And we have to be very humble in those settings. But it probably doesn't surprise anyone that the core value at Stanford Medical School was not humility. So, that was a clash of cultures and values, and it was really difficult, to be honest. I was very unhappy during the training, but what kept me going was the inspiration that I had from a cultural perspective, knowing that there is a higher purpose to this. And, in many ways, I was thinking of medical school like ceremony. Our ceremonies are challenging. We have four-day Sun Dance ceremonies, and there's a lot of preparation that goes into it, a lot of physical exertion and lack of food and water. Physically, mentally, emotionally, and spiritually, it’s an incredibly challenging ceremony. So, I kind of equated medical training to a ceremony—that it's a huge challenge, and it makes us feel very uncomfortable, physically, mentally, and otherwise. But that at the end of it, there's going to be benefit. That's the approach I took.
There’s a quote from Black Elk, a Lakota traditional healer from the late 1800s and early 1900s. We did not have a written language, historically, and so he worked with a writer in the early 1900s, John Neihardt, and published a book called Black Elk Speaks. My favorite quote from him was: “Of course it was not I who cured. It was the power from the outer world, and the visions and ceremonies had only made me like a hole through which the power could come to the two-leggeds. If I thought that I was doing it myself, the hole would close up and no power could come through.” What he was talking about is humility—the opportunity to serve a community as a healer is a sacred responsibility, but it's not about us as individuals. That healing energy is rooted in spirituality, in our ancestors, and in the natural forces of the world.
As healers we try to channel that healing energy in the right direction, but as soon as we believe we own it, we lose our access to it. And I've seen examples of that over the years. When physicians lose their humility, they lose their ability to heal. When educators lose their humility, they lose their ability to teach. When people lose humility in justice systems they lose their ability to promote justice, and we see that in policing. For me, what's been most effective in terms of linking this work in modern American health policy to the populations who need the interventions the most is recognizing that it's not about us as individuals, it's about the collective. And that gives me a lot of energy and hope moving forward.
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