Majestic mountain peaks, abundant wildlife and unlimited natural beauty have made Alaska a vacation dreamland for millions of people from all over the world. But while tourists come and go, America’s northernmost state is also home to thousands of indigenous peoples, including Aleuts (people native to the Aleutian Islands), Eskimos (natives who live primarily in Alaska’s coastal regions) and many smaller tribal groups. Collectively, Alaska Natives constitute one of the smallest ethnic minority populations in the U.S.—only about 2 million people in the entire country.
According to the 2000 U.S. Census, there are nearly 100,000 Alaska Native and American Indian (AN/AI) people living in Alaska. By no means a homogeneous population, this group breaks down into numerous subgroups, each with its own distinct culture and, in many cases, its own language or dialect. In fact, the Women of Color Health Data Book, published by the Department of Health and Human Services’ Office of Women’s Health, estimates that there are more than 300 languages spoken among American Indians and Alaska Natives.
Unfortunately, awareness of Alaska Natives and their health care needs is extremely limited outside their home state. Down in the “lower 48,” as Alaska residents call the continental U.S., medical researchers and health care providers have traditionally lumped Alaskan Natives together with American Indian tribes from other parts of the country, even though they live thousands of miles apart and have different cultures and living environments.
The good news is that as researchers delve deeper into investigating the disparities in health outcomes between Americans of color and the white majority, Alaska Natives are finally being addressed as a group with its own identity. The bad news is that this research clearly indicates that Alaska Natives face many of the same serious health problems, in varying degrees, as minority populations in the rest of the nation.
“Overall, [the health issues here] are very much like those for people of color in the rest of the United States—they just differ in magnitude,” says Kathleen Kinsey, RN, BSN, MPA. “For example, Alaskan Natives’ smoking and obesity problems are greater.” Kinsey, an American Indian nurse originally from Washington state, is administrator of nursing services for Mt. Edgecumbe hospital in Sitka, Alaska, part of the Southeast Alaska Regional Health Consortium (SEARHC).
Here’s a closer look at what nurses interested in working in Alaska need to know about the major health care issues affecting Alaskan Native communities, both historically and in the context of current initiatives to close the minority health gap in the 21st century.
Alaska Native Health 101
Heart Disease [N Elia – These headings under the main subhed are sub-subheds. Please format this section the same way you did the section called “The Present” in the “One Name, Many Faces” article in the previous issue.]
For decades, the number one cause of death for Alaska Natives was infectious diseases. But as medical advances brought these illnesses increasingly under control, the mortality picture shifted toward chronic conditions. Today, one of the leading killers of Alaska Natives is heart disease, as it is for the rest of the U.S. population. According to the American Heart Association (AHA), 25.2% of all American Indian and Alaska Native males who died in 1999 suffered from heart disease or stroke. Women fared even worse, with 27% of all deaths attributed to these causes.
Interestingly, even though the Centers for Disease Control and Prevention (CDC) still rank it as the number one cause of death for Americans as a whole, the mortality rate for cardiovascular disease (CVD) in the United States has dropped by more than 50% during the past 40 years. Experts say much of this decrease is a direct result of improved medical technology and earlier diagnosis. But during this same period, according to the Indian Health Service, the incidence of CVD among Alaska Natives and American Indians rose dramatically.
In fact, Indians and Alaska Natives between the ages of 35 and 44 have a CVD risk at least two times higher than that of their Caucasian counterparts. Even though this gap diminishes with age, it doesn’t disappear: AN/AI people in the 55-64 age group are still 1.5 times more likely to suffer from heart disease than whites of the same age.
Researchers and health professionals alike point to increased tobacco use as one of the key factors contributing to this disparity. Both the AHA and the American Lung Association (ALA) report that nearly 40% of all American Indian and Alaska Native men and women over the age of 18 smoke regularly, compared with only about 26% of Caucasians in the same age bracket.
Why the rising occurrence of heart disease among young Alaska Natives? Is smoking the lone contributing element? Health experts who work in Alaska Native communities believe changing dietary habits are also to blame.
In recent years, many Alaska Natives have moved away from their traditional diet of seafood and game to embrace fast food and prepackaged meals, especially in the state’s more urban areas. (According to 1990 figures, 69% of Aleuts and 50% of Eskimos in Alaska live in cities.) As the food choices increased, so did Alaska Natives’ weight. Just two or three generations ago, malnutrition had been a pressing concern. But as AN communities became more urbanized, or as native people left their villages for larger cities, their diets began to include more saturated fats and processed foods.
Former U.S. Surgeon General Dr. David Satcher declared obesity a national epidemic in 2001 when research revealed that 60% of all Americans were overweight or obese. But the Alaska Native population has been hit especially hard. SEARHC routinely conducts a health survey of the various AN communities and tribes it serves. Its most recent survey (April 1998) found that 46% of adult participants were overweight. For such a small sample, that’s a staggering statistic. Additionally, SEARHC found that one in three youths in Alaska qualify as overweight, compared with one in five for the country as a whole.
“I grew up in an Aleut community in Kodiak, Alaska, on what was basically a subsistence diet of fish and venison,” says Kathy Belanger, RN, BSN, CNOR, nurse manager of surgical supply services at the Alaska Native Medical Center in Anchorage. “I didn’t eat beef until I was in the sixth grade. Our eating habits have gotten much worse and as that changed, so did the health of our people.”
Not only does obesity increase people’s risk of developing cardiovascular disease, it can also increase their likelihood of suffering from diabetes—the sixth leading cause of death in the U.S. Most racial and ethnic minority groups have been disproportionately affected by this serious chronic disease and its related conditions, such as renal failure, amputations and blindness. However, the disparity gap for Alaska Natives is narrower than for other Americans of color. For example, Hispanics and American Indians have two to six times the incidence rate of diabetes compared to Caucasians. Alaska Natives, on the other hand, are also more likely to have diabetes than whites, but their incidence rate is less than twice as high.
Still, the number of cases diagnosed each year in AN communities continues to climb. According to the Women of Color Health Data Book, the rate of diabetes mellitus in Alaska Natives has grown tenfold in the past 30 years. Not surprisingly, the disease is less common in the more remote villages where people maintain their subsistence-like diets.
While obesity and diabetes are relatively recent health problems for Alaska Natives, AN communities have been battling tuberculosis for generations. Indeed, TB was once called “the scourge of Alaska.” According to a report recently published on http://www.tribalnews.com/, an online AN/AI news source, when the state first started recording the number of TB cases in 1952, officials were stunned to learn that there were nearly 400 cases per 100,000 Alaskans. But the epidemic was far worse for Alaska Natives, with more than 1,800 cases per 100,000. Throughout the past 50 years, Alaska’s health care providers have struggled to treat and prevent the spread of this highly infectious disease.
Although never completely eradicated, up until the 1990s health experts believed the disease was on the decline. Unfortunately, it rebounded with mutated, drug-resistant forms, and Alaska is once again the hardest-hit state. In 2000, the CDC reports, there were 17.2 TB cases per 100,000 people in Alaska—the highest incidence in the nation. The 108 new cases reported that year represented a 75% increase over 1999 statistics.
“As a nursing student working in public health, I was surprised at the number of TB cases, especially among children,” Belanger remembers. “Today, I still see the isolation signs when I walk through the hospital.”
The threat of tuberculosis is greatest for Alaska Natives who live in the farthest reaches of the state. A full 90% of adults age 60 and older in remote Alaskan territories have had positive TB skin tests. Of those positives, approximately 10% develop active cases, which can pose a significant public health risk if left untreated or partially treated.
A new study published this year in the journal Alaska Medicine confirms that cancer has moved up from second place to become the leading cause of death for the Alaska Native population. In particular, Alaska Natives are now 40% more likely to die of lung cancer than white Americans, and their risk of colorectal cancer is also greater. Breast cancer rates are also high among Alaska Native women, especially those who live in remote areas with limited access to health care facilities that can provide screening and early detection. Again, doctors and nurses point their fingers at the high rate of tobacco use in AN communities and the steady movement away from traditional foods as key factors behind the rise in this once-rare disease.
In the 1950s, cancer was hardly found among the aboriginal peoples of Alaska, according to TribalNews.com. But in 1988, former Alaska Native Medical Center Director Robert Fortuine drew statewide attention to the fact that rising rates of cancer and heart disease were directly linked to a drastic change of diet and lifestyle among Alaska Natives. Low-income people were especially at risk, he noted, because “they tend to eat more inexpensive meats like bologna and hot dogs.” These types of foods lack the healthier, unsaturated oils found in such traditional staples of the Alaskan Native diet as fish, seal, whale and walrus.
However, the results of the Alaska Medicine study did contain some good news: Alaska Natives are less likely to die from prostate cancer, leukemia, lymphoma and uterine cancer than members of other racial and ethnic groups.
Although this deadly infectious disease is on the rise among Alaska Natives, the actual number of cases reported throughout the past 20 years is still quite low when compared with the rest of the U.S. population. According to the ALA, which tracks AIDS-related respiratory diseases, Native Americans as a whole represent less than 1% of all AIDS cases in the nation.
“The low incidence of AIDS [in Alaska Natives] might be because of our lifestyle,” suggests Belanger. “The village setting with its small group of people is not necessarily exposed to the risk behaviors associated with the big cities. But that is changing as well.”
Much of this change has occurred rapidly over the past ten years. From 1992 to 1993, the CDC recorded a nearly double jump in the total number of AIDS cases in American Indian and Alaska Native communities—from 445 to 818. Just two years later, that figure hiked to 1,333 cases, of which less than 400 were reported in Alaska. By June 2001, the number of cases had again nearly doubled, reaching a total of 2,433. Additionally, at least 25% of new AIDS cases in Alaska are reported by young people.
Alaskan health officials remain uncertain as to how any future spread of the immune-attacking disease will develop, but they do acknowledge that at-risk behaviors appear to be on the rise. For example, alcohol and drug use is abundant among Alaska Natives. In fact, the SEARHC survey respondents listed alcohol and drugs as their leading health care concerns.
While alcohol abuse is disproportionately high among American Indians, the SEARHC survey concluded that the drinking habits of Alaska Native teens do not differ significantly from those of their counterparts in the majority population. But Alaska Native youths use marijuana at nearly twice the rate of whites. Moreover, suicide rates among Alaska Natives are four times higher than in the rest of the United States, with AN males between the ages of 15 and 34 at the higher risk.
As serious as these illnesses all are, one of the most critical health crises facing Alaska Natives is not a disease at all—it’s lack of access to health care services. While the larger cities, such as Anchorage and Juneau, offer a reasonable choice of health care options, native people who live in outlying areas and remote villages are often cut off from even the most basic care. Transportation can become a formidable obstacle when emergencies or acute care issues arise, especially during the winter.
“Our facility is located in a region where the only way to get into town is by plane or boat, which can take several hours,” explains Kinsey. “For many people, they’re only making the trip to the hospital because they have an acute health care need.”
The state government, however, is taking steps to bridge these access gaps. One solution has been to provide outlying areas with community health aides, who work under the guidance of physician consultants. While they’re not nurses, the aides are trained in a wide range of health care assessment skills, from baby wellness to trauma.
In addition, new advances in telecommunications technology are enabling more hospitals and clinics to reach out across the miles and bring their services directly to remote communities. Although it’s still a relatively new option, Kinsey says SEARHC has begun to use telemedicine as a means to help villages maintain their health. Doctors and nurses can now provide patients with one-on-one consultations via telephone, videoconferencing and even cyberspace, as more villages gain computer access.
“We need to ask how we can keep health care delivery in the villages and support them in real time,” Kinsey emphasizes. “I think telemedicine is an important issue for this region, especially because I don’t see transportation improving significantly.”
But geographical isolation is not the only problem that can limit Alaska Natives’ access to quality health care. Cultural differences can also be a significant barrier, especially when Alaska Native patients are hospitalized. Because the state’s health facilities typically have many staff interpreters or bilingual providers, language isn’t usually an obstacle per se. However, the way in which Alaska Natives speak is different from what most Americans are used to, which can often lead to communication breakdowns.
For example, says Kinsey, Alaska Natives often talk slowly with pauses, and they communicate through storytelling with the most important elements at the end of the speech. “Nurses should expect to sit and listen to patients and not talk over them. That’s probably the biggest cultural difference,” she advises.
Belanger adds that nurses should look beyond the surface response to make sure Alaska Native patients truly comprehend their instructions for treatment and follow-up care. “Natives are trusting people and they may say they understand, but that isn’t always the case,” she says. “In training new nurses, we tell them what clues to look for to see if the native patient is really understanding what they say.”
Wanted: Alaska Native Nurses
This need for cultural competence training is extremely important given the fact that the majority of Alaskan hospitals’ nursing staff comes from outside the state. Furthermore, the University of Alaska Anchorage School of Nursing estimates that American Indians and Alaska Natives make up more than 15% of the state’s total population but only 2% of Alaska’s registered nurses.
The school hopes to change this situation through its Recruitment and Retention of Alaska Natives into Nursing (RRANN) Program, launched in 1999. RRANN offers Alaska Native students in associate and baccalaureate degree programs a variety of resources, including tutoring, mentoring, support groups and “student success facilitators,” to aid them in completing their nursing studies and transitioning into the workforce.
Kinsey, too, has been working to increase the number of Alaska Natives in SEARHC’s nursing rosters. She helped establish an LPN program to assist Alaska Natives’ entry into the profession. From there, the nurses are encouraged to pursue a degree leading to RN status. “Right now, we have eight employees signed up for the LPN program and we expect all of them to move on to the RN program,” she notes. “Of those eight, half are Alaska Natives.”
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