The next 50 years
UND’s first-of-its-kind Indians Into Medicine program celebrates a half-century of cultivating Indigenous health providers.
Collecting her thoughts, Dr. Adriann Begay frowned slightly as she reflected on the challenge of being a health provider for the Navajo Nation in 2020 and 2021.
“It was really, really stressful,” she sighed.
Recalling the difficulty of those long months, Begay described how the high COVID-related hospitalization and mortality rates among the Indigenous population in New Mexico and Arizona not only ended lives and undermined Indigenous culture – “What really hit me was when we had to create two more teams [to manage the bodies],” she said, “because our mortuaries here were full” – they cut into decades of work by her and programs across the country that have been working to bolster the Indigenous health workforce.
“A lot of our IHS [Indian Health Service] staff retired after the pandemic,” said the Arizona native, family physician, and former hospital administrator from Gallup, New Mexico, explaining how isolation and what felt like endless trauma from illness, deaths, community lockdowns, fear, and a relentless increase in COVID numbers at many IHS clinics and hospitals led to staff burnout and frustration. “Many staff – from physicians and nurses to other allied health professionals – decided to retire or resign due to burnout or to protect their own families as their risk of infection was higher than normal.”
Provider retirement is only one side of the coin, continued Begay. Just as concerning to her in 2023 is the fact that since she took her medical degree from UND in 1997, with help from the University of North Dakota’s historic Indians Into Medicine (INMED) program, the percentage of American Indians both matriculating into and graduating from American medical schools has “flatlined” – despite the growth in university-based Indigenous health programs across the nation. One Association of American Medical Colleges (AAMC) report from 2018 noted, for example, that between 2006 and 2017 the proportion American medical school matriculants who identify as American Indian-Alaska Native (AI-AN) dropped from 0.4 to 0.2 percent.
These two factors – the resignation of veteran providers at all levels and the peaking of Indigenous health students – sets up a frightening future where a growing Indigenous population finds itself with fewer Indigenous physicians and other providers on average than it saw in the 1980s and 1990s.
“After the pandemic there’s been a lot of emotional and mental strain on the [Indigenous] community and we need to help individuals access services,” Begay added. “It’s been tough.”
The political determinants of health
All of this is a result less of the social determinants of health that have contributed to lower life expectancy significantly among Indigenous Americans relative to their non-Indigenous colleagues, said Begay, than the political determinants of health.
“The political determinants of health are really the foundation of the social determinants of health,” the physician continued, describing the structural and policy-based factors that affect population health, from voting access and policy development to political representation and the distribution of power and wealth in societies. “The Indian Health Service came out of an infectious disease model and the legislation that our healthcare is dependent on. It’s all politically-based. It’s really that simple.”
Although this notion of the “political determinants of health” was given a refresh in 2020 following not only COVID but the Daniel Dawes book of the same title, it’s really nothing new. In fact, the concept was arguably what drove the founders of the world’s first comprehensive Indigenous physician program at UND more than five decades ago.
UND’s INMED program turns 50 years young this year. This feat is even more incredible given not only the cultural and political challenges the program has faced over the years, including budget cuts, occasional state and federal questions concerning its efficacy, and even the waxing and waning of support from some Indigenous tribes, but the socioeconomic challenges that still affect the majority of its target population.
Here INMED is in 2023, though, said current INMED Director, Dr. Daniel Henry, looking at year 51 with fresh eyes and new motivations.
“For the first 50 years we saw that it can be done,” Henry said, marveling at his program’s scrappy history. “Now this next 50 years we need to start developing our own community clinics, filled with not only INMED doctors but nurses, specialists, administrators. I think that’s what the INMED brand can focus on – reservation hospitals that are 100% Indigenous.”
INMED at UND: A brief history
It’s a bold vision that sounds daunting – but doable. After all, said Henry, the program’s first 50 years was arguably an even harder lift. And look where INMED is today: nearly 300 Indigenous physicians to its name and more than 300 graduates representing a half-dozen other health professions.
Such grads include not only Begay but Dr. Lionel DeMontigny, INMED’s first graduate who went on to serve as director of Community Programs for the IHS; Bernard Long (P.T. ’83), who worked at IHS as both a physical therapist and an administrator; Monica Mayer (M.D. ’95), a U.S. Army veteran who became the first female physician to serve on a tribal council (Three Affiliated Tribes) out of all 500+ federally recognized tribes in the U.S.; Kayana Trottier (D.P.T. ’21) a physical therapist practicing in rural North Dakota; and Michael LeBeau (M.D. ’02), who serves as vice president and chief of health services operations for Sanford Health.
For Twila Martin Kekahbah, such outcomes were far from certain in 1972-73.
“When I started [at UND] there were only three identifiable American Indians in attendance,” Kekahbah told North Dakota Medicine over the phone from Belcourt, N.D., in 2019, describing how she and a handful of other intrepid Indigenous men and especially women – Art Raymond, Phyllis Old Dog Cross, Connie Jackson – drafted up a program designed to both recruit Indigenous students into medicine and help prepare them for medical studies even before they got to college. “We wanted to show our people what a brown person in a white coat with a stethoscope looked like and what they could do.”
An enrolled member of the Turtle Mountain Band of Chippewa, Kekahbah (B.S. ’72) understood both the socioeconomic and cultural difficulties American Indians faced in trying to engage formal health education and allopathic hospital systems, and the need to change the political structures that kept many American Indians from higher education.
So she and her group brought their idea to then-Chair of the UND School of Medicine & Health Sciences Department of Family & Community Medicine, Dr. Robert Eelkema (BS Med ’59), and former UND President Tom Clifford.
Both men were on board immediately.
The administrators assembled a team to write an initial INMED grant, which Eelkema, who died in 2021, submitted to a federal agency then known as the Office of Minority Health Manpower. Along the way, Eelkema and his allies – including DeMontigny – lobbied former North Dakota senators Quentin Burdick and Mark Andrews on the value-add to North Dakota of a program that would recruit, train, and graduate AI-AN students into the health professions and send them off to practice on reservations and underserved rural communities in the state.
“We knew we had to encourage science and enrichment programs for grade schools and high schools, so we developed a program that incorporated extra help in schools on reservations and brought students in for a summer program,” said Eelkema in 2019, noting how representatives of more than one federal agency “decided to come and visit us to see what we had. So we took them to the reservations – Spirit Lake and Belcourt. They supported the program. And we had a great president in Tom Clifford. He said, ‘It works – we’re gonna fly with it.’ So we put it all together and got the first grant.”
Hiring UND family medicine residency grad Dr. Lois Steele away from Dawson Community College in Glendive, Mont., the group soon had a director and got building.
And so the program grew – at least for a time. Despite producing hundreds of Indigenous physicians and scores of Indigenous physician assistants, occupational and physical therapists, medical laboratory scientists, and public health professionals, INMED saw a $600,000 cut in its operating budget in 2006 after the U.S. Congress cut the Health Care Opportunities Program, one of two federal programs that had been keeping the program afloat.
This is what Begay meant when she referenced the political determinants of health.
“We went from nine employees to four,” Eugene DeLorme, INMED director from 1994 to 2017, told North Dakota Medicine in 2019. “But we carried on with the same program and burnt ourselves out trying to do the same workload as nine people.”
An attorney by training, Delorme called the cuts devastating, admitting nonetheless that after a re-group, his team soldiered on, if for no other reason than to get to “watch that seventh grader cross that stage and get their M.D. degree. That’s when they first came to us, seventh grade. And they went through all five years of Summer Institute and did undergraduate and medical school at UND. So that was a pretty special day.”
INMED’s Student Advisor, Kathleen Fredericks, remembers those days well.
“We had study hall, prepared meals on occasion, and had more events,” explained Fredericks of the time just after Begay would have been at UND and referencing the art show, student organization, and annual powwow that INMED at one time sponsored. “This space was truly a home away from home for these students. It was very supportive.”
A 21-year veteran of the program, Fredericks today oversees the advisement of undergraduate students looking to enter the health professions. And as Fredericks’s colleagues suggest, even if INMED no longer makes fry bread for students, its significance hinges on its status as a second home, which increases retention and graduation rates for American Indians, some of whom had never set foot off the reservation before their Summer Institute session or freshman year at UND.
This is what Begay remembers best about the program.
“The biggest thing I received when I was going through med school is peer support,” she recalled. “Even far away from home, I still had other Navajo students to help me, either talking the [Navajo] language for a little while or sharing stories about back home or cooking meals together. I wouldn’t have been as successful and probably would have had mor academic obstacles if I didn’t have that support around me.”
The next 50
Having recovered some since the cuts Delorme managed, INMED – which in between Delorme and Henry saw interim director Dr. Joycelyn Dorscher and director Dr. Donald Warne – has found itself the recipient of different federal dollars, new grant funding, and multiple donor gifts. The next step for INMED, said Henry, is building as many multi-generational Indigenous medicine families as his team is able.
“We don’t have much of that in Indigenous country – yet,” Henry said, referencing the Turtle Mountain-based father-daughter doc combo Gilbert Falcon (M.D. ’09) and Emily Falcon (M.D. ’22) and father-daughter physical therapist combo Eugene Monette (D.P.T. ’05) and Winter Monette (D.P.T. ’21). “We do have our traditional and holistic medicine people who are usually part of a clan or a family, and we need that now with western medicine.”
Although it’s too early to know if her children might take an interest in medicine, South Dakota native and INMED grad Dr. Arna Mora understands this need for playing the long game, having started with INMED as a seventh grader in 2004 and graduating with an M.D. degree in 2022.
“I can still hear the words of support that provided me a sense of validation from Kathleen, Dr. Delorme, Dr. Warne, and Dr. Dorscher,” Mora said of her 18 years of contact with the program. “The staff at INMED remind us that although there are unique challenges that come from having a large sense of extended family or being from communities with longstanding hardships, there is more we can do, more support we can give others.”
Having interfaced with INMED since she was a teenager, Mora, a Lakota Sioux woman who has lived on several reservations over the years, echoed Begay in noting that the community INMED built makes all the difference.
Explaining how she chose UND because she knew she would have “not only academic support with as-needed tutoring and the Med Prep program [a summer program for American Indian college upperclassmen and graduates preparing to take the Medical College Admissions Test], but also personal support to help navigate developing a new sense of work-life balance with a demanding study schedule,” Mora said that while it was challenging, moving from South Dakota to New Mexico to North Dakota was worth the effort.
“There are many individuals who really helped make UND a home away from home, which can be important when you need to live farther from your family while also taking on a relatively intimidating career path,” she explained. “Though difficult, it was a great experience. It is really a different level of support. I knew some of the staff since 2004, such as the woman my kids called ‘Grandma Kathleen.’ I have spoken with many people who felt the same, who’ve said, ‘I came here because of Kathleen [Fredericks]’ or ‘Susan [Holden] always makes my day.’” [Ed. Note: Susan Holden is today in the SMHS Office of Research Affairs.]
Such connections are what make a program work, added Henry, explaining how INMED now even embeds Indigenous language study into its program.
“Wherever our students go – whether Turtle Mountain or maybe a reservation in Montana or even down in Arizona – we really want them to be able to use these tribal connections, in part by using their language,” said Henry. “Even if it’s on your own reservation, knowing the traditions, knowing the people, but also being able to speak with patients in their language – even if it’s just saying ‘hello’ – is big. We’re doing that right now with UND’s Department of Indigenous Health.”
This is why, summarized Danielle Thompson, INMED’s program manager, that the program’s future remains bright: applications to INMED at UND are up in 2022-23. Thompson noted that her program saw a record number of both medical applicants and interviewees over the past year. This increase mirrors the rise in applications other Indigenous programs at the School have seen over the past two years, including for the world’s first doctoral program in Indigenous health.
The record level of engagement is the result of many factors, said Thompson, including a lot of hard work by INMED and other UND staff on recruitment and outreach.
“These figures indicate the success of the many INMED ‘prep’ programs like Med Prep and the Summer Institute,” she said, referencing the six-week academic enrichment session for precollege students interested in exploring careers and fields of study in healthcare. “The ongoing work to address and correct the disparities in access to medical education is going in the right direction.”
Hopefully such figures help Begay rest a bit easier. For her part, said Begay, even though her own children didn’t take on medicine as a profession, she is nevertheless working on recruiting the next generation of Indigenous providers in a different way.
“I have two grandchildren: one who is a junior in college, a pre-med major, and one who is in high school and wants to be a surgeon,” Begay laughed, wondering, tongue-in-cheek, if maybe such interests skipped a generation.
“We still have some individuals in Native communities who don’t trust some of the [non-Indigenous] providers,” she concluded. “It’s not their fault. Thinking about historical trauma and having people be aware of our history and the impact it has on our current health status – you want people to have an understanding of why things are the way they are. And if you have more Native providers – nurses, doctors, and mid-levels – you can instill a level of trust there since [providers] already have an understanding of the community that [the patient] comes from and has gone through that.”
Building that trust, Begay said, is a task for the next 50 years.