Principles

NHI got its start in the fall of 2004, initiated by the request of a foreign medical student for U.S. programs in which she could work with AI communities. Our own struggles to find a similar summer internship years earlier, along with the aforementioned, inadequately addressed health issues of the AI population spurred us into action, and NHI into existence.

At initial meetings that brought together community leaders (health workers, ministers), a liason from the North Carolina Commission of Indian Affairs, and NHI coordinator Anthony Fleg, our group came up with the name of the project and developed four principles to guide NHI’s work:

Four guiding principles to NHI and its work

A gestalt of these four principles was that we would use health equity as our gold standard for our work, doing so through the “loving service” of community and student volunteers. While this does not fit neatly in a linear description of our raison d'être, it speaks to the circular nature of Indigenous culture in which all aspects of life are related, interwoven, and not always amenable to Western (linear) explanations.

            Health equity differs in three fundamental ways from the biomedical model that dominates the literature under the titles health disparities and health inequalities. First, the issue of our ethical stance. Disparities and inequalities simply denote a difference in health and disease, taking no ethical position on these differences. Health inequities, however, suggests that such disparities and inequalities are, by definition, unjust.

            Second, the scope of our work is critical to the ultimate success in eliminating differences rates of health and disease. Health inequities broadens the scope from the disparities model, which often focuses on a specific disease within a specific population, and instead seeks to understand the common inequities in health and healthcare that affect certain segments of the population disproportionately (See figure 2). We believe that this shift in language is critical if we are to address the underlying causes of health inequalities – we must recognize them as unjust and search for the root causes of the injustices across populations.

            Third, we must know what we are holding as our goal in this work. The biomedical framework points out the disparities/inequalities, but as a curse of its ethical neutrality, it posits no corresponding answer regarding the solution. NHI feels that health equity is a critical gold standard by which we must work, pointing to the goal of restoring justice by the elimination of systematic inequalities in health.

Framework is everything: An example illustrating the differences in the disparities/inequalities approach to the health equity approach, and the effect this has on the question asked, the intervention planned, and the endpoint for the intervention

First, it is important to understand that Indigenous culture values, above degrees and titles, relationships with others. Congruent with this, NHI could not expect to enter as a guest to these communities as an academic or volunteer program, but rather as a group seeking to build relationships, a group whose work was grounded in “loving service” and not merely intellectual interest.

In the same sense, we decided that this project would not simply be a “volunteer experience,” where volunteers are often treated as customers, asked to pay for their experience. We would instead use “loving service” as our funding source, and would invite volunteers to NHI to “pay” back through their energy and talents, through their loving service. We make it clear that because we are not in the business of having volunteer “customers,” NHI and its projects are not about us, the volunteers, but about the communities we partner with. This might be called the “tough love” side of our work!

Volunteers from the tribal communities offer meals and places to stay in the tradition of the hospitality of Indigenous culture while the NHI coordinators and interns offer their time and talents, sharing of their own cultures. Congruent with this philosophy, we invited each person into the NHI family as equals, forgoing a hierarchy of coordinators vs. interns, community members vs. students. The sincere friendships and cross-cultural connections that are made with this approach provide the support and foundation for our work.

The love we have for this work, for all the Indigenous communities we work with, the volunteers we are honored to invite into the NHI Family, and the larger community of those putting themselves on the line for justice, cannot be put into words. Your best way to see this is to let your heart speak, your ears talk, and to feel the power of this way of being.

1) Educating health professions students about health equity, about health inequities in American Indian communities and in U.S. society, and doing so within an interdisciplinary, holistic model of health

The work this summer goes beyond the immediate projects to which we are devoted. It is NHI’s responsibility, as we as your own, to try to understand some of the larger framework in which the issues you see first-hand occur.

 The health statistics for native people in the United States point to obvious disparities in health and health care (two separate entities), but it our job, as future health providers to dig deeper. Why are teen pregnany rates high? Why is the suicide rate high? Why is substance abuse a problem? Why is diabetes found in high numbers?

Beginning to answer these questions is the first step in beginning to visualize solutions to the problems.

2) Creating Tribe-directed sustainable health projects

Sustainability is critical element to NHI’s work. At the same time, it is one of the most challenging aspects of our work, seeing that most of us will not be in the communities we are working in after this summer.

It is not hard to prove that short-term interventions often are of little benefit to the persons or communities to which they are targeted. Health fairs, for instance, have proven to have little or no effect on a given population’s health (studied through the public health and epidemiology literature), likely due to the difficulty in making real, lasting changes from a one day event. So, we want to focus our work this summer on interventions that will outlive our time in the community, and therefore have real impacts on the lives of those citizens living there.

However, there is an added sense of urgency to this objective that is specific to the history of Native Americans. From the invasion of their communities centuries ago by Europeans looking for land and wealth, these communities have continued to feel the invasion, only at the hands of newer forces. Government and industry invading sacred lands looking for oil or uranium. Universities invading for material for scholarly works. Tourists invading for a simple “picture with the Indian”. The health field is often no better. Health workers, and the universities they work for, invade native communities under the pretense that they are there to help the community, but often leave as soon as they have the data they need and their study is completed. Native communities are now very wary of outsiders coming in claiming to have the health of the Native people as their first priority, having seen so many cases where this was not the case. This context makes our drive for long-term projects all the more important.

3) Fostering cultural exchange and sincere, loving interactions between all involved in the “NHI Family”

It is amazing when you think of how diverse the group of NHI volunteers and mentors are! If there was no agenda to NHI except having people of all races, ethnicities, and cultures come together to learn from each other, we would have enough to fill an entire summer! Given that we do have a lot to accomplish in a short amount of time, learning from each other in this way may be more difficult. However, this is a critical part of NHI, a part which you should take as seriously as your health-related work.

For those coming from out-of-state or even out of the country, imagine what an honor it feels like when you have someone come from afar to your home, to your community, simply because they want to learn about you and want to work with you on issues that matter to your people! Of course, you would be honored and would want to meet these people – your communities this summer feel the same, and want nothing more than to spend time from you and learn where you are from.

For those with host families, recognize that these families have graciously asked to do something they probably wouldn’t offer to their neighbor or even to their own family – that is, to join their house and live life alongside them. Sit with them, share with them, clean the house with them. Remember that your very invitation to stay with them means they want to learn from you.

4) Youth empowerment toward healthy living, becoming health leaders in their communities, and toward health careers

Empowering youth is a foundation of NHI for several reasons. First and foremost, we, as future health professionals, cannot underestimate the opportunity we have to inspire youth towards health professions. Native youth who may inspire to enter into the health fields often lack the role models and educational opportunities that allow them to follow through on their aspirations. The end result is a shamefully low percentage of American Indians in the highest ranks of health systems, even those serving their own communities. For instance, in the IHS, entire hospitals may not have a single doctor or administrator who is Native American. The downstream effects of this are quite obvious – Native communities are cared for by outsiders, persons lacking insight into the needs of the people and often lacking the motivation to fight for the good of the community at all costs. The remedy is equally obvious – WE NEED MORE NATIVE YOUTH BEING ENCOURAGED, INSPIRED, AND MOTIVATED TO ENTER THE HEALTH PROFESSIONS!

Secondly, it is important to remember what it means to be health educators. Educate comes from the latin word meaning “to shed light upon,” meaning that our education is our job is to simply empower those we work with to see what they can do for themselves to make good health a reality. In other words, we are not “giving health” but rather shedding light upon the ways and tools needed for them to create health for themselves.

With young people today, where most of our causes of morbidity and mortality are linked to our day-to-day choices – what to eat, whether to be physically active or not, what risky behaviors to partake in – it is of utmost importance that our education empower youth to take control of these choices and to make decisions which will lead them to healthy lives.