Presidential Podcast: Episode #10

On this week’s episode of the UND Presidential Podcast, Interim President Joshua Wynne sits down with Associate Dean Dr. Don Warne, director of the Indians into Medicine program (INMED) and the Public Health program at the School of Medicine and Health Sciences, as well as Dr. Nicole Redvers, assistant professor in INMED. The three talk about the spread of COVID-19 and the challenges the novel disease presents for underserved communities. They also discuss the newly unveiled Indigenous Health Ph.D. at UND, which is already garnering interest from across the nation.

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Prefer to read it instead? Here is the full transcript, which has been slightly edited for clarity:

Wynne: Hello once again, I’m Dr. Joshua Wynne, Interim President of the University of North Dakota and Dean of YOUR School of Medicine & Health Sciences.  I’d like to welcome you to another informative episode of the UND Presidential Podcast.

As always, I want to thank you for your time and your listenership and for welcoming me into your lives from time to time for these important updates.

We have received a lot of positive feedback from listeners about our previous episode in which I interviewed incoming UND President Andy Armacost. We plan to do more of that kind of thing moving forward –bringing in interesting guests and discussing important topics.

Speaking of, I am happy to welcome – not one but two guests – for today’s show. And I am especially proud to say that they are people I have gotten to know quite well as they continue to do amazing things at UND and in the School of Medicine & Health Sciences. They are Associate Dean Dr. Don Warne, director of UND’s Indians into Medicine program as well as our Public Health Program; And Dr. Nicole Redvers, an assistant professor in the Indians into Medicine program.

Dr. Warne, Dr. Redvers, thanks for joining us today!

Warne: I think one thing that’s important to keep in mind is that it’s a rapidly changing issue. So as we sit here and talk this morning, on a Wednesday, or I’m sorry, on Tuesday, we could see very different numbers by next week. So it really is important to recognize that it’s an evolving issue. Coronavirus is one of a family of viruses that cause upper respiratory infections at various levels of virulence or severity. So with Coronavirus, some people get very mild symptoms like a common cold. For others, it can cause severe acute respiratory syndrome and actually can result in pneumonia and even death for those who are severely affected. Internationally, there’s been thousands of cases and hundreds of deaths. It started in Wuhan, China but it’s spread all over the globe as we know. So, there’s severe outbreaks in places like Italy and in Iran. But we’re also now seeing cases here in the United States. As far as the numbers in the United States, actually, as of Tuesday morning at 10am or so, we’ve had about 650 cases of Coronavirus here in the US, and about 20 deaths. And I think these are very much underreported because we’re just now getting testing out into the field. In terms of North Dakota, again, as of this morning, the numbers could change by the time you’re listening to the podcast, but as of this morning, we’ve tested five people in North Dakota who were symptomatic, and so far four of the tests have come back negative and we’re waiting on the fifth. In truth, from a public health perspective, it’s just a matter of time with how much travel there is and people going back and forth to various parts of the country, various parts of the world in which there is exposure. My sense is we will see COVID-19 here in North Dakota. We just have not identified cases at this moment.

Wynne: You know, one of the interesting things about the COVID-19 experience, at least from what we understand so far, is that unlike influenza, which it resembles in some regards, the most severe effects of it have been in the elderly and people with underlying medical conditions. Now, that’s true with influenza too, but what is seemingly strikingly different is that COVID-19 is not as bad, if you will, in the younger people, and particularly in neonates, infants and young children. And I don’t think we understand why that is, but at least for me, as a grandfather, I find that very reassuring. Any comments from either of you about that observation that appears to be true? Any comments?

Warne: Well, immunology is a very interesting science to study. We don’t understand why it is that children are not as severely affected as adults from COVID-19. We don’t really know yet why that is the case. But what the data are telling us is that children if they are testing positive, they have more mild symptoms. Adults, particularly over the age of 60 are the ones who are at the greatest risk for bad outcomes. But also at any age, if you have an underlying health condition, lung disease, heart disease or immune compromise, I should say, then you’re at a higher risk for bad outcomes. But exactly why it’s not affecting children to the same degree, we don’t know. But we do know here in North Dakota, particularly in facilities where we have a lot of elders congregated, that’s a really big risk for the spread of the disease.

Wynne: So, Nicole, are there unique challenges to managing information dissemination, prevention strategies and treatment methods for COVID- 19 as well as other conditions in underserved areas of the country and here in North Dakota?

Redvers: Absolutely. It’s a large concern with our underserved population. If we think about one of the most basic public health measures, which is simply washing our hands with soap and water to avoid spread, and we know in the United States generally that 58 out of 1000 households in Native American communities in specific do not have plumbing and running water comparatively to three out of 1000 in the white population. So this very basic public health measure can be very difficult for some of our underserved communities. We think about the homeless on the streets who don’t have access to bathrooms or regular hand washing and who are often congregated in large spaces.

Many of our Native American homes have up to two to three families within close proximity living with each other, including here in North Dakota and South Dakota as well. So overcrowding is a definite risk for infectious diseases as we’ve seen from previous outbreaks of things like tuberculosis. So ultimately, those measures become difficult, especially performed on low levels of health literacy that could also happen within our underserved populations. So I think, you know, we have some encouraging measures of the $8.3 billion that was appropriated from Congress for the COVID-19 spread. $40 million of that was designated for tribal health facilities, urban health facilities as well. So we are seeing some planning purposes with that, but definitely still concerned about the lack of ventilators and ICU beds within IHS facilities or Indian Health Service facilities, but also our rural communities as well. I’m also concerned about, you know, possible issues of discrimination, because if we have limited healthcare beds, and we have homeless populations or Natives or people of color, who’s going to get those beds? Those are all issues that underserved populations are going to be facing in the coming months and definitely concerns for sure going forward.

Wynne: Hearing you talk about some of those populations, I’m curious on a personal level if each of you could tell us a little bit about your upbringing, and your paths to where you are now as leading voices for American Indian health issues specifically, and public health in general. Don, would you lead off and then we’ll have Nicole follow up?

Warne: Sure. I’m originally from Kyle, South Dakota on the Pine Ridge Indian Reservation, so a very small town on the reservation. We have a three-way stop sign. That’s about as big as our little town is. But when I was in grade school, actually, my family and I moved to Arizona, so I spent most of my childhood and early adulthood in Arizona. I went to Arizona State University as an undergraduate, but I would spend my summers growing up going back to South Dakota. So I grew up just assuming that every kid went to South Dakota for the summer but it turns out that’s not the case. But it was a really wonderful way to grow up because I have a lot of uncles and other relatives who are traditional healers and medicine men. I was able to learn a lot about traditional medicine from a Lakota perspective. And I think growing up in that way, it kind of set a different framework for going into a field like medicine and having maybe a more holistic perspective on what health is, and the meaningful and valuable nature of culturally based interventions.

I kind of went into medicine with a very open mind, and I did well in college, so I wound up going to medical school at Stanford University. I did a residency in family medicine. I worked as a family doctor in Indian Health Service and tribal programs for a number of years. And my frustration, actually in primary care medicine in those settings is that almost everything I was dealing with was preventable. And we were not going to prevent diabetes, for example, in the hospital. That has to be done in the community. So that’s when I changed my focus to public health. And I was very fortunate; I did a fellowship in Minority Health Policy at Harvard. So I did my master of public health focused on health policy at Harvard School of Public Health, and that was back in 2002. So over the last nearly 20 years, I’ve been focused on working with indigenous populations in terms of health policy, public health programming, academics, research and other types of broader based interventions to try to improve outcomes.

Wynne: Yeah, so you know, it’s interesting. I also have a public health degree; mine from the University of Michigan. And, it was interesting for me as a physician – and the two of you as healers as well – to look at the contrast between dealing with an individual patient as well as the societal and community-based aspects of looking at a population and thinking about what we can do, not just individually, but on a wider scale. I learned a lot about a different perspective of looking at healthcare than just on a given individual. So I really appreciate your observations on that.

Nicole, what about you? What was your journey here? How did you come to UND and how did you become such a passionate voice for these population-based approaches that we’ve been talking about? Tell us a little bit about your background, if you would.

Redvers: Yeah. Thank you. I think Dr. Warne and I have very similar upbringings coming from very small communities. I was born and raised in a very small community in the Canadian north. I’m a member of the Deninu Kue First Nation from up there, a town of just under 400. And my family moved us when I was just in elementary school to be able to attend school within a community, a big town of 3500 people within the Canadian north.

Throughout those experiences I witnessed many of my family members and community members refuse medical care, refuse to go in for preventative visits, refuse to go in for any sorts of care. And it was just mind boggling to me the amount of mistrust that existed within some of our native communities towards healthcare services. It embodied this desire to create more opportunities for our people that were more meaningful and culturally based. So with that, I decided to do an integrative medicine degree, combining both Western and traditional forms of care. I practiced as a clinician for 10 years in the Canadian north. And what I found was that there was a greater uptake with the services because the philosophy of care merged more with the traditional worldviews and led me to work with a number of elders within our region to develop a federal charity called the Arctic Indigenous Wellness Foundation with the purposes of revitalizing traditional and indigenous medicine practices for the purpose of dealing with our suicide and addiction epidemics that we have across native country.

When the announcement came, and I know we’re going to talk about it soon with the soon-to-be Indigenous Health Ph.D., it was a very exciting opportunity to me. My MPH is through Dartmouth College and similar to the sentiments that we’ve heard today, that realization of the need of community-based health promotion activities is so important in our Indian Country here, but not only here but around the world as well. So I’m very excited to continue this very important work and ensure that the voices of indigenous peoples are continued at the platform that we can and continue the great work that needs to be done.

Wynne: In that regard, Don, you recently made a big announcement regarding indigenous health that certainly will have an impact in North Dakota, in this country and beyond. Can you break that news again here? What’s happening at UND that’s newsworthy?

Warne: Well, very pleased to announce that the State Board of Higher Education did approve our proposal to establish the first ever Ph.D. in Indigenous Health and that will be right here at UND. So the Ph.D. in Indigenous Health really is the first of its kind in the world. There are some similar programs in other parts of the world, in which they do interdisciplinary approaches and people can kind of touch on issues related to indigenous health. But our curriculum really is focused on developing the next generation of indigenous health specialists. So when we look at our challenges, we have all kinds of health disparities and issues related to poor health outcomes. And quite often, I think that the research community is so disconnected from the communities that need them the most, that we’re not even asking the right research questions quite often. So what we’re focusing on is the best of scientific methodologies, but also the best of indigenous methodologies, whether it’s research or evaluation or policy issues, or even leadership frameworks, and bringing those two worlds together.

What we’re hoping to build is community-driven research questions and a research portfolio that’s really directly addressing the needs from a community perspective. I think that quite often the research community is very good at addressing very discrete issues, but quite often, the issues that are unique to Indian Country and other indigenous populations are kind of outside the purview of what academic researchers are accustomed to addressing. So we want to bridge those two worlds and over time, have cohorts of doctorate-level trained researchers, program evaluators and administrators who really understand the depth of scientific perspective and the indigenous worldview as well as the needs from indigenous communities.

Wynne: Nicole, what’s the response been so far, as far as public sentiment and maybe more importantly, enrollment interest since the announcement that UND would be launching this first ever PhD in indigenous health?

Redvers: The response has been absolutely overwhelming, which just goes to show the desperate need of this type of program within the North American region. In the first week of us posting the announcement of the Indigenous Health Ph.D., we’ve had over 300 inquiries to the school. And as of right now, we have 45 active applicants within our system for 12 spots in our program. We’re going to have some difficult decisions going forward in terms of our enrollment. Our first deadline is April 1, the second one May 1. So sooner than a month, we’ll start to review applications to be able to narrow down our pool and I am very excited to accept our first ever cohort in North America of the Indigenous Health Ph.D. And we’ll have students on site here in July for their first on-site week session and then formal classes starting in September.

Wynne: Dr. Warne, talk some more about the team that you’ve been able to assemble here at UND that has made the launch of the Indigenous Health Ph.D. program possible.

Warne: Well, in addition to Dr. Redvers and myself, we have three other indigenous health scholars that we’ve hired over the last year. One is Dr. Siobhan Wescott, she’s Athabaskan from Alaska. She has her MD from Harvard, MPH from UCLA and has worked in pediatrics as well as working in cancer prevention and public health in general. We also have Dr. Melanie Nadeau. She’s one of less than 10 American Indians to have a Ph.D. in epidemiology. So she’s one of our epidemiologists, also has her MPH as well as her Ph.D. from the University of Minnesota. And finally, Dr. Ursula Running Bear. She’s from the Rosebud Tribe in South Dakota, has her master’s in sociology and her Ph.D. in clinical science and she’s also a methodologist and has tremendous experience in doing community-based participatory research. So, among the five of us, we have nearly 100 years of experience in indigenous health. So it really is unprecedented in terms of skill sets at the faculty level.

Wynne: Don, you and this new program were specifically called out by Governor Doug Burgum during his State of the State address here at UND as an example of the exciting things happening in higher education in North Dakota. You clearly have the governor’s attention. How can the new Indigenous Health Ph.D. program assist in healthcare workforce development here in North Dakota?

Warne: Well, when we look at the population in North Dakota, we know that the worst health status and the greatest health disparities are within the American Indian population. If we even just look at things like average age at death, it’s about 54 for American Indians in the state of North Dakota. Whereas in the non-Indian population, it is about 79. So we see about a 25-year difference in average age of death. The excess death rates and illness rates are largely preventable. So we really do need a renewed approach to addressing these challenges. And again, we can’t just keep doing the same thing over and over and hoping that we get a better outcome, right. We have to look at innovative ways to address these challenges.

With the PhD program here, we have a lot of students who are coming from North Dakota who are very interested in this program. And I would envision that eventually they become faculty members, researchers, tribal health administrators, even tribal college presidents I would envision in the future. And with the solid training in scientific methods and addressing community needs from a cultural perspective, I think we can start to develop new and innovative ways to tackle these health disparities.

And it’s not an issue related to just access to medication. I mean, for example, the issue of diabetes in Indian Country is not a lack of insulin in the pharmacy. That’s not the problem. There are so many other social determinants of health and other upstream components of health disparities that are not being adequately addressed. Even things related to historical trauma, adverse childhood experiences, the long-term impact of forced boarding school participation, and the intergenerational impact of those types of traumas have an impact on holistic health. So I’m really looking forward to this first cohort of students but then over the years, graduating multiple cohorts of well-trained doctorate-level indigenous health experts, who can then start to address these issues.

From an economic perspective, in truth, if we can prevent things like diabetes and prevent cancer, prevent heart disease, not only is that good for the community, it’s also good for the economy, quite honestly, if we have less people needing to use healthcare resources. That’s actually good for all of us. That’s good for the entire state of North Dakota. Investing now in preventing disease and promoting health equity is good for the individuals who benefit directly from better health status. It’s also good for the entire state.

Wynne: Well, we’re unfortunately just about out of time for today’s episode, but I’d like to thank Dr. Warne and Dr. Redvers for making this such an enjoyable and informative podcast. What you and your colleagues are doing and what is happening at UND in the field of indigenous health is truly exciting news. And we look forward to keeping an eye on the successes that are sure to follow. Thank you so much for all that you’re doing.

Warne: Thanks very much for having us.

Redvers: Thank you for having us.