HIV/AIDS Rising Among American Indians and Alaska

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HIV/AIDS Rising Among American Indians and Alaska Natives
By Matt Pueschel
Posted: 26-Sept-2006

WASHINGTON—Some 1,000 Native American community representatives, and federal, state and local health officials gathered in early May in Anchorage to address concerns over the growing incidence of HIV/AIDS among American Indians and Alaska Natives (AI/AN).

Data collected by the Centers for Disease Control and Prevention (CDC) show that the disease is a significant and rising problem in the Native American population, said Frank Canizales, MSW, a management analyst and HIV/AIDS coordinator for the Indian Health Service’s Division of Behavioral Health in Rockville, Md., as well as a federal government advisory member for the conference planning committee.

“But if you’re looking at the diagnosis of HIV/AIDS among [AI/AN] in the year 2001, [it] was 9.5 per 100,000, and it went up to 11.1 per 100,000 in 2004. So, it’s increasing each year,” Canizales advised. “One of the things with the increase is [that] the size of the population is affected much more severely, because we have a small population to begin with. So it becomes more significant.”

According to CDC, although HIV/AIDS diagnoses of AI/AN represent less than 1 per cent of the total number of cases reported, when population size is taken into account AI/AN ranked third in AIDS diagnosis rates. In the 33 states that have long-term confidential name-based HIV reporting, women accounted for 29 per cent of the HIV/AIDS diagnoses among AI/AN. “Overall, surveillance data show that HIV/AIDS is a growing problem among American Indians and Alaska Natives,” CDC reported.

Canizales added that IHS has some problems with accurate reporting of HIV/AIDS. “There certainly is some resistance to being diagnosed in the clinics because of confidentiality, especially on the smaller reservations across the United States. A lot of tribal and family members work in the programs and there is the issue of [wanting] anonymity when you go in for testing,” he said. “That’s a concern certainly of tribal people. There is every effort in the IHS clinics to have obviously a secure confidentiality adhered to, but certainly there is a tribal perspective of misuse of confidentiality. It leads to issues of not being tested until later on when more severe reactions are occurring as a result of HIV/AIDS, rather than [getting an] early diagnosis.”

This has also caused clinicians to believe that CDC’s estimate might be low. “That number is very unimpressive because I know that the numbers are higher than that for people who are HIV-infected,” said Anthony Dekker, DO, associate director of the Phoenix Indian Medical Center (PIMC), director of ambulatory care and community health, IHS’s national chief clinical consultant for addiction medicine, and a member of the conference’s National Planning Committee. “You don’t get AIDS until you have had the infection for at least six to 10 years. And so if this wave that we are seeing right now of patients who are getting infected is not going to be detected until they are symptomatic, we are not going to see them until six to 10 years after they become infected.”

The emergence of HIV/AIDS as a significant problem in AI/AN appears to be somewhat of a surprise to those unfamiliar with the population. “It’s interesting, number one, we don’t have much data in regard to HIV in the American Indian population or the Alaska Native population, but we have very good data in regard to STDs [sexually transmitted diseases] and we have very good data in regard to substance abuse,” Dr. Dekker said. “If you look at patients in the American Indian population, they have very high rates of chlamydia—higher than any other ethnic group—and they have very [high] rates of other forms of sexually transmitted diseases. We do know that non-protected sexual contact is a significant issue in the American Indian/Alaska Native population. We also know that there is a very high rate of alcohol and [drug abuse] in the American Indian/Alaska Native population. There are many reasons for that, but what happens is that when you take a population that has had high rates of substance abuse and high rates of sexually transmitted diseases, [any population in the U.S.] also has high rates of HIV.”

Access to care, particularly in rural Native American regions, is another issue with HIV/AIDS treatment. “In most cases, the rural and remote reservations, if we have the tribal or IHS run clinics, transportation to and from the clinic is always a problem,” Canizales said. “And not just for issues of total health care. At any time, the preventive health care services are more difficult for our population to be able to address. Certainly transportation, isolation are key issues.”

Traditional Medicine
Canizales said the conference included a section on spirituality and healing. “There are traditional healers in different communities that do work with HIV/AIDS patients, and the medical doctors are becoming and are much more aware and supportive of sort of collaborative approaches in working with patients,” he said. “Many of our IHS hospitals have traditional healers that are there to work with patients, if the patient chooses to do that. IHS hospitals allow different tribal ceremonies to occur in the hospital setting if the patient chooses for that to happen and they are not able to get out from the hospital in order to receive these types of cultural healing practices.”

Canizales said the combining of traditional and western HIV/AIDS medicine practices is a relatively new concept. “I know of American Indian individuals that have been HIV/AIDS-infected for the last 20 years who have been receiving both, from traditional healers and the western medicine, and doing a combination of that,” he said. “If you consider that these individuals were on western medicine 20 years ago, which we had lost a lot of patients actually to HIV/AIDS in its first onset, that combined with a traditional healing, we still have those people with us. I think that it has and can be effective based on one’s beliefs and traditions, and combining it with western medicine.”

The form of traditional practice depends on the healer and the area. “It can be ceremonial, it can be herbal, it can be different types of herbs that different healers use, and all these are within the training of the healer and their background and their learned traditions,” Canizales said. “So they vary from tribe to tribe, and from area to area. You may have herbologists, you may have people who do ceremony, you have people who do combinations thereof. It would just depend on the individual healer.”

Testing For HIV
“I think that services are certainly provided, and treatment services are referred to IHS as of course a limited budget,” Canizales said of providing the most modern HIV/AIDS treatment to AI/AN. “[But] for instance, California does not have any IHS hospital. They have tribal programs and tribal health clinics that receive some IHS monies to operate the clinics. Other areas have their IHS hospitals and clinics that are staffed by IHS federal people.”

There is a significant American Indian population in California, despite the lack of IHS hospitals. “California has over 300,000 American Indians and Alaska Natives, [and] there are 116 federally recognized California tribes in the state,” Canizales said. “And those are just the federally recognized tribes, plus we have the largest urban population nationally.”

This creates a challenge. “Many people go to the urban areas, where they can do the testing anonymously, if they feel they need that,” Canizales advised.

Many times that is outside of the IHS system. “There are [also] urban Indian health programs out there that do the HIV/AIDS testing,” he said. “The tribal clinics, many of them can do the HIV/AIDS testing. They send it off to the labs and get the results. They have all of that on a contractual basis that they can work with the different labs and the hospitals in the surrounding areas. So, the accessibility to testing is there.”

If they do test positive, the next question becomes is the treatment available to everybody? “We are currently upgrading the data reporting system in the Indian Health Service to more accurately reflect current data collection. So that is moving forward in a positive fashion,” Canizales said.

Evolving Approach
Canizales’ appointment as HIV/AIDS coordinator of the behavioral health division was a new evolvement over the last several months. He previously had a position in the division, working with other federal agencies on the language of proposals that come out so that they allow AI/AN to apply for funding from different federal grants. In reorganizing the HIV/AIDS program, it was decided that the behavioral health division would play a significant role in working in the field, specifically since they had not had an opportunity in the past.

The relationship between alcohol and substance abuse, behavioral health and HIV/AIDS is significant in any population, Canizales said. “They’re certainly influenced and swayed within all populations, with the misuse of substances and alcohol that people become less inhibited and do things that they normally would not engage in,” he said.

Canizales said IHS has a number of treatment facilities for alcohol/substance abuse. “For adolescents, they are still looking at the data to determine the success rate of that, and we do have programs that also include single women with their children that are in treatment, and the children are able to be a part of that live-in treatment process,” he said.

Canizales said IHS and the tribes have treatment programs for adolescents throughout the country. There is even a treatment facility in Bethel, Alaska, which specifically focuses on inhalant abuse (such as gasoline), which is a problem in rural areas there. “And certainly there are problems with HIV/AIDS throughout Indian country, including Alaska,” he added.

The conference may have been a step to highlight areas of need in HIV/AIDS treatment in the AI/AN population. “I think one of the wonderful things that happened at the conference in Alaska was a clear coming together of Indian people acknowledging and recognizing that we can stay silent no more,” said Canizales, who is an American Indian from a California tribe.

“There was one [African American] individual [who] said, ‘the best way I can make an analogy of this conference is in the story [of] when the lion is approaching the village, we wake up all people in the village.’ And I think that is so significant in terms of our communities. The lion is in the village, and we need to wake up our people, and ‘we’ meaning the people who are in the village themselves [need] to take responsibility, and this conference really did reflect that. We had a large group of youth attending the conference who are themselves learning about HIV/AIDS and becoming more accurately aware of their critical role and assisting their peers, and fighting this disease and battling the issues of stigma, stereotyping and bias and prejudice that follows this disease, and not only in our communities, but nationally.

“There was also a clear response from many of the traditional healers in terms of their need to assist and continue to grow that and to share that knowledge, and the willingness of traditional healers to enter into fields that they may not have worked in before in terms of healing practices, specifically with HIV/AIDS patients. And so with this awareness, certainly grows strength and the ability for us as indigenous people to take on a battle within our own communities. The strength is in the communities, the strength is in knowledge, and the strength is in recovery. So, those types of issues were reinforced at the conference significantly.”

The Numbers
According to CDC, in 2004 about 1,506 AI/AN adults and adolescents were living with AIDS. Furthermore, of those who received a diagnosis of AIDS since 1996, AI/AN survived for a shorter time than Asians and Pacific Islanders, whites and Hispanics. “The HIV/AIDS virus is back on the move again forward and numbers increasing, and certainly in terms of their heterosexual population, looking at that, is also in the increase,” Canizales said.

Since the AI/AN population is young on the whole, it was important to have youth attendance at the conference. “We had a wonderful young lady, who is 16 [and] was born HIV/AIDS-positive, actually share at the conference, which was her first I think what we would call probably coming out with acknowledgment that she is HIV/AIDS positive, and then standing alongside her on the panel also was a person who was in their 40s who had had the disease for 20 years,” he said. “There was also a two-year old of a mother with HIV/AIDS who was born HIV/AIDS negative as a result of the medication and the traditional ceremonies being able to keep her viral load down low enough so that it would not affect the child,” he advised. “The fact that we had the 16-year old there saying that and other youth listening to this was a remarkable experience, and I think very humbling for us as older adults to be able to witness this circle of the disease, and yet the strength of us as a people to be able to share that among ourselves, and to both cry and laugh together in a very impacting conference.

“I think we all gained strengths that we came back with. It was a very different type of conference. [Some] people had been to many HIV conferences, but never one to the extent that this was in terms of open caring about individuals, the emotional commitment and the strength of individuals, it was just truly open and sharing throughout. We had over 1,000 people that attended this conference—monumental for Indian country.”

The conference drew attendance from both tribes and the federal government. “It was primarily tribal representatives,” Canizales advised. “There were not a large number of federal employees there. In fact, the planning committee that I served on for almost two years, the direction of the conference, the planning of it, really was one that was developed by design and a desire of the Indian people from organizations, tribal communities and tribal leaders nationally. It was not a government-designed conference. It was a people-designed conference, which was very significant. At the very beginning, the feds were asked actually to step out of the room and let them do their planning, which was a wonderful thing to happen in terms of self-determination. As a result of that, there was a very successful conference. In addition to that, we had a host committee in Alaska that was made of all Alaska Native individuals, not government officials, who did the local planning in terms of their part of the conference, coming to Anchorage. [There] was a two-hour cultural presentation in the performing arts center there in Anchorage [in which] Alaskan villagers came and did different cultural dance presentations. It was an incredible learning and sharing experience for all of us that were there.”

Tribal Compacting
“I think whether [IHS and tribal care capacity is] strong enough to stay with the new surge in HIV/AIDS awareness and acknowledgment is going to be determined by the tribes,” said Canizales. “As the tribes assume more responsibility for our own health care, I think we need to know first of all that certainly the [IHS] funding level is not at the level that it needs to be to be able to provide that total comprehensive health care services for American Indians/Alaska Natives, which is a major reason why we need to look at combined funding in order to operate health clinics across the nation. So, you look at multiple funding resources to make the mix and match of services. The [local] tribal programs and the health boards are the ones that determine health care services to their populations, and the emphasis on specific areas of health care are at the direction of the health board, generally, when you try to compact [care from IHS].”

An administration 2007 budget proposal to eliminate all IHS funding for urban Indian programs has also raised concerns. “There certainly would be a necessity to look at other resources. I think you need to engage in health care services,” Canizales said. “Some of the urban Indian health programs are already financed by multiple funding sources, including other federal grants, state and county monies, [but] some of the clinics are solely IHS-funded.”

Areas Most Affected
Canizales said IHS is conducting three behavioral health regional trainings this year. “We selected the three highest [prevalence sites] of HIV/AIDS in urban populations, and those are going to be Phoenix, Oklahoma City and San Francisco,” he said. “We will be doing another at least five regional trainings in the Indian Health Service, from a behavioral health perspective. These are two-day trainings, which include multiple federal agencies that deal with HIV/AIDS.”

IHS received funding for the second straight year to provide the two-day trainings. In addition to working with other federal agencies, IHS will also bring in traditional healers to each of the trainings to look at the utilization of resources within those urban areas. “We’re also providing training to the surrounding reservations and tribal organizations,” Canizales said.

IHS further works with a team in Albuquerque, N.M., involved in the epidemiology and study of the disease.

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Canizales said developing technologies such as the electronic health record and telemedicine have the potential to benefit HIV/AIDS care of AI/AN. “I think as we integrate more of the data into the system, and work with the individuals in communities in reporting procedures, that we’ll be able to utilize that more universally than we currently are,” he advised. “The other thing I think that is going to be really impacting or helping us successfully is the rapid HIV/AIDS testing, (or rapid oral swab; in 2002, FDA approved a HIV diagnostic test kit that provides results with 99.6 per cent accuracy in as little as 20 minutes. Using less than a drop of blood to reliably detect antibodies to HIV-1, The OraQuick test is made by OraSure Technologies, Inc., in Bethlehem, Pa.). That’s going to help reduce the time for testing results, and reduce the time in terms of health care intervention.”

The test is not yet in widespread use in IHS outreach efforts. “It is just beginning,” Canizales advised. “We’re working with SAMHSA to look at the rapid HIV/AIDS testing. Some of our sites already do that. Most do not. Part of our behavioral health training will include presentations about the readiness to do that, what the process is. Each of the states have different health care standards, and you have to meet those standards in order to be able to be a rapid AIDS tester site.”

The test could be done in mobile health units. “We also need to look very clearly about accounting services and supportive services as a result of any type of [test or diagnosis] that occurs,” Canizales said.

Treating a drug-addicted person who also has HIV/AIDS is a challenge. “My feeling is that those communities that have trained their community reps in that area of concern in health care are very good and very persistent with the patients that they work with and it depends upon the depth to which their training has occurred and the need within their communities [that] exists,” Canizales said.

On reservations such as the Ojibwe of White Earth, Minn., behavioral health care is a large area of need. The IHS clinic there essentially operates on just a 9-5 schedule, so the tribe’s own outreach services try to fill in the gaps and get out into the community to address people’s needs.

Canizales said IHS will sometimes have some mental health providers and licensed social workers on call in some reservations. “And then the tribal programs certainly have the flexibility, based on their own individual needs and their desire to deliver the health care services,” he said.

Urban Trend Leads To Risks
Dr. Dekker, whose opinions are his own and do not necessarily represent those of IHS, believes that health data on AI/AN is lacking because HIV is an epicenter disease. “If you live in Houston or Chicago or New York City, or Baltimore or San Francisco or L.A., and you have a high rate of STDs and a high rate of substance abuse, you most likely would have gotten infected,” he said. “If you live in a very rural area, you have minimal contact with the outside. The chance of getting this infection was low. But over the past 10 years, the Native population has become very mobile and so contact with urban communities is the rule, not the exception. Sixty per cent of American Indians now live in urban areas. We’ve created a high risk situation with a patient population that has high rates of STDs, high rates of substance abuse and now they are in harm’s way from the standpoint of being in communities that have higher rates of HIV and hepatitis C. So, we’re seeing more patients seroconvert. And they are seroconverting secondary to two major routes: unprotected sexual contact, regardless of sexual orientation; and injectable drug use. Those two things are going to contribute [to] probably 75 per cent of all HIV/AIDS that is transmitted in any population, including American Indians/Alaska Natives.”

Dr. Dekker said the recent conference provided an opportunity to relay information that can help decrease the likelihood of seroconversion and educate a community that certain behaviors could direct them in the path of this infection. “And that it is avoidable if they can actually participate in urban strategies,” he advised.

The migration toward urban areas has been going on for some time in the AI/AN population. “But it has become more of an issue recently because poverty is the common denominator on most reservations,” Dr. Dekker said. “You take the Oglala Sioux reservation, Pine Ridge, [South Dakota], the unemployment rate is 85 per cent. On most reservations, the unemployment rate is 75 per cent. So when you have a fairly large population and with no means of support, the likelihood of the person being able to support himself or herself is extremely limited. There is another reason why I’m concerned about HIV/AIDS in the American Indian population and that is an unfortunate stratospheric rise of methamphetamine abuse.”

Dr. Dekker spent the first 16 years (1978-1994) of his medical career on Chicago’s south side and saw how crack cocaine expanded the HIV/AIDS epidemic dramatically. “Because of behaviors associated with crack cocaine use, which was high risk sexual practices, sex for money or sex for drugs, and then the conversion of smoking crack to injected cocaine, injected heroin, which was speedballing,” he said. “Here we are in 2006 and I’ve seen very similar situations with methamphetamines. American Indian communities are at significant risk of methamphetamines because of the lack of drug interdiction services available to the communities. It’s easy for people to infiltrate into a reservation itself. There is lack of appropriate legal law enforcement with drug interdiction services, [and] the young people that are getting involved in methamphetamines don’t realize the potential side effects and the severity of the abuse.”

Dr. Dekker said someone may start off using meth occasionally, but then they accelerate very rapidly into significant use. “Many of my patients who are using methamphetamines [also may] realize that the ultimate use to feel the power of this drug is to mix it, and to mix it with heroin, or to mix it with the prescription pain relievers and smoking it or injecting it. What happens with cocaine and with methamphetamine is that it is a significant stimulant, and what it does is it causes the sensors to be hyper sensitive, hyper vigilant, hyper excitatory,” he said. “From a sexual standpoint, a person feels not only sexually aroused, but the act of sex is more intense. But the problem is that when a person is extremely aroused and extremely stimulated, the actual sex act is more traumatic, and so the likelihood of injuring the genitalia is higher, and that’ll increase the likelihood of transmission of viruses and transmission of sexually transmitted diseases.”

Dr. Dekker said if you have a STD, you are at a higher risk for getting HIV. “Open lesions, such as syphilis, they are not only contagious for syphilis, but they also have a port of entry for HIV to be able to get to them, so they can infect someone else with syphilis, but they in turn [are at risk of] getting an infection from sexual contact,” he advised. “So, we’ve seen an increase in STDs, and unfortunately I don’t think people are getting tested [and] know if they have actually contracted HIV. Most people deal with STDs and HIV in the same way, and that is to deny that they are vulnerable. And so it becomes an issue of people receiving primary care services that look at these things.”

However, Dr. Dekker said most patients cannot get good primary care services because they may be inadequate on reservations. “And so what they end up having to do is go to the emergency room and clinics, and [the doctors there] take care of the one thing you had a problem with and then you leave,” he said. “Good primary care should take time to provide full evaluation, to listen and then provide the appropriate intervention. And the intervention here, if necessary, is testing. And then if you identify the person [as positive], to provide them care.”

Dr. Dekker said that it is under these circumstances which make the concerns so great, especially for the underserved urban Indian and the underserved reservation-based Indian.

The Dangers Of The Epicenter
Dr. Dekker recounted how in 1983 he came across his first patient with HIV, a 15-year old male who came in with a severe infection. “Since that time my practice in Chicago had about 600 HIV-infected patients—we had a very large practice—before I left,” he said. “We don’t have that many people back here at PIMC. Part of it’s because the epicenter for the disease in Chicago was on the north side and the south side, and I was right in the middle of the epicenter. For our Native population, there are no epicenters in the reservation area. However, people are highly mobile now. And so it’s usual for a person to live in Phoenix, work in Phoenix, and go back home to Navajo on the weekends. That is very common in Phoenix, and the same thing goes with many urban Indians, that they live and work in the area of the job opportunities, but they go back to the community.

“So if you have a 23-year old male, who is working here in Phoenix, but then he goes back up to Navajo on the weekends and he has either girlfriends or he participates in activities that put him at risk with either sexual practices or being intoxicated or using drugs…you can see how that person picks up an infection in Phoenix, can easily deliver it 250 miles north, [in] an area where the epicenter has not come yet. Now, we spread chlamydia that way very easily. We [may] be spreading HIV that way, too.”

Another issue is consent to HIV testing. “You can’t do an HIV test without the person’s permission,” Dr. Dekker said. “I have many Native patients who don’t give permission.”

Dr. Dekker said he might ask a patient if he can screen for gonorrhea and chlamydia because he or she had unprotected sexual contact, and that he’d also like to screen them for hepatitis A, B and C, syphilis and HIV. “And I had many patients who said, ‘well, I don’t need that because I don’t have sex with men. I just have two girlfriends, that’s it.’ And I say, ‘well, you should be tested for everything.’ But there is a resistance, and more of a resistance in the American Indian population than in the non-Native population,” he said.

Dr. Dekker said often the patients are willing to be tested for gonorrhea and chlamydia, since it is done through a urine tube. “To actually take blood, I have patients who are resistant and they don’t want to have them done,” he said. “But I tend to drive a very convincing reason, so I actually spend time to talk to the patient and explain why we are doing this, do the pre-test counseling, which takes about 10 minutes to do and then do it right. I don’t know if very many providers have the time to do that, but because I’m an administrator, I really don’t see that many patients, I see about 200 patients a month. That’s not that many. That’s a fraction of what a full-time doctor does. But I end up diagnosing, and this past year I diagnosed five patients with HIV infection in our hospital. That’s for a doctor who has a small number of patients.”

Dr. Dekker said most of his patients have drug problems, since his specialty is addiction medicine. At the same time, he feels that diagnosing illnesses like HIV is really important. “I have to develop trust with my patients. I have to let them know that I’m doing it for them, not for me. But I also feel that I see it in a way that’s sincere, that I truly am concerned. My patients are very sensitive about that.”

And if his patients realize that testing is appropriate, many times they will end up saying, ‘okay, let’s go ahead and do it,’ Dr. Dekker advised. “We try hard to convince patients to allow us to test them, and what happens after that is we need to follow up with post-test counseling and information. If the person comes back testing negative for everything, which is the usual even with high risk behaviors, their clear response is, ‘wow, I can’t get this.’ ”

Dr. Dekker will tell them that is the wrong attitude to take. But Natives do not believe in luck, he added. “For the person who is typically traditional, they believe that there is a reason why they are negative, and sometimes that reason is maybe misinterpreted,” he said. “Sometimes they will misinterpret testing negative as something very personal, rather than something that is for the community. If they think that, ‘well, I’m just protected, I don’t have to worry about this,’ I need to say, ‘well, I don’t know if you ought to be that cavalier about this.’

“For instance this morning I had a patient in the hospital who was admitted who had severe alcohol withdrawals, and so I was asked to see him this morning, and just provided the best care I could. But also I let the patient know that we are very concerned about his behavior that’s ultimately going to really kill him. My opinion is that drug abuse will ultimately kill you, and ultimately it’s going to take everything that you have and will destroy you. That’s just my opinion. Unfortunately I think it’s true. But I don’t go in and just try to scare the patients. I clearly try to say, ‘listen, I really want you to know I’m worried about you.’ And I think that that makes a difference to patients. If I’m really concerned, many of them will become more concerned themselves.”

PIMC Not The Norm
Dr. Dekker advised that the intensive behavioral health services available at PIMC are not the norm in IHS. “If someone comes in now and says [they] need to talk to someone, we will see that person within 30 minutes, and sometimes even faster than that,” he said. “That’s unheard of, but we have three people that just do walk-ins and we see 50 walk-ins a day, just in behavioral health. [We have] another 50 that are appointed. It’s not easy to deliver that kind of service. That’s better than the community has to offer. Not every Indian Health Service [facility] has the capacity to do that, but our feeling was that with the drug epidemic and the amount of behavioral instability that’s out there, the community told us this is what they want. So that’s what we decided to do, just deliver the products they want.”

As far as preventing HIV, Dr. Dekker said the most important thing is to address sexual practices and to provide intervention that decreases the chance of infection. “A lot of people think that this is a disease that really is limited to men having sex with men, and that is as far from the truth as they can be,” he said. “We want to very clearly state this is an infection that is transmitted with wet sexual contact. And the second part would be drug abuse. Injection drug use is skyrocketing in Phoenix. It is also skyrocketing across the country because heroin is so cheap.”

Prices for a gram of heroin have dropped some 75 per cent in the Phoenix area over the past several years. “Afghanistan has quadrupled their heroin production in the past four years, despite our occupation of the country, so what’s happened is that there is more heroin on the street,” Dr. Dekker said. “The reason that so many of my patients are getting involved in heroin is that they start off by getting high doses of opioid pain medications, both legally and sometimes illegally, and then what happens is they try to buy their opioids on the street.”

It ultimately may be cheaper to buy heroin.

There is also a number of transgenders and homosexuals that Dr. Dekker treats. “The Native community is far more accepting of different sexual orientation than the general population, I think because there is an ancient belief of what’s called the two spirits, the two-spirited people,” he said. “Some people are more male and have a male’s mentality, they have a male’s body, but they also have a male’s personality and a male’s strength. Some people are born into a male’s body and they have another [personality]. So what do you do with a male who doesn’t hunt and a male who is not a warrior? In the Native community in pre-Colombian times, those people were given special roles, they were given the role [of] praying for the rain, the role of when to plant the corn, the role of telling what the future holds, everyone had a role, which is different than our society [that says] this is deviant behavior, ‘don’t ask, don’t tell.’ The [Native American] families [on the other hand will just] say, ‘he’s always been this way.’ ”

Dr. Dekker said the goal is to identify patients who are at risk, provide comprehensive strategies by accepting them as a real person, developing a relationship and providing them with an intervention strategy that allows them to express themselves in a way that they want to, Dr. Dekker said.

For instance, Dr. Dekker asked the patient he saw that morning if he thought he was in trouble. “He said, ‘I think I am.’ I said, ‘well, what do you think your biggest problem is?’ He said it was alcohol. He drinks 12 to 18 cans of beer at a time. He really thinks he can stop the methamphetamine and the cocaine because he said he doesn’t use it very often and it is just too expensive. He says he only uses meth maybe twice a month. Now that’s a person who’s an addict who’s telling you this, so there may be more [to it] than that,” said Dr. Dekker.

The patient agreed that day to go into residential care after initially refusing the previous week. “He realized that his life was falling apart,” Dr. Dekker said, adding that it was very timely to get him into treatment now. “I believe in my heart of hearts that alcoholism and drug addiction is a fatal disease, and that given enough time it will ultimately kill you. But in the process it not only destroys you, it destroys the people you love around you, too.”

The Drug Cycle
“If you take too much stimulant, it actually makes you paranoid,” Dr. Dekker said. “It makes you out of control, and the same thing is true of the methamphetamine. People like it at first because you have incredible energy. After a while, though, your mind can’t do it. You wear the system out. What happens is that after a point in time, whether it’s meth or crack, opioids calm you down. And that’s when people start mixing the two drugs together—whether it’s cheap heroin or prescription opioids—because they don’t like being paranoid, but they like being charged up.”

And then they get hooked to the feeling of being high, rather than when they may have used it initially to increase their energy for work or other things. They also continue to use to avoid getting sick from withdrawal. “It’s an everyday thing for us here,” he said.

Dr. Dekker recently testified on Capitol Hill in Washington, D.C., on the increasing use of meth in Indian country, and feels that it has reached a crisis level.

The AI/AN community is especially vulnerable, based on the cultural genocide that has been inflicted upon them. “Especially with American Indians, this multi-generational grief and trauma has a significant effect on how people observe, how people feel about their addictions,” Dr. Dekker advised.

According to CDC, during 2002-2004, about one quarter of AI/AN, or twice the national average, were living in poverty. The 2004 National Survey on Drug Use and Health indicated the rate of current illicit drug use among AI/AN, at 12.3 per cent, was higher than among persons of other races or ethnicities. “Life expectancy of this population is shorter than that of any other race/ethnicity,” CDC reports.

In 2001, CDC reported the syphilis rate among AI/AN was six times higher than among the non-Hispanic white population, the chlamydia rate was 5.5 times higher, the gonorrhea rate was four times higher and the AIDS rate was 1.5 times higher. Furthermore, AI/AN death rates from accidents and motor vehicle crashes were up to two times higher than that of all racial groups, while suicide rates for AI/AN youth were three times greater than for whites.

Some CDC-funded programs that state and local organizations provide for AI/AN include helping tribes develop or expand HIV prevention services, as well as improving services for those already infected or affected by AIDS. Other CDC initiatives include building the capacity of some tribal organizations and urban Indian health centers to develop HIV prevention through networking and collaboration; providing HIV prevention education in rural Alaska Native communities; developing outreach models for HIV testing among AI/AN, and integrating routine HIV testing programs such as rapid HIV testing in Indian health centers.