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Hello, my name is
Dr. Donald Ward.

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I am Ogallala Lakota,

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originally from a small
town called Kyle,

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South Dakota on
the Pine Ridge

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Indian Reservation.

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And a family physician

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and a number of hats at

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the University of
North Dakota School of

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Medicine and
Health Sciences.

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And the Associate Dean for

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Diversity, Equity
and Inclusion.

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I'm the chair of
our department of

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indigenous health
and I'm also

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director of a
couple of programs,

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the India's into
medicine or

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embed program and also

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our public health program.

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So the topic that
I want to cover,

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looking at things from

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an American Indian
perspective and addressing

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bioethics is the
longstanding underfunding

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of the Indian
Health Service.

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And it's a little
known fact.

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But in the United States,

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the right to health
care is not universal.

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So we have a lot of
people who do not have

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access to basic
health services.

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And that's true for
everyone in this country.

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Accept American
Indians and Alaska

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Natives as

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American Indians and
Alaskan Natives.

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We actually have
a treaty right

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to health services.

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And those treaties are
basically contracts

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that were between
the tribal nations

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and the federal
government.

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And there are

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several 100 treaties
that were signed,

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primarily in the 1800s.

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And in those treaties,

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in exchange for land
and natural resources,

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the tribes were
promised health care.

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Got the typical language

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in those treaties was

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promise of all proper
care and protection.

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And when we look
at the history of

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funding of the Indian
Health Service,

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we're not receiving
all proper

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care and protection.

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So if you look at
the numbers in 2022,

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we're getting
about $4 thousand

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per patient per year

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in the Indian
Health Service.

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To put that in
perspective,

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the Medicare
recipients are

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receiving well over
$12 thousand per

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person per year and Akkad

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is $9 thousand per
person per year.

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So Indian Health
Service is funded

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about half of
its actual need.

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One of our big
challenges is that

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we have tremendous
health disparities.

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In North Dakota,
for example,

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the average age
at death for

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American Indians
is about 59 years.

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White population
in North Dakota,

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the average age at
death is closer to 79.

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So we have over 20
year disparity in

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average age at death for

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American Indians in

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the state of North Dakota.

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So how do we
manage that with

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the health system that is

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so terribly underfunded.

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So because the Indian

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Health Service
is underfunded,

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we cannot provide all the

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services that we need.

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So if somebody needs
specialty care,

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we actually have
to purchase

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those services in the
private sector because

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IHS cannot afford to

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hire and retain
specialists.

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So for example, if
somebody has cancer,

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we can rarely provide

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cancer services within

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the Indian Health Service.

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They have to be provided

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in the private sector.

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And this really is
an ethical dilemma

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and a social
justice dilemma,

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as well as a policy
and legal issue.

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In many ways, this is
a civil rights issue.

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So, when you look at
the US Constitution,

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treaties are
considered the

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highest order of
law in the land.

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So treaties are
stronger version of

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the law even
than legislation

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passed by congress

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and signed by
the president.

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So there's a treaty clause

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in the US Constitution.

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And where are the only
population that has

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a treaty right
to health care.

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But the US government

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is just not living up to

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its treaty obligations to

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American Indians
and Alaska Natives.

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So in a very
practical way,

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what is the
impact of that?

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I can share a story
from my own family.

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In the 19 nineties
and late 1980s,

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my grandmother
came to live with

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us when we were in
Arizona at that time.

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And again,

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where from South
Dakota originally.

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And she was
getting older and

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she was very frail.

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So she moved from

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South Dakota to live
with us in Arizona.

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And she unfortunately
had been

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a lifelong smoker and she

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we had developed a cough

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that wouldn't go away.

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So we took her to the
Indian Health Service

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in Phoenix and they did

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a chest x-ray and

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it was very clear
that she had

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a mass in her lungs

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and it looked
like lung cancer.

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So because Indian
Health Services

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so terribly underfunded,

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there was not an
oncologist or

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a cancer doctor working

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within the Indian
Health Service.

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So she needed
to be referred

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to the private sector.

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And because of
underfunding that

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referral rules
within the within

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the Indian Health Service

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are such that she
was not eligible

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for a referral from

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Phoenix Indian
Medical Center

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because she's from
South Dakota.

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So within the IHS
is what's called

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purchased and
referred care or PRC.

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And in order to
be eligible for

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a referral from
the PRC budget,

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to be referred
for the services

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from your home institution

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or your home clinic.

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So we weren't able to
get a referral from

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Indian Health Service
out of Phoenix.

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In addition, in order

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to be eligible
for Medicaid,

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we had to prove that
she was living in

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Arizona for at
least six months,

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but we couldn't prove it.

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We didn't put

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the electricity
bill in her name.

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Her she was just
living with us

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also because she

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was really a
full-time mother

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and a full-time
grandmother.

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She had 10 children and

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then many, many
grandchildren.

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She also did not work

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her 40 quarters you
have to work for

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ten years to be eligible
for Social Security.

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So she was not on
Social Security,

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she was not on Medicare,

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she was not eligible
for Medicaid,

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and she was not
eligible for

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a referral from the
Indian Health Service.

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So we literally
had to bring

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her back to South
Dakota just to

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get a referral to be

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seen for her lung cancer.

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And in all the delays

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of getting that to occur,

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my grandmother
wound up dying from

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lung cancer without

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ever seeing an oncologist.

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And she was born
with a treaty

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right to health care.

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So I really look at

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underfunding of the
Indian Health Service,

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not just as an
academic policy issue,

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it's a very personal
issue and it's

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an unethical when we
think about this.

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The fact that human beings

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deserve health care
when they need it.

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But also from a
legal perspective,

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we have a treaty right
to health services.

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And the federal
government is just simply

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not living up to
its obligations.

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So I'd encourage you
to look into this

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more and to try
to understand

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the history and
dynamics of

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American Indian
health policy and

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in particular funding of

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the Indian Health Service.

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And we can see how

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very directly
underfunding of

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the IHS can lead

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to unnecessary suffering
and early death.

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And we're seeing that
play out in the data.

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So please do look
into this further

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as you move forward
in your careers.

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And I really appreciate

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your attention and thank

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you so much for letting me

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be a part of this series.