Pictured above: Anishinaabeg family in the Ludington, Michigan, area, ca. 1880s. The family’s Euro-American
clothing does not necessarily indicate assimilation, but may instead have been a practical
adaptation, says Associate Professor Michael Witgen, director of Native American Studies
—Photo: Courtesy of UM’s Bentley Historical Library.
A Widening Gap
Native Americans are more likely to die from cancer, diabetes, and heart and lung disease than other Michiganders. The question is, why?
Native Americans are Michigan’s smallest minority group. They make up only 1.3 percent of the state’s total population. But though small in numbers, Native Americans face some major health issues. They are more likely to die from cancer, diabetes, and heart and lung disease than other Michiganders.
“American Indians in the Great Lakes region have the highest lung cancer rates of any region in the country,” says Kristin Hill, director of the Great Lakes Inter-Tribal Epidemiology Center in Lac du Flambeau, Wisconsin. “A recent study of health disparities among all U.S. populations found that differences between minority and white populations are decreasing for all groups except for Native Americans, where the gap is increasing.”
What makes Native Americans more vulnerable to these diseases? It’s an important public health question, but the answer is unknown.
Epidemiologists at UM SPH are working to identify the underlying causes of health disparities in Michigan’s Native American population. To do this, researchers need up-to-date and accurate information. Unfortunately, the databases traditionally used in epidemiology research—official state and national birth and death records—often omit Native Americans or misclassify them as being white, African-American, or Hispanic.
“One of the first steps toward health equity is to be represented accurately in data,” adds Hill. “But we know that American Indians are undercounted or misrepresented at rates between five percent and 50 percent in state and national data registries. It’s a common problem throughout the country.”
“People can be born white but die American Indian, and vice versa,” says Rick Haverkate, a member of the Sault Ste. Marie tribe of Chippewa and former director of public health for the Inter-Tribal Council (ITC) of Michigan. “Death certificates are often filled out by funeral directors, or the county coroner who will guess the race of the deceased based on appearance rather than ask the family.”
“If someone gets a diagnosis of cancer or a biopsy through a clinic, the results must be sent to the state’s cancer registry,” says Haverkate. “But if you go to a traditional tribal healer, there may be no Western medicine–style diagnostic testing. We know that many of our Native Americans seek out traditional native healers, but statistically we don’t know for certain how common that is in the overall native population of Michigan.”
Amr Soliman, an associate professor in epidemiology who directs the SPH Cancer Epidemiology Education in Special Populations Program (CEESP), says UM researchers have worked hard to reach out and build relationships with Michigan’s Native American tribes.
A native of Egypt, Soliman is sensitive to the fact that research with a minority population involves much more than just collecting data. When he joined the UM faculty in 2003, Soliman started CEESP to prepare MPH students to conduct research studies in special populations, both overseas and in the United States.
“Native Americans have special issues and concerns about participating in research studies that must be respected,”says Soliman. “It takes a lot of time to establish trust and do this in the right way.” Soliman credits his former CEESP student Jenna Johnson, MPH ’08, with “being a pioneer” in establishing an important and continuing relationship between SPH, Michigan’s native tribes, and the Michigan Department of Community Health (MDCH). During her CEESP internship in 2007, Johnson worked with Haverkate at the ITC on a project to generate more complete and accurate data on the prevalence of cancer in the Native American community.
“It was a collaborative project,” Soliman says, “so Jenna worked closely with Glenn Copeland, the director of the MDCH’s cancer registry, tribal leaders and other UM researchers. She traveled to the Indian Health Service office in Albuquerque, New Mexico, to learn how to use special software to link tribal records to the state’s cancer registry.”
According to study results published in the June 2009 issue of the American Journal of Preventive Medicine, Johnson and her co-authors found that the state’s cancer registry was undercounting the number of Native Americans with cancer. “Some individuals were in the cancer registry, but were not identified as being Native American; others were not in the registry at all. This study involved just one tribe in Michigan, but we believe the same situation exists for other tribes,” says Soliman.
“Accurate data is important to tribal leaders, because they need to know if prevention programs are making a difference in reducing the rate of cancers,” says Haverkate. “Everyone wants to reduce the burden of cancer on American Indians, so it’s important to make sure money goes to programs that work.”
Officials at MDCH were so pleased with the outcome of the study that they want to expand the project to include other Native American tribes in Michigan, according to Soliman. Another CEESP student will start work on the project this summer.
As an epidemiology student at SPH, Jenna Johnson, M.P.H. ’08, worked on a project linking health data from tribal records to Michigan’s cancer registry. Johnson now works in Chicago as a consumer safety officer for the U.S. Food and Drug Administration. She spoke to Findings about her cancer-registry work:
What was the most difficult part of the cancer registry project?
I would say the most challenging part of the data linkage project was the coordination with all the stakeholders—making sure everyone was aware of exactly what we were doing, was comfortable with how we were doing it and what they were getting out of it.
Was there a secret to your success?
First, my SPH colleagues partnered me with the Inter-Tribal Council (ITC) of Michigan, a longstanding trusted partner of the tribe involved in the study. With ITC colleagues by my side, the tribe was much more open to the project and to me. With more specific data on cancer in tribal members, the tribe could better plan their cancer prevention and treatment efforts. The second factor leading to success was preparedness. I had done my research on the process, I knew the risks and how we planned to mitigate them. I knew about the history of research and betrayal between tribes and academic institutions, and I respected the tribe’s hesitancy to trust me. I understood that I would need to earn their trust.
What was the most important result of your project?
After finishing my analysis, I returned to the tribe and made a presentation on the tribe’s cancer statistics. The tribe also has a copy of the dataset to use for health-planning purposes. I don’t know to what degree it changed tribal health policy, but I do know that it is a resource that they didn’t have prior to the linkage.
Another major outcome was that our study showed that race for American Indians/Alaska Natives is not being accurately reported to the state’s cancer registry. Glenn Copeland, the registry director, was aware of the problem and generously provided his time and support to this project. As a result of the linkage, we were able to provide him with more complete information on cancer cases in the tribe in our study. For further details: Jennifer C. Johnson, “Tribal Linkage and Race Data Quality for American Indians in a State Cancer Registry,” American Journal of Preventive Medicine, June 2009 (36) 6, pp. 549-554.
This summer, as part of a new and ongoing internship program, the SPH Department of Epidemiology will send its first student intern to work with the Great Lakes Inter-Tribal Epidemiology Center in Lac du Flambeau, Wisconsin.
SPH faculty mentor Eden Wells, clinical assistant professor of epidemiology and a member of the Tribal Epidemiology Work Group of the Council of State and Territorial Epidemiologists, says, “There’s ongoing interest nationally among federal, state, and tribal epidemiologists to reduce racial misclassification and enhance data quality regarding American Indian/Alaska native populations, so this is an excellent opportunity for an MPH student.” Prior to joining SPH, Wells spent ten years working with the Indian Health Service.
Trust Is Crucial
An SPH student learns firsthand what it takes for treatment and recovery programs to succeed.
Justin Rodgers, an SPH master’s student in epidemiology, has a family member who is Native American, so he has personal reasons to be interested in the health issues of this special population. Before enrolling at UM, Rodgers worked at an Indian Health Service clinic in his native Seattle. When he saw a notice in the SPH Office of Public Health Practice that the Inter-Tribal Council of Michigan (ITC) was looking for a summer intern, he applied right away.
Rodgers got the job and spent the summer of 2011 working with ITC leaders in Michigan’s Upper Peninsula. He helped compile and analyze survey data from a federal program designed to encourage more Native Americans to participate in substance abuse treatment and recovery programs.
“Substance abuse, primarily alcohol, is a problem, and there are many medical, financial, and social obstacles to treatment and recovery,” Rodgers says. “One obstacle is a general distrust of scientists and medical professionals in the Native American community. People have to trust the treatment program before they will agree to participate.” <
By Sally Pobojewski
Indigenous people moved into what is today the state of Michigan about 14,000 years ago to hunt in the shadow of receding glaciers. By the early 1600s, French fur traders and explorers arriving in the area found a rich Woodland culture and thriving population of Native Americans — primarily made up of the Chippewa (or Ojibwe), Ottawa (also known as Odawa), and Potawatomi tribes, known collectively as “The Three Fires.”
During the 1700s and 1800s, British and American colonization of native lands led to the forced removal of some Michigan tribes and the restriction of other tribes to small reservations. Native Americans faced intense pressure to abandon their traditional languages and lifestyles, convert to Christianity, and send their children away to be raised in federal boarding schools. Although native peoples maintained their language, religion, and connection to landscape and life-ways, many say the effects of their forced assimilation to white culture remain with them today. The history of interactions between Native Americans and U.S. government agencies has left a lasting legacy of distrust and suspicion of outsiders in the native community.
Michigan’s 12 Indian Tribes
Today there are 12 federally recognized American Indian tribes in Michigan. Each tribe is an independent sovereign nation with its own leaders, constitution, and cultural identity:
- Bay Mills Chippewa Indian Community
- Grand Traverse Bay Band of Ottawa and Chippewa Indians
- Hannahville Potawatomi Indian Community
- Huron Potawatomi-Nottawaseppi Huron Band of Potawatomi
- Keweenaw Bay Indian Community
- Sault Ste. Marie Tribe of Chippewa Indians
- Little Traverse Bay Bands of Odawa Indians
- Little River Band of Ottawa Indians
- Match-e-be-nash-she-wish Band of Potawatomi Indians
- Pokagon Band of Potawatomi Indians
- Saginaw Chippewa Indian Tribe
- Lac Vieux Desert Band of Lake Superior Chippewa Indians
—Source: State of Michigan, Michigan Tribal Governments
More information about Native Americans in Michigan:
For an overview of health issues in the Native American community in the Great Lakes region: “Community Health Data Profile: Michigan, Minnesota and Wisconsin Tribal Communities, 2010,” Great Lakes Inter-Tribal Epidemiology Center, Great Lakes Inter-Tribal Council, 2011.