*"It doesn't matter if the cat is black or white as long as it catches
mice."*

*Chinese Proverb*

This a page for sharing "what works" as seen in the published literature
as well as what is done at sites that care for American Indian/Alaskan
Native children. If you have any suggestions, comments or questions
please contact Steve Holve, MD, Chief Clinical Consultant in Pediatrics
at sholve@tcimc.ihs.gov

IHS Child Health Notes

**February 2007**

# Quote of the month

*"The most effective way to remember your wife\'s birthday is to forget
it\
once."*\
Anonymous

**Editorial Comment**

The essay below by Dr. Ratmeyer grew out of conversation at a Navajo
Area Pediatric meeting this past fall. Dr. Ratmeyer makes an important
plea for empathy and dialogue, not just criticism. This collaborative
approach will allow health professionals to develop a successful working
relationship with tribal employees that will benefit American Indian and
Alaska Native children.

# Understanding the Child Protection Role of Child Health

# Care Practitioners in Indian Country

Recently, pediatricians working on the Navajo Nation asked me to share
my thoughts about our role in child protection. Although much of what
I'll say comes out of my 15 years of experience at the Gallup Indian
Medical Center, I suspect that many of my observations are applicable to
doctors and other medical practitioners working elsewhere with Native
American populations.

I have to start out by saying that I feel the pain of everyone tasked to
interact with our social work and law enforcement agencies in Indian
Country.  We need to first acknowledge the reality of the professional
environment in which we work.  Although there are many examples of
professional competence mixed with caring individuals doing the work of
child protection, we tend to see agencies whose work product is the
result of under funding, under training, and understaffing. 

We have folks who have no training other than \'on-the-job\', courtesy
of the previous child protective service (CPS) worker or police
officer.  There are often minimal job requirements for these positions. 
Most tribal social work (SW) positions don\'t require a degree in social
work. Many Family Court judges also may have little experience with the
Navajo Nation's Children\'s Code, which is supposed to guide Family
Court decision-making.  We, in the medical profession, come from an
entirely different world of expectations and experience in which we are
not put "on the job" until after at least 7 years of intense training. 
That being said, we can only do the medical job for which we trained,
with a bit of child advocacy to create and support a system that
protects children.  We cannot be social workers, and we cannot be law
enforcement officers, and we cannot be officers of the court, either
prosecutors or judges. 

 

Our temptation is always to step out of our own discipline to point out
the shortcomings of those in other disciplines, because of what we think
they should be doing.  A better and more effective approach is to come
to understand what the folks in these agencies do.  We need to learn
about their reality, including what allows for such difficulty in
responding to child maltreatment. 

To do that, we have to stay in dialogue.  We dehumanize people when we
view them as equivalent to what they do (or, as we see it, what they
fail to do).  And it shows in how we talk to people.  We \-- often
unwittingly \-- paint ourselves as aloof, self-righteous, intolerant,
and unapproachable when we go on our tirades of lambasting CPS staff for
what we perceive as poor performance.  It\'s a sure way to burn
bridges.  People will avoid us, refuse to speak with us, and work around
us and at cross purposes to what we want to and need to do in these
cases. We need to cooperate.  We do that by talking, not just about
work, but by getting to know one another by name and developing healthy
personal relationships.  They need to get to know us for who we are, as
well as for what we do. 

The only way to do that is by establishing a routine of regular
meetings, always at the same time/day, in the same place, month after
month, year after year.  It requires that we commit to the process, as
well as the entity, of the multi-disciplinary team. People need to
understand we approach these situations from the perspective of
\'diagnosis and treatment\', just as we need to understand that they do
so with a set of expectations imposed by the law and the courts.  With
have to be very objective in approaching this work within our own
discipline, but we have to be more subjective about how people in other
disciplines approach this work.  We have to be aware of their
shortcomings and the environment that allows those problems, while
resisting the temptation to destructively criticize everything they do. 
Lastly, we need to do our job with a standard of excellence that makes
us shine.  People will look at us and say, there goes a real
professional!  He knows so much and understands so much.  He\'s so good
at sharing that knowledge with us.  He\'s so good at listening to our
concerns.  He has such good suggestions about how to approach this
problem.  And he really cares about kids.  If the CPS people can say
things like this about us, then our stature grows.  They trust us.  They
call us to ask about how to approach a particular problem, to discuss
the urgency of an exam, to gain understanding about a chronic health
condition of one of the kids in custody.  That\'s collaboration and
that\'s what we want.  

 

This takes patience, self-insight, consistency, and commitment!  This is
what has worked for me over the years.  But, I love the work and I love
the process.  And I appreciate the people in CPS who struggle against
great odds to deliver a \'good product\'.  Most of all, I want to
protect kids.  If we all truly want that, we\'ll realize that making
incremental change over a long period of time is far more reasonable
than tilting at windmills, while alienating entire agencies, to
effectively lock us out of any influence over decision-making in the
ultimate dispositions of these families embroiled in violence, abuse,
and neglect. Building relationships between professionals and
establishing continuity and consistency in our child protection
processes may prove the most effective way to advocate for all our
Native children and their families. And that may just bring us all some
peace of mind.

 

John Ratmeyer, M.D., FAAP\
Gallup Indian Medical Center

e-mail: john.ratmeyer@ihs.gov

**Infectious Disease Updates**.

Rosalyn Singleton, MD, MPH

**Human Papilloma Virus (HPV) Vaccine Rollout Issues: Cost and
Availability**

Quadrivalent HPV vaccine (Gardisil^®^), which prevents two HPV serotypes
associated with 70% of cervical cancer and two types of HPV serotypes
associated with 90% of genital warts, promises to be an important tool
in our prevention armamentarium. The vaccine is a 3 dose series and is
licensed for 9-26 year old females. ACIP recommends routine vaccination
of 11-12 year old females with catch-up vaccination for 13 -- 26 year
olds. This vaccine is available through the Vaccines For Children
program (VFC), and some states have already started offering it to all
VFC eligible (which includes American Indian and Alaska Native) females
9 -- 18 years.

However, the cost of the vaccine (per dose costs are \$120 private
market, \$96 federal contract) has put stress on the ability of states
with universal vaccine programs like Washington, Alaska and New Mexico
to provide HPV vaccine universally. Universal states combine VFC funding
with other state and federal funding to provide free vaccines for all
children [\<]{.underline}18 years old. As these states gear up to
provide HPV vaccine, some may initially restrict HPV vaccine to a
limited age group (e.g. 11-12 year old VFC-eligible), but eventually the
vaccine should be available to all VFC-eligible females 9-18 years

There is a variation in the rollout of HPV vaccine in Indian Health
Service and tribal facilities depending on the availability of the
vaccine through state VFC programs. Because the vaccine is not yet
available in some states, at least one tribal facility has purchased HPV
vaccine and is seeking Medicaid and private insurance reimbursement. If
you have concerns about how HPV vaccine will be rolled out in your
state, please contact Amy Groom (Amy.Groom@ihs.gov).

HPV forecasting will be incorporated into the next version of the RPMS
immunization package and will probably include options for forecasting
for either 11-12 year old or 11-26 year old females.

**Recent literature on American Indian/Alaskan Native Health**

Doug Esposito, MD

**[Article]{.underline}**

Early Obits Media Among Minnesota American Indians: The Little Ears
Study. *IS J Public Health*? 2006 Dec 28; \[E Pub ahead of print\]
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17194873&query_hl=2&itool=pubmed_DocSum>

**Summary**

This study was designed to investigate the epidemiology of and risk
factors for the development of early onset otitis media (OM) in a group
of mostly Ojibwe infants living in a rural reservation or urban setting
in Minnesota. Pregnant women 16 years and older were recruited into the
study between June 1998 and April 2001. To be eligible, either the
mother or the father had to self-identify as Native American.

Data was gathered through interviews conducted during the prenatal
period and at 2 weeks and 6 months postpartum. Ears were examined by
trained research nurses and tympanograms completed in enrolled infants
at 2 weeks and 2, 4, and 6 months of age. In addition, hearing
screenings were performed at least 4 times during the study and medical
records were reviewed. A series of questionnaires were distributed at
various intervals. Rigorous criteria were employed in the diagnosis of
OM combining results from the ear examinations, tympanograms, and
hearing screenings obtained during study visits. OM diagnoses were also
tallied from clinic visit notes.

The study sample consisted of 408 women. This represented a
participation rate of only 20%, a potential source of significant study
error. Sufficient data for inclusion in the analysis was collected on a
lesser number of participants.

Of the total universe of eligible study participants, 344 infants
completed ear examinations in the first 6 months of life. Of those, 63%
or nearly two thirds of the infants had at least 1 episode of OM and 34%
had 2 or more episodes. OM occurred before 2 months of age in 25%,
between 2 and 4 months of age in 40%, and between 4 and 6 months of age
in 35% of these infants. Risk factors significantly associated with the
development of early onset OM included a preceding URI and a maternal
history of childhood OM. Risk factors found to be associated with OM in
previous studies such as short breast-feeding duration and tobacco smoke
exposure were not replicated here.

**Editorial Comment**

According to the authors, the incidence of early onset OM in this study
exceeds that found in a similarly designed study of a White cohort of
infants in Minnesota (63% vs. 48%). This study of mostly Ojibwe infants
supports what many IHS pediatricians already know to be true: that
Native American children have more OM at an earlier age than other U.S.
populations. Other studies exist that thoroughly validate this
perception.^1^

Unfortunately, the authors tread on dangerously thin ice when they
allude to a possible genetic predisposition of Ojibwe infants to early
onset OM. The authors base this conclusion solely on a statistically
significant association between early onset OM in study infants and a
maternal history of childhood OM. They also suggest that a poorly done
study of Apache infants published in the late 80s also supports this
contention. ^2^ No such conclusion can be reasonably drawn from either
study design, in my opinion, and the authors of the Apache study make no
such assertion.

As any regular reader of my reviews knows, I flatly reject the notion
that genetics can in any way explain the significant health disparities
suffered by minority populations (please refresh your memories by
reviewing two previous editions of the IHS Child Health Notes:
<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ICHN107.doc>,
<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ICHN306.doc>),
although variation between individuals within a population can occur on
a genetic basis. Yes, "race" does in fact exist, but it is a purely
human invention, born entirely out of the human psyche.

The paper under review is particularly rife with uncontrolled bias and
confounding on many fronts, and independent of my own perhaps quirky
personal prejudice, no reasonable conclusion invoking genetic factors as
a source of disparities in early onset OM in the studied population can
be drawn. This is yet another unfortunate example of the ongoing medical
institutionalization and ratification, or "biologification," of racism.
C'mon guys, more critical thought processes are surely in order!

Let's no longer scapegoat the biology of minority populations as the
source of their own suffering. Ample scientific evidence compels the
conclusion that health disparities derive in their largest part from
socially imposed inequities and injustices in exposure and access to
resources (i.e. poverty and all its trimmings and trappings). Although
it is easier, more convenient, and more comfortable to blame the victim
than to blame society and ourselves, we must trash junk science and
finally take responsibility for the existence of health disparities in
the U.S. We need look no further than five hundred years of exploitation
and domination of a "race" of people for answers. Accepting this, I
believe, is the critical first step that will free a just society to
make hard choices and truly end health disparities once and for all.

**Additional Reading**

1\. Todd, NW. Familial predisposition for otitis media in Apache Indians
at Canyon Day, Arizona. *Genet Epidemiol*. 1987;4(1):25-31.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=3569876&query_hl=1&itool=pubmed_docsum>

2\. Curns AT, Holman RC, Shay DK, et al. Outpatient and hospital visits
associated with otitis media among American Indian and Alaska native
children younger than 5 years. *Pediatrics*. 2002 Mar;109(3):E41-1.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=11875169&query_hl=2&itool=pubmed_docsum>

# Announcements from the AAP Indian Health Special Interest Group 

Sunnah Kim, MS **Locums Tenens and Job Opportunities**

If you have a short or long term opportunity in an IHS, Tribal or Urban
facility that you'd like for us to publicize (i.e. AAP Web site or
complimentary ad on Ped Jobs, the official AAP on-line job board),
please forward the information to <indianhealth@aap.org> or complete the
on-line locum tenens form at <http://www.aap.org/nach/locumtenens.htm>

.