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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.

Amarie Swallow (right) in her jingle dress. Children on the Wind River Indian Reservation face obstacles to health care, which can determine their "life course." (photo by Matthew Copeland/WyoFile)

Amarie Swallow (right) in her jingle dress. Children on the Wind River Indian Reservation face obstacles to health care, which can determine their “life course.” (photo by Matthew Copeland/WyoFile)

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

Sunny Goggles, White Buffalo Recovery Center Director, is blunt about the serious challenges to childhood well-being on the Wind River Indian Reservation, and also entirely optimistic. "I believe in our youth. They are the solution," she said. (photo by Matthew Copeland/WyoFile)

Sunny Goggles, White Buffalo Recovery Center Director, is blunt about the serious challenges to childhood well-being on the Wind River Indian Reservation, and also entirely optimistic. “I believe in our youth. They are the solution,” she said. (photo by Matthew Copeland/WyoFile)

“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.

Lifelong health is determined by a complex interaction of many variables. Only 40 percent of the equation is subject to an individual’s behavioral choices.

Lifelong health is determined by a complex interaction of many variables. Only 40 percent of the equation is subject to an individual’s behavioral choices.

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.

Childhood experience is the foundation on which a life’s health trajectory is built. (Source: Centers for Disease Control and Prevention website)

Childhood experience is the foundation on which a life’s health trajectory is built. (Source: Centers for Disease Control and Prevention website)

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.

Amarie Swallow runs in the yard of her grandparents' home. Experts say social, economic and environmental risk conditions are more predictive of someone’s lifelong well-being than the things they can control. (Matthew Copeland/WyoFile)

Amarie Swallow runs in the yard of her grandparents’ home. Experts say social, economic and environmental risk conditions are more predictive of someone’s lifelong well-being than the things they can control. (Matthew Copeland/WyoFile)

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:

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2 Responses to Generation of Hope: Future of Native health depends on kids

  1. Bayard Johnson October 23, 2015 at 3:15 am #

    I liked your story. Like most good articles, it raises almost more questions than it addresses. Each time the article turns over a new rock, the reader finds a host of interconnected issues. I’d like to look at just one of these points and see where it might lead.

    As you write, “Used by practitioners, educators and caregivers worldwide, the ACE questionnaire…” correlates problems in early childhood with health issues in later life. In my experience with several different Indian nations in the United States, I’ve seen such diversity and variation between different Indian people and cultures that I am a little dubious about therapists who work with Indians using a one-size-fits-all diagnostic tool, that was developed by non-Indian people for use among non-Indian cultures. I freely admit that I could be completely wrong, and this may be a very useful diagnostic tool, but I am suspicious that there might be additional factors at work.

    Several cultures have gone through horrible genocidal periods in the last few centuries. But it’s time to face facts–NONE can even approach the horrific numbers and ghastly span of centuries of the American Indian holocaust. But the reason that American Indians continue to suffer so terribly from the worst holocaust in history is that the AMERICAN INDIAN HOLOCAUST IS STILL GOING ON TODAY!! RIGHT NOW!!!! Today. Tomorrow. The day after that.

    To say that the bad health of Indian people today is due to the terrible legacy of slaughter in the past is to blame history for these problems, when the causes are not confined to history. It’s a healthy and hopeful present that will truly help heal these wounds. Current conditions are the real problem. The reason that American Indians today suffer from the trauma of historical atrocities and tragedies is that they are constantly reminded of them.

    The Holocaust engulfed Indians every time throughout history that they tried to assert their rights to be Indians. Many Indians are daily reminded–continually reminded, by the circumstances of their life, by the CONSTANT reminders of the great nations and cultures and languages that have been lost–what happened the last time they tried to assert their right to be the people they are and to live by the culture in which they believe? What are the options for a young Indian person today? Try to stand up for your rights and eat shit (again)? Massacred by the U.S. military (again!?). Keep your mouth shut and don’t cause any trouble, work crappy low-income jobs on the rare occasions that there are any jobs at all. You’ll get by for a while, you’ll survive…sort of. Not for long. Life expectancy 48??!!???!!! What kind of deal is that?? When I was a kid, this would be termed a real “screw job.”

    If you’re a “good” “hang-around-the-fort” type Indian, some racist who is getting rich by destroying Indian people and culture will make sure you get access to drugs and alcohol along the way. Think White Clay, Nebraska. How are those liquor stores still there on the southern border of Pine Ridge? Guarded by Nebraska State Troopers in riot gear. Wow. Someone is really out to destroy Indian people, to obliterate all traces of Indian ways of life from the face of the earth. It’s time we woke up and dealt with reality, because reality is dealing with us!

    The Armenians seem to have largely recovered from their holocaust. Jewish people are doing all right, and their holocaust was so recent that I’m friends with some of the survivors. Where do the Armenians and the Jewish people fit in the ACE questionnaire box? They don’t, apparently. The difference is that their Holocausts ended. American Indians are still in the thick of it. To a worse degree than any other group in the U.S., their rights have been blatantly stolen, their property has been stolen (billions a year via the BIA). The past is less important than the present–and at present, everything Indian has been pummelled, continuously assaulted for centuries, and stolen by the United States.

    So for the United States to send therapists into Indian country, with European or Euro-derivative (U.S., Canada, Japan) therapies is, in my opinion, wrong. “It’s all because of those bad mofos in history, we didn’t do anything, and furthermore there’s not really anything we can do.” That sounds to me a bit like the new party line. Bullshit. Fix the present. It doesn’t help to blame Chivington or Washington or Lincoln or Jackson or any of those other dead people. They were horrible, they broke every law of “human decency” (what’s that again?), they broke every U.S. law, they violated their own Constitution to keep the loot flowing out of Indian Country. But guess what–they’re dead. Have been for a long time. Let’s deal with NOW. Let’s deal with the mofos of today. I’m not sure some group therapy sesh about terrible events of 150 years ago is going to help much, when you leave the session and step out into an insane upside-down heyoka world where known liars rule, where greedy hoarders are treated with honor and respect, where every official statement of, say, the U.S. “intelligence community” is a lie. I’m not making this up, I have proof. No room to get into it here.

    Education has been eviscerated and mangled beyond recognition and the result, on purpose or not, is that nobody knows their rights. When American Indians were declared to be U.S. Citizens, in 1924, they acquired the rights of U.S. citizens. This was a double-edged sword. I’m not sure the idiot functionaries (“politicians”) of the time had any idea what they were doing.

    Among the rights of U.S. citizens which Indians acquired was the right–actually, the OBLIGATION–to correct the government by whatever means necessary when the citizens believe their rights have been violated. I wonder how many of us feel our rights have been violated lately? Can I get a percentage here? Anybody heard of the Patriot Act?

    At the end of the Revolutionary War, American people had thrown out the legally constituted British government, and seized all the rights for themselves. The citizens had fought for, and won, ALL rights. There was no real “government” and it had no rights. A grip of movers and shakers got together and tried to figure out how to make this work. Certain functions would go smoother if the bureaucrats didn’t have to ask all the people about every little detail. So the movers and shakers agreed that for convenience, and to help business run smoother, the people would grant certain rights to the administrators. That’s why, today, the government has only the rights that have been granted to them by the people, authorized by the people, and these government rights or prerogatives can be revoked BY THE PEOPLE at any time they believe they have become oppressed.

    So at the close of the Revolution and for some years after, representatives of the people got together and formed committees of functionaries and petty bureaucrats (now called politicians), to handle necessary functions like sewers, roads, shipping, international defense, etc. (the “government”). But the American citizens retained the right to disempower and change the adminstration ( or government) any time the functionaries began to overreach and take rights belonging to the people. Didn’t T. Jefferson say America needed a new revolution every 20 years?

    My family is sons and daughters of the American Revolution (though we never bothered joining any dorky club by such names). What American who believes in freedom and personal liberties would join a nerd.org that wouldn’t let an American citizen–a world-renowned singer–perform in their ornate hall because the nerds didn’t approve of her skin tone? These are not revolutionaries. I’m not a joiner.

    My point is, we did not fight a revolution and throw out a king so that we could “elect” a new king and his/her entire retinue every 4 years. How did this clown-car circus routine ever work it’s way into the mix? Trying to choose some important bureaucrats here. The function of the government is to take out the garbage, not to host 3-year “election” extravaganzas that never lead to any better garbage removal. The petty functionaries that are supposed to make sure basic needs are taken care of in American society are living like delusional royals on our nickel, while working not for us but for their financial backers. Somehow the English language has become so perverted that bribery and influence peddling–crimes that functionaries/politicians went to prison for when I was a kid–are now called “lobbying” and are treated as if it’s legal. It’s not. It’s a billionaire’s game–sorry you’re not one–and the list of billionaires who have bought the U.S. govt. includes many people who aren’t even Americans. For example, CEOs of foreign corps who use their companies’ billions to buy our government, and push their interests and their interests alone. Free trade ain’t free. Very expensive for you and me, for the mountain Mayans in Chiapas, etc. Remember “No taxation without representation”? I asked some recent college graduates–they never heard of that. It’s not taught in school any more. Nobody in government has represented me for decades. How about you? Based on the total lack of rational and logical arguments out there, it’s clear that few people have any idea what government is, why it exists, or what it is supposed to do.

    Your article begins to scratch the surface of a HUGE can of worms. Current measures being discussed and proposed are generally light years from any true and logical solution. Let’s bust out some band-aids, we got a serious heart attack going on over here. Yeah. We all see the way it is.

    We the People–Indians and non-Indians, all of us, together–WE have all the rights. Why aren’t we asserting them? Nobody from either “party” is going to fix this. They’re just going to keep grabbing all the rights and privileges and money (our money, by the way) they can get their hands on. Besides, fixing the fiasco they created isn’t going to be done by the people who created it, obviously. Why should they? They just don’t get it. They’re partying, they’re making money, they leave political office in order to become millionaire lobbyists. They’re doing fine. Besides, fixing a completely dysfunctional government is not the functionary’s job. We’re the ones who need to wake up. Like any bully, the functionaries and their nerdly minions are real kiss-asses when the heat is on, they fold and panic the moment they see we’re serious. And why shouldn’t we be serious? Why give up when you’re right? It’s not anyone else’s job to fix it. It’s our job.

    Bayard Johnson

    Santa Monica, California

  2. Chesie Lee October 20, 2015 at 9:15 am #

    Great story and much needed story to be told. Thanks!

    Chesie Lee

    Riverton, Wyoming

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