Getting it just right
UND’s M.D. Class of 2027 makes history by electing the nation’s first Indigenous President and Vice President
Set in and around an American Indian reservation in rural Oklahoma, the FX television series “Reservation Dogs” follows a group of Indigenous teens as they explore their cultural heritage, argue with their parents, and navigate the alternatingly exasperating-lifesaving Indian Health Service (IHS) clinic nestled within their small east Oklahoma town.
On this last, says Ross Ogden, an eastern Oklahoma native and first-year medical student at the UND School of Medicine & Health Sciences, the program gets it “just about right.”
Confessing to having spent his share of time in more than one IHS clinic in Oklahoma over the years, the new President of the M.D. Class of 2027 finds the depiction of Indigenous health and healthcare in his state insightful.
Nodding in understanding, first-year student Reese Siegle, Ogden’s Vice President and fellow Oklahoma native, agrees, calling the depiction of the IHS by a television program written, produced, and directed by Indigenous filmmakers and featuring an all-Indigenous leading cast almost unsettlingly spot-on.
“As far as IHS, yeah, pretty accurate,” Siegle laughs of the award-winning show, in which several characters work in healthcare and social services. “I’m the product of an Indian Health Service nurse and public health service physician, so I remember lots of stories around the dinner table about working in public health service and Indian Health Service. They had to get really creative about how they took their care to people.”
Education and history
Much like Sterlin Harjo’s and Taika Waititi’s team-produced television program, Ogden and Siegle are making history in a largely rural setting. The two Indigenous medical students, members of the UND’s Indians Into Medicine (INMED) program, are the first-ever American medical college class administration whose President and Vice President are both enrolled members of one of the 574 federally recognized American Indian tribes.
That fact matters as much for the education and training of the pair’s classmates as it does for public policy and Indigenous health broadly, suggests Siegle, who notes that patient care and policy have always gone hand-in-hand. Describing how the American government agreed to provide Indigenous communities with “relief of distress and conservation of health” in the Indian Citizenship Act of 1924 (also known as the Snyder Act), Siegle recalls how little most of his classmates know about the history of American Indian health policy.
“The first week of class we had PCL [patient-centered learning group], and it was an American Indian patient we were working with for the case,” says Siegle. “When I brought [the Synder Act] up to my classmates and showed them the treaty, the trust responsibility, and exactly what the federal government said it was going to provide – and then the relative lack of funding today for IHS – my classmates were angry. It was encouraging to see them get upset at this fact, knowing that they’ll carry this knowledge into their practices.”
This opportunity to educate not only their fellow providers but their future patients on the social and political determinants of health is what gets the new administrative team most excited.
“The main thing is education,” says Ogden, the child of a teacher parent and grandparent, who spent three years doing epidemiological work for the Cherokee Nation after earning his Master of Public Health degree. “My first day here, somebody asked what brought me to UND, and I told them INMED. And they said ‘What’s that?’ I was a little shocked at that. But like Reese said, we’ve had the opportunity to bring up ethics in medicine and other scenarios in our PCLs. So, I hope to help educate people. And I want to draw from different peoples’ backgrounds as well, because I’d be doing a disservice to myself not to learn from others.”
From IHS to tribal health
Both Ogden and Siegle note that their focus on education is the natural result of having watched education work in their home communities during and after the SARS-CoV-2 pandemic.
Describing being on the front line of the pandemic as it hit Oklahoma, Ogden recalls the day – March 24, 2020 – the first COVID patient was recorded with Cherokee Nation, and how his work changed immediately.
“Early on in the pandemic, my team at Cherokee Nation created a COVID dashboard for all of the public,” he says. “I created a testing calculator based on multiple factors such as exposure date and presence of symptoms, which helped people know when they should get tested if they were exposed. Most importantly, we set up a COVID hotline for people to call if they had questions. This hotline allowed first language Cherokee speakers to call and ask questions as well.”
All of this helped curtail the pandemic in Oklahoma, says Ogden.
“I was also really impressed with my tribe’s response to COVID,” adds Siegle. “We were able to develop the first drive-thru vaccine clinic in the state of Oklahoma and got most of our community vaccinated. In rural Ada, Oklahoma, we had better vaccination statistics than other rural areas. And I attribute that to education.”
Even so, improving health education, whether on or off the reservation, only goes so far, says Siegle, insofar as improving health outcomes still requires considerable financial resources.
“When you look at all the statistics and social determinants of health, not only are most ‘sicker’ people from rural and underserved areas, but they come from more financially disadvantaged backgrounds,” he says. “That was something we talked about a lot at the dinner table growing up, because we saw increased risk for things like hypertension and diabetes in Chickasaw Territory. We saw that in rural Chickasaw country, especially during COVID where you would have a patient that needed a ventilator and didn’t have access to that because there just weren’t enough.”
Ogden agreed, adding that during his years as an epidemiologist he documented the direct correlation on Cherokee Territory between chronic conditions like diabetes, hypertension, and chronic kidney disease and COVID patients’ likelihood of ending up in intensive care.
“Having any of those comorbidities and getting COVID significantly increases your risk of being intubated or getting sent to the ICU,” he says.
All of this is why increasing tribal resources and reducing poverty in general is so vital to improved health outcomes. It is also where the tribal health model comes in, the pair says.
Noting how the IHS funding model remains similar to what it was in the 1970s, even after the Patient Protection and Affordable Care Act reauthorized the Snyder Act in 2010, Siegle says that the shift away from IHS and toward tribal-run health systems has been forced by a financing structure that still pays only around $5,000 per tribal member annually, relative to the Medicare and Medicaid payments of more than $12,000 and $7,000, respectively, per enrollee in Oklahoma (fiscal year 2020).
In other words, it’s a funding model that may no longer work for most tribes, Siegle suggests.
“Simple procedures cost hundreds of thousands of dollars, and you put that burden on an entity that is still funding every patient at about $5,000 a year for healthcare?” he asks rhetorically. “Tribes are having to go out and figure out a way to take care of their people through other means.”
In the absence of an improved funding model, the shift to tribal health “is something that’s going to happen,” concludes Siegle.
For many tribes, it already has.
“The Cherokee Nation bought out our contract with IHS and we are now the nation’s largest tribal health system,” Ogden adds, explaining how the move allows his tribe to have more oversight of its health programs. “That allows us to have our own resources and our say over how we want to spend our money, instead of being told by the federal government ‘You can only spend this much here or only this much there.’ That’s the opposite of sovereignty.”
‘How good of a doctor she would have been’
Part of that sovereignty includes producing more Indigenous health providers, of course, which is where UND’s 50 years-young INMED program enters the picture.
A longtime IHS nurse, Siegle’s mother had at one time considered becoming a physician, he says. Unfortunately, the lack of support for Indigenous students looking to study medicine decades ago kept her away.
“She was always told that she should have gone to medical school, but she didn’t really have the support to facilitate a medical education,” Siegle explains. “If she’d only heard about INMED and about people like (INMED College Coordinator) Kathleen Fredericks or (INMED Academic Advisor) Yvette LaPierre – those people who will literally say: ‘If you’ve got kids and it’s exam time, I’ll babysit your kids,’ or ‘If you pop a tire, give me a call and I’ll give you a ride.’ It was that INMED family component that got me here.”
Calling such supports huge for Indigenous students, some of whom have never been to a city as large as even Grand Forks, N.D., Ogden echoes his veep in a desire to share the news of UND’s INMED program far and wide.
“We definitely want to spread the word about INMED,” he says. “As a kid from rural Oklahoma graduating from eighth grade with eight classmates, I never imagined I would be sitting where I am today. Young Indigenous kids need to know these opportunities exist so they might be able to chase a dream of their own.”
“I look back and think, man, if my mom had heard about this, how good of a doctor she would have been,” muses Siegle. “Because she didn’t know about it, she didn’t go to medical school. But imagine the impact she would have had if she did.”
