Culture is the cure for Native American heart disease

February is American Heart Month, which is observed to encourage Americans to adopt healthy lifestyles to prevent heart disease. According to the American Heart Association, cardiovascular disease (CVD) is the leading cause of death among Native Americans and Alaska Natives. Over the past 50 years, the prevalence of CVD has risen among Native Americans and Alaska Natives. CVD rates are now about 50% higher for those in the United States who self-identify as Native Americans and Alaska Natives compared to their white counterparts and this percentage is suspected to be underreported by 21%.

CVD is also the leading cause of death in the U.S. overall, but the CVD that ends the lives of Indigenous people has unique considerations and deserves informed attention. For example, CVD rates are particularly high in younger Native Americans and Alaska Natives. More than one-third of deaths among Native Americans attributed to CVD occur before age 65, vs. 14.7% of non‐Hispanic Whites and 31.5% of Blacks.

Dena Wilson, MD, FACC, (Oglala Lakota) is cardiology clinical consultant for the Indian Health Service (IHS). Her personal story is inspiring. She grew up on the Pine Ridge Indian Reservation in South Dakota. She was raised by a single mother who was a social worker. Her early experiences going with her mother on hospital trips motivated her to become a physician.

“Growing up on a reservation and not having any mentors or really any clue for how to go about getting into medicine, it was quite a struggle. The opportunities afforded to me were not the same as those afforded to others. But my mom and I figured it all out – how to take the MCAT and apply, and eventually all the doors opened for me.”

“It’s still a challenge for me to be away from my tribe and culture and I don’t have the magic formula for how to make (the system) work for other Native people. It’s different for everyone. I think my drive for knowledge so I could help my Native people was the most influential factor in my success.”

When interviewed in 2020, Wilson was possibly the only female Native American cardiologist in the country. Other than herself, she thinks IHS employs only two other cardiologists in the country.

“Cardiology services within the IHS are limited,” she says. Advanced diagnostics are not available usually within IHS service units, just echocardiography and treadmill testing, so most facilities refer patients to private cardiologists.

“Through my involvement with ACC (the American College of Cardiology, an education and advocacy group for health care professionals) and what I saw in practice, I’ve become more involved in the administrative side of medicine to focus on system-wide improvements that will increase and improve the quality of care we can provide. There are several avenues in which we can partner with outside organizations to provide quality specialty care to our patients.”

According to Wilson, substance abuse coupled with the constant strains of cultural dislocation and trauma as well as discrimination and microaggressions, are a unique issue to Native American communities and can’t be overlooked. In a 2019 report, almost one in four Native Americans (23%) reported experiencing discrimination in encounters with health care providers, while 15% avoided seeking health care for themselves or family members due to anticipated discrimination.

“When communities deal with poverty, alcohol/drug abuse, racism, violence and trauma on a daily basis, there is no time to recover. People function in a constant mode of stress, which as we know is detrimental to heart health, and health in general,” Wilson says. “There are many individuals who live on the reservation surrounded by the community and culture, yet because of substance abuse they have lost that connection.”

For clinicians treating Native Americans outside IHS facilities, Wilson suggests connecting to the Tribal community. “Understand the beauty of the culture and people. Yes, there are many negatives that affect rural and isolated communities but there are also so many strengths such as the support of the community. Incorporating the culture and community into health care will help improve outcomes.”

To place Native American heart health in a historical context, experts note that displacement, war, infectious disease, broken treaties, and decimation of tribal lands by the federal government in the 1800’s all created an understandable wariness and lack of trust among Native Americans. Forced removal from native lands and living in rural areas with limited access to health care worsen the situation. Transportation to health care can be a challenge and roughly 20% of Native Americans have no health insurance, with the remainder split between public and private health insurance. The IHS provides care for less than one-third of the total Native American population.

Diabetes rates are also high among Native Americans and are the main driver of heart disease that occurs in Native Americans. The rate of diabetes varies by region and sex among indigenous people, reaching as high as 72% of women and 65% of men ages 45 and 74 years living in the Southwestern U.S.

According to Wilson, diabetes prevention is a substantial achievement by the IHS, with current data showing a slowing in the prevalence of diabetes. Wilson says she is focusing on how to expand excellent diabetes prevention and care and reach to rural areas. One focus of her efforts is telemedicine as a means of expanding care.

The Special Diabetes Program for Indians (SDPI), established by Congress in 1997, has contributed to this success. With $150 million per year in grants, the SDPI provides funding to 301 programs for Native Americans and Alaskan Natives in 35 states.

Much of the success can be attributed to culturally centered interventions for health promotion driven by the community. In addition to relying on modern medicine, clinicians in IHS have been focused on finding ways for communities and patients to reconnect with culture.

The Strong Heart Study, a long-term study of CVD in Native Americans, used community-based participatory approaches in its research methodology. Strong Heart Study researchers achieved high participation rates by consistently obtaining community input and consent for all activities and returning study findings to community members for tribal use and community improvement. The expansion of the study to include a genetic component involving family members and using native team members in leadership roles demonstrate the commitment of the communities to the health of future generations.

Resilience – a marker associated with cardiovascular health among minorities – is accessed through cultural knowledge and practice. Greater tribal cultural spirituality was linked to better mental health among Native Americans, while prevention interventions that meshed with cultural activities had greater effectiveness than interventions that were not culturally specific.

Some experts have called for a “strengths-based approach” to improving health among Native Americans. This requires strengthening tribal identity and traditions in ways that offer holistic approaches to improving both physical and mental health in the community.

One small example of this is Community Talking Circles which allow each member a chance to express their perspectives and thoughts uninterrupted. A longstanding tradition among some Indigenous peoples, Talking Circles allow for shared decision-making between patients and their health care providers. They have been used in both reservation and urban settings to provide diabetes education and empower individuals to manage their diabetes better.

“When you see the interesting approaches that are being taken in the communities where investigators are working to adapt interventions to really fit the needs of the community but also the ways in which the communities work together, it makes you realize how all health care really is local,” says Elizabeth A. Jackson, co-author of a scientific statement on Native American CVD published by the American Heart Association.

Along with the prevalence of diabetes, another risk factor for CVD is obesity, present in an estimated 30% to 40% of Native Americans. The Strong Heart Study found some of the risk for obesity and diabetes is inherited.

Other risk factors, such as exposure to toxic metals in groundwater, which is high in the Midwest and Southwest, need to be addressed at the policy level, the report said. Arsenic and cadmium are associated with increased risk of atherosclerosis as well as increased total cholesterol levels in multiple Indigenous populations. Atherosclerosis is the slow narrowing of arteries that underlies most heart attacks and strokes.

“Racial and ethnic minority groups in the U.S. have suffered from inequitable policies for hundreds of years,” said Dr. Khadijah Breathett, chair of the Heart Association’s writing committee. “These policies have contributed to mistrust in the traditional health care system. The most effective way to create change is through restructuring of inequitable policies and empowerment of communities.”

Native American and Alaska Native populations have worked to revitalize traditional languages and cultures. They exert sovereignty in their social, political, and economic ways of life, including those that relate directly to health and well-being. However, Indigenous peoples continue to have high rates of CVD. Native American and Alaska Native researchers, teams, and communities are increasingly partnering to develop and test culturally centered, community-driven health-promotion interventions to improve the lives of Indigenous peoples.

In a proclamation issued on January 31, 2024, declaring February Heart Health Month, President Joseph R. Biden, included this reminder:

“…It is important for every American to be aware of individual actions we can take to keep our hearts healthy: Exercising regularly, eating well, managing weight, and avoiding smoking or vaping are proven to reduce the risk of cardiovascular disease. Experts also recommend that everyone should learn the warning signs of a heart attack and stroke and that they should consult a doctor if they experience risk factors or symptoms.

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