Generation of Hope: Future of Native health depends on kids

— This is the first in a series of stories examining childhood health on the Wind River Indian Reservation, as part of our reader-supported Generation of Hope series. See below the story for more details. — Ed

If love is the answer, Amarie is acing the test. Mom, aunties, uncles, grandparents, great-grandparents, cousins — her sprawling Eastern Shoshone family — brims with it. Her ready wide-eyed smile reflects the abundance, and she lavishes it on her favorite dolls. As a natural-born performer, the 3-year-old is pretty good at getting it elsewhere, too. It would take a hard heart to keep from melting when she dons her trademark grin, and her tiny jingle dress, and dances with the big girls.

Watching Amarie chase a cousin across her grandparents’ yard, it’s hard to imagine a future for her that’s anything but happy, healthy, and full of opportunity. Toddler energy is infectious that way. It makes the dispassionate world of vital statistics — numbers that describe a Wyoming where Native Americans die young — feel inconsequential. But, the numbers are real, they are sobering and they cannot be ignored.

Infant mortality among Wyoming’s native population — the number of Indian kids who never get to celebrate their first birthdays — is, at 14.7 deaths per 1,000 births, more than double that of white Wyoming. Those Native American kids who, like Amarie, survive the critical first year, find in their second, and beyond, a continued struggle. Compared to others, they are twice as likely to die of an accident, eight times more likely to die of chronic liver disease, three times more likely to be felled by the flu or pneumonia, four and a half times more likely to die of diabetes, and more than eight times more likely to have their life taken by another person.

“There aren’t many health outcomes you can pick where there aren’t disparities,” said Dr. Ashley Busacker, Wyoming Department of Health Senior Epidemiology Advisor for Maternal and Child Health. “In fact, I can’t think of one.” Asked about Alzheimer’s rates as a notable positive exception, Busacker paused for an uncomfortable beat, then pointed out that Alzheimer’s is primarily an old person’s disease. The average life expectancy for Native Americans in Wyoming is 53 years.

No single smoking gun accounts for the health inequities facing Amarie and her peers. Rather, a tangled web of related, entrenched, and often self-perpetuating social, environmental, and historical factors combine to stack the odds against them. Aggravating matters further, the healthcare system in Indian country — chronically underfunded, bureaucratic, difficult to access and dogged by low expectations — is outmatched by, and often ill suited to, the scope of the problem.

Taken together, the challenges can seem insurmountable. Until, that is, one meets the cast of individuals fighting to overcome them. Professionals from a host of different disciplines, cultures and organizations are committed to leveling the playing field. They don’t always agree on the best approach, but they share a common understanding: early childhood experience is eerily predictive of future health, and with some counts placing more than half of the Wind River Indian Reservation’s population younger than 18, efforts to break the cycle must focus on kids.

White Buffalo Recovery Center Director Sunny Goggles is one of those professionals, and she is unabashedly optimistic. “I present the mortality figures to people all the time,” she said. “I’m not making a case for doom and gloom. I do it so they can appreciate our progress 10 years from now. Where there’s a problem, there’s a solution. I believe in our youth. They are the solution.”

It’s a weighty bet. The next 10 years will be crucial for the long-term health and well-being of an enormous generation on the Wind River Indian Reservation. As such, it will also lay the foundation for generations to come.

Child health starts pre-prenatal

“Let’s do an exercise,” Goggles suggested . She spoke, as she usually does, with the upbeat energy of a good kindergarten teacher. But she doesn’t spend her days with bright-eyed five-year-olds. Her work is instead mostly concerned with drug- and alcohol-addicted adults.

“What are the three most important things in the world to you?” she asked.

“My wife, son and wide-open spaces,” I replied.

“Great,” said Goggles. “Let’s see, I’m going to kill your wife. I’m going to take your son away and beat him until he stops acting like you. Oh, and all the wide-open space is mine now. You have to stay inside this fence for the rest of your life. Okay? Still on board? Now fast-forward a generation. Hi, I’ll be looking after your health care.” That she delivered the rhetorical blow with her characteristic cheeriness made it all the more jarring.

She was trying to share a small taste of historic trauma, an insidious and multi-edged phenomenon that plays a role in nearly every Native American health issue. If lifelong health is an intricate symphony, historic trauma is the constant, discordant street noise against which it competes.

The effects of direct trauma — personally surviving a traumatic event — are still coming to light. The fact that a soldier could suffer consequences from combat exposure, though, for example, doesn’t require a big intuitive leap for most people. It just makes sense.

Historic trauma, by contrast, is a form of secondary trauma, and is much more difficult to recognize. Sufferers of historic trauma weren’t personally present for the traumatic event, but their physical and psychological health can still be affected by it in very real, measurable ways.

To understand how, it’s helpful to think like Ashley Busacker, the epidemiologist. She considers health issues from a population-level perspective. One concept that Busacker returned to repeatedly in discussions of maternal and child health was the life course model. Life course is a tool that helps researchers identify, track and measure the myriad factors known to affect an individual’s health over a lifetime. Many of those factors are grounded in personal lifestyle choices — whether or not a person uses tobacco say, or engages in unprotected sex. Others are social determinants over which the individual has no control, for example being born into a racially segregated or predominantly poor community.

When a life course model is populated with data, some startling revelations snap into focus. Perhaps most surprising are the relative impacts of social vs. personal determinants. Social, economic and environmental risk conditions — those factors outside an individual’s genetic makeup or personal choices, and largely beyond their control — are more predictive of someone’s lifelong well being, than the things they can control.

This is a population-level modeling tool that deals in probabilities. It is not the immutable hand of fate. Any individual can defy the odds, and of course, many do. Given a large enough collection of people, though, the tool is uncomfortably reliable. Some will do better, and some will do worse, but most of the population will follow the path outlined by the model, until something changes.

Another striking fact made evident by the life course model is the disproportionate impact of early life-stage factors. A life that stumbles out of the gate into obstacles erected before she was conceived — poverty for example or household food insecurity — is unlikely to ever catch up with their health potentials.

“Child health starts pre-prenatal,” Busacker said. “And child health is the key to the whole trajectory.”

Adversity breeds adversity

Indian Health Service clinical psychologist Dr. Roland Hart understands the importance of a strong start as well as anyone. In his 23 years of service to the Wind River Indian Reservation, Hart has treated the long lasting impacts of adverse childhood experiences (ACEs) in more than 1,000 patients. Their effects are so pervasive that he points to a simple 10-question survey as one of the most useful tools in his diagnostic toolbox.

Used by practitioners, educators and caregivers worldwide, the ACE questionnaire anticipates a host of ailments seeking only yes or no answers about a person’s first 18 years. A score of 1 to 10, tallied from the yesses to questions such as “Did a household member go to prison?” and “Did you often feel that you didn’t have enough to eat?” can say a lot about a person’s likelihood of developing substance abuse disorder, cardiac trouble or even cancer.  

According to Dr. Kim Donohue, Medical Officer of the IHS Wind River Service Unit, clinical data suggests that seven of the 10 leading causes of death among the clinic’s patients correlate to ACE. Together, those causes account for 20 years of lost life expectancy.

Kelli Webb, Director of Eastern Shoshone Recovery, uses the ACE questionnaire in her work, too. “I give it to everyone who walks through the door,” she said. “No one ever scores below a four, and those are rare.”

Elk Sage, Director of the Northern Arapaho Meth and Suicide Prevention Initiative, skipped the numbers in his explanation. “Some people are just so wounded,” he said with a head-shake and long sigh. “People get wounded out here.”

With that simple statement, Sage also inadvertently hinted at an explanation of how historic trauma, like that demonstrated by Goggle’s exercise, can negatively affect a person’s health.

The mass atrocities suffered by Wyoming’s Native community — for example, the Sand Creek Massacre; the loss of their homelands; the forced removal of children from their families by abusive, assimilation-focused boarding schools; the violent destruction of their religion, language, lifestyle and culture; the decimation of their traditional food sources; the deliberate introduction of alcohol, drugs and communicable diseases — scarred the individuals who survived them. The long litany of traumas also established and systematized many of the conditions that today contribute to negative social determinants of health and adverse childhood experiences.

Being born into a loving and conscientious household helps, but that alone can’t entirely insulate a child when a community is beset by trauma, particularly when that community is as tight-knit and hyper-relational as the Native community on the Wind River Indian Reservation.

Amarie lives in a safe, alcohol- and drug-free home, surrounded by educated, gainfully-employed adults who are focused on her well-being. Yet, at 3-years-old, she’s already lost a cousin, Stallone Trosper, to white-on-native gun violence. Her ACE score has already started climbing.

Read the entire Generation of Hope series:
Generation of Hope: Future of Native health depends on kids, Oct. 20, 2015
Pure Poverty: ‘If you don’t have money, you don’t have health care,’ Oct. 27, 2015
Broken Promises: Despite treaty assurances, health care remains underfunded, Nov. 3, 2015
With low expectations, many Natives go without health care, Nov. 10, 2015
Leaders confident Native community can reorder status quo, Nov. 17, 2015

— Generation of Hope is a special project of WyoFile, focusing on childhood health on the Wind River Indian Reservation. It is made possible by generous readers who donated to WyoFile’s crowdfunding effort in March, via the Beacon crowdfunding platform. Please share these stories with your friends, and tell us about your experiences regarding childhood health and well-being on the Wind River Indian Reservation. If you enjoyed this story, please consider making a tax-deductible donation to WyoFile. We could not have done this series without the support of our readers. — Ed.

WyoFile writer Matthew Copeland and WyoFile editor-in-chief Dustin Bleizeffer discussed the Generation of Hope series with Miranda Birdahl and Sean Ingledew, who produce Rally Casper‘s No Label Roundtable podcast. Take a listen: