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S. HRG. 107–601

NATIVE AMERICAN ELDER HEALTH ISSUES

HEARING

BEFORE THE

COMMITTEE ON INDIAN AFFAIRS

UNITED STATES SENATE

ONE HUNDRED SEVENTH CONGRESS

SECOND SESSION

ON

OVERSIGHT HEARING TO EXAMINE THE LONG TERM CARE AND

HEALTH CARE NEEDS OF NATIVE AMERICAN ELDERS

JULY 10, 2002

WASHINGTON, DC

(
COMMITTEE ON INDIAN AFFAIRS

DANIEL K. INOUYE, Hawaii, Chairman

BEN NIGHTHORSE CAMPBELL, Colorado, Vice Chairman

KENT CONRAD, North Dakota

HARRY REID, Nevada

DANIEL K. AKAKA, Hawaii

PAUL WELLSTONE, Minnesota

BYRON L. DORGAN, North Dakota

TIM JOHNSON, South Dakota

MARIA CANTWELL, Washington

FRANK MURKOWSKI, Alaska

JOHN McCAIN, Arizona,

PETE V. DOMENICI, New Mexico

CRAIG THOMAS, Wyoming

ORRIN G. HATCH, Utah

JAMES M. INHOFE, Oklahoma

PATRICIA M. ZELL, Majority Staff Director/Chief Counsel

PAUL MOOREHEAD, Minority Staff Director/Chief Counsel

(II)
(III)

C O N T E N T S

Page

Statements:

Allery, Alan, director, National Resource Center on Native American

Aging .............................................................................................................. 12

Annette, Kathleen, M.D., area director, Bemidji Area, Indian Health

Service ............................................................................................................ 5

Baker, Frederick, chairman, Mandan, Hidatsa and Arikara Elders Organization, Three Affiliated Tribes, North Dakota ........................................ 23

Baldridge, Dave, executive director, National Indian Council on Aging ..... 21

Campbell, Hon. Ben Nighthorse, U.S. Senator from Colorado, vice chairman, Committee on Indian Affairs .............................................................. 2

Conrad, Hon. Kent, U.S. Senator from North Dakota .................................. 16

Finke, Bruce, M.D., elder specialist ................................................................ 5

Inouye, Hon. Daniel K., U.S. Senator from Hawaii, chairman, Committee

on Indian Affairs ........................................................................................... 1

Jackson, Yvonne, director, Office for American Indian, Alaska Native

and Native Hawaiian Programs .................................................................. 3

Ludtke, Richard L., director of research, Center for Rural Health, University of North Dakota ..................................................................................... 14

McDonald, Leander ‘‘Russ’’, researcher, Center for Rural Health, University of North Dakota, Grand Forks, ND ..................................................... 12

Vanderwagen, Craig, M.D., acting chief medical officer, Indian Health

Service ............................................................................................................ 5

Walker, Edwin, director, Centers for Wellness and Community-Based

Services, Administration on Aging .............................................................. 3

APPENDIX

Prepared statements:

Allery, Alan (with attachments) ...................................................................... 46

Annette, Kathleen ............................................................................................ 39

Baker, Frederick ............................................................................................... 78

Baldridge, Dave ................................................................................................ 69

Cantwell, Hon. Maria, U.S. Senator from Washington ................................. 31

Ludtke, Richard L. (with attachments) .......................................................... 46

McDonald, Leander ‘‘Russ’’ (with attachments) ............................................. 46

Walker, Edwin .................................................................................................. 32

Note: Other material submitted for the record retained in committee

files.

(1)

NATIVE AMERICAN ELDER HEALTH ISSUES

WEDNESDAY, JULY 10, 2002

U.S. SENATE, COMMITTEE ON INDIAN AFFAIRS, Washington, DC.

The committee met, pursuant to other business, at 10:15 a.m. in

room 485, Senate Russell Building, Hon. Daniel K. Inouye (chairman of the committee) presiding.

Present: Senators Inouye, Campbell, and Conrad.

STATEMENT OF HON. DANIEL K. INOUYE, U.S. SENATOR FROM

HAWAII, CHAIRMAN, COMMITTEE ON INDIAN AFFAIRS

The CHAIRMAN. The committee meets this morning to receive testimony on an ongoing study that is being conducted by the National Resource Center on Native American Aging within the Center for Rural Health at the University of North Dakota School of

Medicine and Health Sciences. This study examines the long term

care and health care needs of America’s Native American elders.

Despite the fact that the American Indian population is one of

the fastest growing populations in the United States, the status of

elderly Native Americans is, to put it simply, poor. As the testimony today will indicate, almost three out of five elderly Native

Americans live well below the poverty level. Diseases such as diabetes afflict Indian elders at epidemic rates, and the mortality rate

from diabetes is five times higher than the national average.

Deaths associated with kidney disease are three times the national

average among Native American elders.

These statistics are overwhelming and the need for age sensitive

health care and for long term care is obvious. Unfortunately, the

long term care options for most Native American elders are minimal at best and often require decisions that break families apart.

With few long term care facilities available on most Indian reservations, elders requiring such care may have to be placed hundreds

of miles from their homes and families. Poor families don’t have

the means to travel back and forth to visit their grandmothers and

grandfathers, and sadly, we know that many families in Indian

country are constrained in this way.

Home health care alternatives are also extremely limited in most

tribal communities. So while families may ultimately decide that it

is best to keep their loved ones at home, like most families across

America, few have the professional training to adequately care for

their elders. These are the tragic circumstances that many Native

American elders face as they enter into their twilight years.
2

Today we hope that the testimony will shed some light not only

on the conditions in Indian country as they affect the elderly, but

what can be done to better address their needs. As one who qualifies under almost any definition as an elder, I take these matters

very seriously. And I look forward to the constructive solutions that

we anticipate will be forthcoming from the testimony received

today.

And may I recognize the vice chairman.

STATEMENT OF HON. BEN NIGHTHORSE CAMPBELL, U.S. SENATOR FROM COLORADO, VICE CHAIRMAN, COMMITTEE ON

INDIAN AFFAIRS

Senator CAMPBELL. Thank you, Mr. Chairman.

We don’t normally make headlines in the New York Times and

the Washington Post about the activities in this committee, but

they are extremely important to one segment of the American population, and that’s the Indian people. The hearing today is one of

those that involves Native elders, a group revered in Indian cultures, but also a group that is often quiet and in the background

when it comes to public debate. As the 2000 census makes clear,

the Native population, like the U.S. population, is growing at a

very fast pace.

I think that when we talk about the future of elders, I might

mention that during the break I went to Montana, visited the

Northern Cheyenne, where I happen to be a member. I was asking

the tribal chairman up there about the growth of that tribe. There

are about 8,000 enrolled in that tribe. But 75 percent are under 25

years old, which of course gives us a whole host of problems with

education and jobs and all that. But those youngsters are some day

going to be elders, too. And we don’t seem to be ahead of the curve

when we talk about what’s going to happen in another 20 or 30 or

40 years about those young people now who are all going to have

these problems. These include, as you know, diabetes, which leads

to poor circulation, gangrene and then amputation of the lower extremities, things of that nature.

I think your comments about the difficulty of families visiting is

really important. I know that in the case of that little community,

Lame Deer, MT, one of the places that elders are put after the

have had their legs amputated, which happens too often, is clear

in Glendive, MT, about 100 miles away. That means if their family,

their grandkids, their youngsters want to visit them, and they don’t

have transportation, they just don’t see them any more, because it’s

just too far to go to be able to visit the elderly that are in the hospitals with their extremities cut off. That means they have a

mighty lonely existence in the last years of their lives, which

shouldn’t be anything that anyone should have to go through. It

seems to me one of the great things about growing older is your

ability to be close to your kids and your grandkids. But when they

suffer these debilitating problems brought on by diabetes, that’s

not the way too many elderly Indian people finally go to their

Maker.

Thank you, Mr. Chairman, for convening this hearing.
3

The CHAIRMAN. I thank you very much. You are so correct, your

autumn years should be the happy years. But in too many cases,

such is not the case.

We have two panels this morning. The first panel, Director of the

Centers for Wellness and Community-Based Services, Administration on Aging, Edwin Walker. He will be accompanied by Dr.

Yvonne Jackson, Director of the Office of American Indian, Alaska

Native and Native Hawaiian Programs, Administration on Aging.

And then we have the Area Director of the Bemidji Area Indian

Health Service of Bemidji, Minnesota, Dr. Kathleen Annette, who

will be accompanied by Dr. Craig Vanderwagen, Acting Chief Medical Officer, Indian Health Service, Rockville, and Dr. Bruce Finke,

Elder Specialist.

Dr. Walker.

STATEMENT OF EDWIN WALKER, DIRECTOR, CENTERS FOR

WELLNESS AND COMMUNITY-BASED SERVICES, ADMINISTRATION ON AGING, ACCOMPANIED BY YVONNE JACKSON,

DIRECTOR, OFFICE FOR AMERICAN INDIAN, ALASKA NATIVE

AND NATIVE HAWAIIAN PROGRAMS

Mr. WALKER. Good morning, Mr. Chairman and members of the

committee. On behalf of the U.S. Administration on Aging, I appreciate the opportunity to discuss the health concerns of Native elders and to provide some information about our programs. I commend this committee’s commitment to Native Americans and the

support you have shown for aging issues in Indian country.

As indicated, I am accompanied by Dr. Yvonne Jackson, the Director of our Office of American Indian, Alaska Native and Native

Hawaiian Programs at the Administration on Aging. Josefina

Carbonell, our Assistant Secretary for Aging, has identified health

promotion and disease prevention among her priorities for the Administration on Aging. Our focus is on encouraging Americans of

all ages to live healthier lives. Healthy living can prevent diseases

and certain disabilities, and it can ensure that today’s older persons, as well as our future generations, not only live longer, but

also better.

Great strides have been made in improving the health status of

American Indians and Alaska Natives. Yet, cardiovascular disease

remains the leading cause of death for all populations in the

United States, and one-half the adults have diabetes. Diabetes

complications are some of the major causes of morbidity and mortality among older Indians. The Administration on Aging is working with the Indian Health Service, tribal health and social service

departments and universities to assist in developing programs and

services for preventing and controlling diabetes.

The AOA annually awards grants to provide supportive and nutrition services for American Indian, Alaska Native and Native Hawaiian elders. Our Older Americans Act Title VI program has been

funding services in Indian communities throughout the country for

the last 22 years, growing from services in 85 tribes in 1980 to over

300 tribes serving nearly 100,000 Native elders today.

Our programs provide a wide range of services, including congregate and home delivered meals, transportation to meal sites and

doctor’s appointments, wellness programs, home health services,
4

adult day care and family caregiver support, just to name a few.

These services achieve the goal of assisting elders to remain in

their homes and communities for as long as possible. In addition

to our programs that directly assist the elderly, AOA now assists

those who care for the elderly and the disabled through our Native

American family caregiver support program.

In order to assist the tribes in developing home and community

based services for their elders, AOA has awarded grants to two national resource centers, one at the University of Colorado and one

at the University of North Dakota. AOA and the resource centers

collaborated on a study that concluded that there is a wide disparity between the need for and the availability of home and community based long term care services. While emergency and acute primary health care is usually met, other services, such as mental

health, home health, personal care and transportation are only

moderately met, and services such as adult day care, respite care

and assisted living are unmet.

In response to requests for assistance from tribes, we asked our

resource center at the University of North Dakota to develop a

needs assessment tool that provides tribes with an accurate picture

of the health status of their elders. Although the resource center

will discuss the results of the needs assessment in detail, I would

like to highlight just some of the data noteworthy in developing

home and community based services.

Nearly 30 percent of Indian elders live alone. As compared to elders in the general population, a greater percentage of Indian elders consider their health to be fair or poor. Many more Indian elders are overweight, and yet may be less aware of their overweight

status since they consider their weight to be just about right. Most

Indian elders indicated they would be willing to go to an assisted

living facility, while only 18 percent of the elders indicated they

would be willing to use a nursing home.

The feedback that we’ve received from the tribes who are using

the needs assessment has been very, very positive. They are happy

to have the data, but now they are requesting additional assistance

in interpreting the data and in how to use the information in program planning. We are working with the staff of the resource center in order to provide this additional assistance.

Mr. Chairman, we are very proud at the Administration on

Aging that we are able to provide services and assistance to American Indian, Alaska Native and Native Hawaiian elders and their

families. We are committed to working with you and your colleagues to improve the quality of life in Indian country in the years

ahead. Thank you very much, and Dr. Jackson and I would be

happy to answer any questions that you have.

[Prepared statement of Mr. Walker appears in appendix.]

The CHAIRMAN. Thank you very much, Mr. Walker. May I now

recognize Dr. Annette.
5

STATEMENT OF KATHLEEN ANNETTE, M.D., AREA DIRECTOR,

BEMIDJI AREA, INDIAN HEALTH SERVICE, ACCOMPANIED

BY CRAIG VANDERWAGEN, M.D., ACTING CHIEF MEDICAL

OFFICER, INDIAN HEALTH SERVICE, BRUCE FINKE, M.D.,

ELDER SPECIALIST

Ms. ANNETTE. Good morning. My name is Kathleen Annette. Accompanying me is Dr. Craig Vanderwagen and Dr. Bruce Finke.

Dr. Bruce Finke is a geriatric specialist in the Indian Health Service, and Dr. Vanderwagen is the chief medical officer.

I have a prepared statement, which you have, and I would like

to take the opportunity now to summarize this for you.

The CHAIRMAN. Without objection.

Ms. ANNETTE. I am an American Indian physician, a family doctor who has worked on reservations off and on most of my life, and

currently am an area director. I also have a mother who is currently in dialysis, diabetic and dealing with personally many of the

issues that we’re talking about today.

Who are these people that we’re talking about, these Indian elderly? In the tradition of my people, the best way for me sometimes

to explain this is really to tell you a story. And this is a true story.

I have, or had, an 84 year old great aunt. She called me one 9day

and said, as many of our elders do, it’s your turn to come and take

me to the clinic to pick up my pills.

So I picked up Aunt Mary and we headed to Cass Lake Indian

Hospital, where she had received her care for 84 years of her life,

and came to the one stop light in town. And the one stop light in

town stays red and red and red. So we pulled up and wouldn’t you

know it, there was a very young couple that was necking at the

stop light. I don’t know how else to put it. And Aunt Mary looked,

and I was embarrassed. She kept pushing me aside and she kept

looking. She said, look at them, they’re hot. I said, oh, Aunt Mary.

She said, well, I used to be. [Laughter.]

This is an 84 year old elder. I took this story about—have any

of you seen Wind Talkers? A wonderful, wonderful film about the

Navajo code talkers. I told this story at a national meeting that I

was attending where the code talkers brought in the colors. I was

so proud. And they listened, and they came up to me afterwards,

and I thought, gee, these wonderful elders are going to really give

me some encouragement. And what they told me is they wanted to

meet my Aunt Mary. [Laughter.]

But these are the people we’re talking about in terms of elders.

They’re the ordinary Indian people that are at home dealing with

issues every day, and they are Indian people that have had extraordinary experiences and contributions to this country.

What are they dealing with at home? When we ask them, and

I think the North Dakota study is fantastic, and you’ll hear more

about that, it gives us some baseline data from 88 tribes, that is

incomplete. It has to be expanded to more, and we’ll have a much

better data base and information to share with tribes.

The issues they bring to us and that we deal with in Indian

Health Service is of course long term care. Are we involved in long

term care? You bet we are. And the reason for that is long term

care is a spectrum. It’s a spectrum. It’s a spectrum of services that
6

ought to be available. We are responsible for the hospital and clinic

portions, along in partnership with tribes.

What is our responsibility? It’s ongoing. We really need to work

with coordination of services. And we find that’s a real challenge

at local, regional and national levels.

We also really must assure that when our doctors and nurses

and providers provide geriatric care, the care we provide can’t be

good enough. Our care has to be outstanding. And whatever we do

to provide that piece, we need to assure that our primary care providers have geriatric training as part of what they bring to our

table when they come to serve our people.

These are the people we serve, these are people that have contributed so much to this Nation. Indian Health Service does have

a role. We must partner with others. We must continue to do much

of what we do and do it better. We have to partner with tribes and

say, ‘‘what is it you really need’’. Because I think if we’re going to

have a successful program, we must work with the tribes to develop what that program ought to be. And again, we’ll be talking

at length I think with you in terms of the services that define long

term care and how we can best design programs with tribes.

Thank you.

[Prepared statement of Ms. Annette appears in appendix.]

The CHAIRMAN. I thank you very much.

If I may ask, Mr. Walker, what gaps in Federal services have you

identified in diabetes or nutrition programs that, if services were

provided to fill these gaps would help alleviate the high incidence

of diabetes?

Mr. WALKER. What we’ve noted is that, and as I mentioned, we

do provide a nutrition program for the elders. What we’ve found is

that we need to continue our educational efforts. We have some

pilot projects, and Dr. Jackson can speak directly about those

projects that include researchers pairing up with elders and tribes

to discuss the types of foods that they eat. We had one case where

they gathered foods, they tested the glycemic level in the foods to

determine the rate at which glucose is generated, I guess, within

the food. Then they incorporated new practices of preparing foods

and which foods to use and eat into the Native culture.

Ms. JACKSON. A couple of years ago, we had some funding for

some pilot breakfast projects. Some of the tribes, notably the Rosebud Sioux Tribe, decided they could best serve their elders, the diabetic elders, by serving a breakfast. Because they would find the

elders would come to the site at lunch and hadn’t had breakfast.

And when they had their glucose monitored, they would be either

really high or really low. So they for 1 year with funding from us,

they provided breakfast for the elders.

The program was so successful that even when our funding ran

out, the tribe picked up the funding of it. They have found that the

elders that participate in the two meal a day program, their blood

glucose levels are much better controlled.

So if we could find practices like that, programs like that that

really made a difference, and then be able to expand those into

other communities, I think we could see some real benefit in the

health of the elders.
7

The CHAIRMAN. What would it cost if we carried out that practice

on all of the reservations?

Ms. JACKSON. I don’t even have a clue. We would have to look

at that. Because some of our programs now are really struggling

to provide one meal a day. The number of elders has increased so

rapidly that the Indian programs differ from the non-Indian programs in that we find many of the non-Indian programs will cut

off the number of people attending the meal site. If they’re running

short on money, then they say nobody else can come. The Indian

programs, we don’t say nobody else can come. We’ll continue serving people and feeding people, and then we have to limit the number of days. So we’ll feed everybody for 3 days a week, rather than

serving fewer people 5 days a week.

So we’re finding a number of our programs now, due to the funding level of the program, are only serving lunches 3 days a week,

rather than the 5 days a week.

The CHAIRMAN. Mr. Walker, as you can imagine, none of us are

experts here, so we have to depend upon you and other experts to

provide us with the necessary statistics and information. Based

upon that, we can act if moneys are needed.

When I became a member of this committee about 25 years ago,

I was told that if an Indian elder reached the age of 50, the odds

were that he had diabetes, and that the mortality rate for those

with kidney problems were 3 times the national average. And apparently, it is still the same. Will any attempt be made by AOA

to let us know what it could cost to bring these statistics above

that of third world countries?

Mr. WALKER. Mr. Chairman, the Administration on Aging, and

I’m sure the entire Department of Health and Human Services,

would be very pleased to work with you in reviewing the statistics

and discussing how we can best achieve better goals in addressing

the health status of Native Americans.

The CHAIRMAN. Has any comprehensive study ever been made?

Mr. WALKER. Related to the?

The CHAIRMAN. The health of elders.

Ms. ANNETTE. From an Indian Health Service perspective, I

think a comprehensive study as you speak of has not. I believe we

have elements. And a coordinated effort to look at those elements

will give us a better overall picture. And perhaps the gaps can be

identified then and we can give you a better feel, I think, overall

of what the need is. But I think the answer to that, to my knowledge, no.

The CHAIRMAN. What would it take for us to have this coordinated study to identify the gaps?

Ms. ANNETTE. I think that to look at this, it may be best to have,

this is my idea, perhaps have an inter-agency group look at this

along with tribes and sit down and say, what has been done, what

needs to be asked. I think we have a beginning of that with the

North Dakota study. We have some tools to take a look at that.

Again, it may be that from a tribal perspective, they would like

to have data, to find out where are we today. It’s similar to what

you’re asking for, Senator.

The CHAIRMAN. Do we need legislation to bring this about?
8

Mr. VANDERWAGEN. Mr. Chairman, I would think that legislation

is probably not necessary. I know this Secretary, Secretary Thompson and Deputy Secretary Allen are very supportive of exploring

ways we can eliminate disparities in health. This is one of the

major initiatives I think that this Department is pushing forward

at this time. So I believe that there is support within the executive

branch for this kind of interest.

I don’t know at the moment that there’s a specific requirement

necessarily for legislation. But that’s something that probably

needs to be studied a little more comprehensively. As we’ve suggested to you, we don’t have a comprehensive look at what the impact of many of these issues are in aging Indian populations. With

study, it may be that some legislative corrections may be needed.

The CHAIRMAN. What can we do to bring about this study?

Ms. ANNETTE. I think we certainly will, you have expressed to us

such an interest that it’s something——

The CHAIRMAN. How much would it cost?

Ms. ANNETTE. Good question.

The CHAIRMAN. We would try to provide it. But we do not know.

You will have to tell us.

Ms. ANNETTE. I’m not prepared today to come up with that number. But I certainly will make sure that we coordinate with other

agencies to get that information to you.

The CHAIRMAN. Will both of you get together and tell us what

you need?

Mr. WALKER. Absolutely. And in fact, the Secretary operates the

Department of Health and Human Services as one department. As

a result, we are working better together, more so than we have

ever done in the past.

Ms. ANNETTE. I would like to interject, we also have another

piece of information that I believe we’ve provided for you, and

that’s a roundtable that was done really looking at long term care

needs within Indian country.

The CHAIRMAN. I have the report here.

Ms. ANNETTE. You have the report.

The CHAIRMAN. Mr. Vice Chairman.

Senator CAMPBELL. Thank you, Mr. Chairman.

Before I ask a couple of questions, let me just maybe make a few

comments. If you were to go into most committees here on the Hill,

and you asked them what the word commodities brings to their

mind, they wouldn’t have a clue. But many of the people that come

in this committee, they know what the word commodity means. Basically, what it means for anybody in the audience that’s not here

is Government surplus food that is given to Indian tribes that is

primarily high starch, some of it is white cans with no labels, it’s

just written on the can what’s inside. Surplus cheese, almost all

the commodities have a high starch content or a high content of

what creates cholesterol, as you know.

So it seems to me that when we do more studies or we talk about

putting more money into the problem, we need to go back and address the underlying problem that got us there. If we don’t change

that, we can pour tons of money into it and it still won’t correct

it. We’ve got to deal, it seems to me, through education and recog-
9

nize that there is a lifestyle problem and maybe in some cases, a

difference of heredity too.

But when I talk to elders about their elders, I don’t know any

that would tell you that their grandparents that lived before the

turn of the century had a problem with diabetes. Maybe after the

reservation system was initiated, but certainly not when they had

plenty to do. They might have died of a lot of other things, but it

wasn’t diabetes. They had a different kind of a diet. And I think

that has an awful lot to do with it.

I happen to live on the Southern Ute Reservation. They just built

a very, very nice facility there that is comprised of, it’s really a

gymnasium but it’s really a wellness center. Because they offer

cooking classes and they do a number of things to try to teach people that just exercise alone isn’t going to cut it. You’ve got to do

a lot of other things, too. I think that’s really important.

And that makes it all the more difficult, because you can educate

young people about having a better diet, but if they don’t have access to money, i.e., a job to buy what they need for a better diet,

they’re still reduced to living on commodities. So you have this kind

of endless cycle that they can’t get out of, and so it seems to me

the health of Indian people is really related to a lot of things just

based on the circumstances which keep them in that hole where

they can’t seem to get out.

Let me just ask a couple of questions. One of them is, I mentioned that maybe heredity plays a part and so on. The Native

Alaskans, they still live, I think, to a higher degree, on subsistence

and gathering, probably more than many in the lower 48. I know

that having gone up there a number of times and eaten muktuk,

high fat from a seal and whale and so on, which doesn’t taste great,

by the way, but I’m interested in knowing if there is any disparity

between the elders in Alaska and the elders in the lower 48 on diabetes or diet related illnesses.

Ms. ANNETTE. Yes; there is, there has been. In the past, when

Alaska Natives lived a life that you describe, their rates are much,

much lower. What we have found is that as they become more acculturated, perhaps, with the western diet as we know it, the rates

of diabetes are going up. So I guess that goes to really support the

point that you’ve made, that it truly is lifestyle.

I’m really intrigued by the fact that you put, and it’s so true, we

have to put an emphasis on prevention. What I’ve found in some

of our elders is they seem to think that they’re beyond prevention

at that point when some of these illnesses have hit. One of our education challenges is to say to the elders, ‘‘prevention never stops’’. There are ways we can maintain, get better, by doing some prevention, interventions throughout a person’s lifetime. That’s a challenge we have and that’s a message we must get out to our elders.

Prevention is always, always important, those activities.

Senator CAMPBELL. Along that line, I might also suggest that 50

years of commodities can’t be turned around in a matter of 1 day

or 2 days or 1 year. Some of the damage that’s done by poor diets

over the years, you just don’t fix it by taking a couple of pills for

1 week. That’s something that takes a long time.

Let me mention one other thing I wanted to get your opinion on,

either you or maybe Mr. Walker. I understand that in the case of
10

the Pimas, there are American Pimas and Pimas that live in Mexico. The American Pimas, like many of us, they eat more processed

foods, their kids probably watch more TV and have less exercise,

like any other kid in America does now, compared to years ago

when they had to work the land. But the Mexican Pimas have a

higher corn diet and different lifestyle, probably not as many

things that we have on this side of the border. Do you know of any

difference between the Mexican Pimas related to diabetes and the

American Pimas?

Mr. VANDERWAGEN. Yes; there are about 1,500 tribal members of

the Tohono O’odham Nation that live in Sonora. We have in the

last few years conducted some health fairs and health surveys in

that population, because the Tohono O’odham Nation of course is,

federally recognized and these are tribal members. In fact, the

rates of diabetes are lower in Sonora than they are across the border in Arizona. Unfortunately, those folks are dying of accidents

much more frequently, so we have a different set of issues to cope

with there. But at least they don’t view Spam as a traditional native food.

Ms. JACKSON. The research that’s been done on the foods that

they eat is what prompted us to work with Utah State University

on doing the nutrient content of foods of the Utes in Utah and the

northwest. Because down in the Pimas in Mexico, they’re still eating much more of their traditional food. And even though it’s corn,

a high starch diet, the corn has a lower glycemic index than the

bread that the Pimas on this side of the border are substituting for

it.

So we’re using the research that was done down there to hopefully incorporate more native foods in the Utes in Utah and the

northwest tribes to again maintain their culture by eating more of

the traditional foods, but also substituting some of the better foods

for the commodity foods and the store-bought foods.

Senator CAMPBELL. Is it less processed, too?

Dr. YOUNG. Yes; a lot less processed.

Senator CAMPBELL. A few years ago, some of us on the committee

tried to initiate a program with the surplus buffalo from the Federal herds to go to nutrition programs for Indian elders. We weren’t

very successful with that, but we are still trying. I know part of

it has to do with low protein, too, in diets.

Let me ask one other thing. Since the University of Colorado was

brought up, and I am from there, could you describe to me the

kinds of activities that resource center is going to participate in?

Mr. Walker?

Ms. JACKSON. The Resource Center in Colorado is developing a

lot of training materials for health care professionals working with

tribal members, and especially urban Indian elders. We find on the

reservations there is much more cultural sensitivity. But in the

urban areas, there is essentially no sensitivity to the needs of elders. They have developed one on diabetes, one on cancer, they’ve

just developed one on depression and cardiovascular diseases and

alcoholism. So their focus this next year is going to be on training

professionals and paraprofessionals for working with Indian elders.

Senator CAMPBELL. Is that the center that’s being developed at

the old Fitzsimmons site?
11

Ms. JACKSON. Yes.

Senator CAMPBELL. Oh. Well, you’ll have to come to the unveiling. They’ve named the thing after me. [Laughter.]

I wondered what the connection was. You’ll have to come to that.

It’s a beautiful building, by the way.

Ms. JACKSON. That’s what I understand.

Senator CAMPBELL. Maybe the last thing I mentioned, about the

elder population and how many youngsters are coming up now, the

2000 census reported only 12 percent of the Indian elder population

is 55 or older. It seems to me that logically, what we need to do

is cultivate in youngsters lessons about exercise, good health habits, that kind of thing. Is that outside of the scope of your agencies,

Mr. Walker?

Mr. WALKER. No; not really. What we are doing is broadening

our scope. While we are certainly focused on the needs of the elderly, we believe that we need to prepare people to be older by giving

out broad based messages about prevention, about lifestyle changes

that need to take place that will impact the quality of life you have

when you are older.

Senator CAMPBELL. Good. And perhaps one last question, you

mentioned that you just awarded caregiver grants to 177 tribes.

What was the total amount of the grants, and what was the average amount given for the grants?

Mr. WALKER. The total amount was $5.5 million, and the average

award was about $18,000.

Senator CAMPBELL. Were those grants given on some competitive

basis, or how do you give the grants?

Mr. WALKER. All federally recognized tribes are eligible to apply.

And they indicate an interest in the ability to provide caregiver

services and the statute prescribes five services that they choose

from in terms of the provision to their elders and to family caregivers. So they have to meet those criteria.

Ms. JACKSON. They’re non-competitive, and everybody that applied received a grant.

Senator CAMPBELL. Everybody that applied received a grant? So

that means about 300 and some odd tribes didn’t apply, is that correct?

Mr. WALKER. That’s correct.

Senator CAMPBELL. Do they know about it? One of the problems

we have sometimes, we put things in place here, it’s administered

by the Administration, then we’re told later by tribes that they

didn’t know, because there is a disconnect, an information disconnect about what is available to the tribes. Are all tribes aware

that they can get these grants?

Ms. JACKSON. Only the tribes that receive the part A grants, the

nutrition and supportive services, were eligible for the caregiver

grants. We have 235 that receive the Part A. So those were the

only ones eligible for the caregivers grants. And some didn’t apply

just because they didn’t think they were ready to begin a new program at this time.

Senator CAMPBELL. I see. Thank you.

Thank you, Mr. Chairman.

The CHAIRMAN. I thank you very much.
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If we may, we would like to submit questions for your consideration and response. Thank you very much.

Our next panel consists of the Director of Research, Center for

Rural Health, University of North Dakota, Dr. Richard Ludtke; Researcher, Center for Rural Health, University of North Dakota, Leander ‘‘Russ’’ McDonald. He will be accompanied by Alan Allery,

Director of National Resource Center on Native American Aging,

University of North Dakota.

May I call upon Mr. Ludtke.

Mr. LUDTKE. If Dr. McDonald would start, please.

STATEMENT OF LEANDER ‘‘RUSS’’ MCDONALD, RESEARCHER,

CENTER FOR RURAL HEALTH, UNIVERSITY OF NORTH DAKOTA, GRAND FORKS, ND, ACCOMPANIED BY ALAN ALLERY,

DIRECTOR, NATIONAL RESOURCE CENTER ON NATIVE

AMERICAN AGING

Mr. MCDONALD. Mr. Chairman and other members of the committee, I’m honored for the opportunity to speak on behalf of my

elders. My name is Russ McDonald, my mother is an Arikara from

the Three Affiliated Tribes and my father is a Dakota from the

Spirit Lake Nation. Both reservations are located in North Dakota.

I am a research analyst at the National Resource Center on Native

American Aging. The Resource Center is located in the Center of

Rural Health at the University of North Dakota School of Medicine

and Health Sciences. Established in 1993 with funding from AOA,

the Resource Center has a mission of providing research, training

and technical assistance to the Nation’s Native American elders.

Today we will be presenting new findings about prevalence of

chronic disease, their effect on functional limitations and differences in life expectancy for Native American populations from a

nationwide elders needs assessment project called Conducting

Local Assessments: Locating the Needs of Elders. The project entails conducting a survey on reservations that voluntarily participate in this project and allows for comparison of elders on reservations with their national counterparts.

The results from the research not only provide us with new information about Native elders, but also gives each tribe data they can

use to help guide them in developing long term care infrastructure

for their communities. The data has been used by a number of tribal communities in their planning efforts, program development and

grant application, primarily directed at addressing the need for

long term care services within our community.

To date, we have 83 tribes with 8,560 Native elders having filed

out the survey. Two additional tribes are being processed this week

and will be added to the aggregate file upon completion.

With that background on the study, let me share with you a picture of elder health and long term care needs on our results. Life

expectancy for Native Americans and Alaska Natives are low relative to the general population. In addition to important differences

between Natives and the general population, it is also very important to note that there is a substantial variation across Native

American and Alaska Native tribes in life expectancy across the Indian Health Service areas. Average life expectancy ranges from a

low of 64.3 years of age in the Aberdeen area to a high of 76.3
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years in the California area, a difference of 12 years. Life expectancy for the general population is 76.9 years.

Earlier this year, I attended the high school graduation at the

Spirit Lake Reservation and watched as grandparents congratulated their grandchildren in accomplishing a major goal. When I

graduated from high school in 1981, I had one grandmother still

living at age 77. She died 2 years later. My other grandmother died

during childbirth at age 37, with my two grandfathers dying both

from heart attacks, one at age 62 and the other at age 64. So while

the number of Native elders living to be old is increasing, old age

is still rare on our reservations.

Chronic disease. While quantity of life is an important indicator

of health for the general population, the health status of the aged

is also an important focus. As populations, including Native Americans, age, there is a likelihood of developing chronic illness like arthritis or heart disease, which can impact both life span and quality of life. For example, the Native elders are 19.5 percent more

likely than the general population to experience arthritis. Similarly, Native American elders are 48.7 percent more likely to experience congestive heart failure, 17.7 percent more likely to report

high blood pressure, 17.5 percent more likely to have experienced

a stroke, 44.3 percent more likely to report asthma, and 173 percent more likely to be afflicted with diabetes. Only cataracts are reportedly higher in the general population. So what we see here in

this data is that the Native elder is sicker than their United States

general counterparts but at least they’re able to see a little bit better.

Our data, as seen in figures 1 through 6, suggests that chronic

disease rates are higher among Native American elders in spite of

their shorter life expectancy. These findings suggest that the disparate health conditions of the Native elder are the result of other

factors, such as lifestyle, socioeconomic status and access to timely

and adequate care. Furthermore, these findings, and the prevalence of chronic disease, like life expectancy, varies across Native

American and Alaska Native tribes.

When the regional chronic disease rates in Native American and

Alaska Native elders are compared, we see apparent differences between areas. Arthritis rates reported in the survey tended to be

lower in the area of the southwest and high elsewhere. The same

pattern holds true for congestive heart disease. High blood pressure

tends to be reported at higher levels in the east and south. Asthma

rates again appear lowest in the southwest. Diabetes, while high

generally, produced lower rates for Alaska and the highest rates in

the Phoenix area. Persons reporting having experienced a stroke

were lowest in the Navajo and Phoenix areas, followed by the north

central and northwest areas.

On the last, I’d like you to keep in mind this represents people

who have been diagnosed with stroke and have survived. The areas

with the lowest life expectancies tended to also report lower rates

of stroke victims in their surveyed area. We believe these lower

and average rates of chronic disease to be the result of lower life

expectancy, rather than being indicative of better health status.

Chronically ill elders in these regions have shorter life spans, resulting in regional chronic disease rates that are lower. In a sense,
14

only the strong and healthy survive to be elders, which in turn affects the chronic disease rates in the Midwest and Alaska regions.

My colleague, Dr. Ludtke, will address the issue of increasing

numbers of Native Americans with functional limitations, reflecting

a growth in the need for long term care services. He will also comment on strategies for decreasing the number of individuals with

functional limitations.

I will be pleased to answer any questions now or after Dr.

Ludtke has completed his remarks. Thank you, Mr. Chairman.

[Prepared statement of Mr. McDonald appears in appendix.]

The CHAIRMAN. Thank you.

Dr. Ludtke.

STATEMENT OF RICHARD L. LUDTKE, DIRECTOR OF RESEARCH, CENTER FOR RURAL HEALTH, UNIVERSITY OF

NORTH DAKOTA

Mr. LUDTKE. Mr. Chairman and honored members of the committee, I’m also honored and grateful for this opportunity to speak.

Chronic disease varies widely, with some people minimally affected, while others have significant levels of disability. The level

of disability is related to functional limitations in the population

and used as a criterion for admission to nursing homes, assisted

living, to community based care, long term care programs. Nearly

all definitions of functional disability use information about activities of daily living and instrumental activities of daily living. Examples of the ADLs, activities of daily living, include such items as

eating and walking. IADLs, on the other hand, focus on limitations

like with cooking and shopping.

When ADLs and IADLs are combined, people can be classified

into four levels of need. The associated care requirements can be

identified as ranging from no long term care services needed to

home and community based care, to assisted living, and to skilled

nursing care, as seen in table 1. Using these categories, we are able

to estimate the numbers of people at these different levels of need

and determine the needs for different levels of long term care services. The prevalence of functional limitations increases with age

and the severity of limitations also increases with age. Figure 1

contains the data from our surveys regarding functional limitation

for Native American elders. It’s clear that the rates for all levels,

from moderate to severe, increase with age and that they do so

most dramatically in the oldest cohorts.

As the population ages, there will be an increased need for long

term care services. The number of people classified as elders in the

Native American population is about to explode, with the arrival of

those born during the baby boom as shown in figure 2. When one

combines the population data with the measure of functional limitation, a picture of growth in need for long term care is generated.

The most dramatic growth will occur as a result of the large

number of the baby boom cohorts in the next decade growth will

expand the population of young old, and barring any change, will

increase the need for moderate levels of care consistent with home

and community based services that are greater than the other cohorts.
15

Life expectancy for Native elders has been growing rapidly and

should be expected to grow in the future. Population projections

using IHS life tables and census data show that as of the year

2000, the Nation has approximately 218,000 Native American elders with functional limitations of a moderate or greater level. As

the population ages, the number of elders with functional limitations will grow assuming the same rates of disability are continued.

By the year 2010, as shown in Figure 3, we can expect a 51 percent

increase, or approximately 329,000 Native elders, to have functional limitations of moderate or more severe levels. The large

number of people becoming elders and the earlier ages of onset

from any chronic diseases that produce functional limitations creates a conservative estimate in the growth of functional limitations

to the end of the decade.

The health and vitality of future elders depends on a healthy lifestyle, including good diet, regular exercise, and refraining from

drinking and smoking. If people take care of themselves, they can

reduce the need for long term care services. Access to preventive

and other health services is important for delaying the onset of illness, as well as effectively treating disease. If we reduce only 10

percent of the Native American and Alaska Native limitations, we

would see a significant decrease in the demand for long term care

services.

Figure 4 presents the changes in the numbers of people with

each level of limitation that would occur if we had a 10-percent

across the board reduction in functional limitation. That could

occur with improved health promotion and access to state of the art

health care.

The recommendations that we derived from these observations is

that we need an initiative to develop an intervention and health

promotion models leading to improved outcomes for Native Americans and Alaska Natives as they enter their elder years. There is

a need for the development of long term care, it requires solutions

that are tailored in terms of both the types of care that work best

and the means by which local communities can realistically

produce the type of care required.

There is a need for increased support for targeted research on

Native American aging and related educational and capacity building programs. These are essential to help fill the gaps in information and help tribes anticipate emerging health care needs.

Three points of relevance to the Native American and Alaska Native people concerning long term care include the need to reduce

chronic diseases and functional limitations, to eliminate disparities

across tribes, between Native American elders and the general population, and to increase life expectancy. And lastly, to address the

shortages and lack of long term care options in Indian country.

I thank you for this opportunity to speak and would entertain

any questions, along with Mr. McDonald.

[Prepared statement of Mr. Ludtke appears in appendix.]

The CHAIRMAN. Thank you very much.

Senator Conrad, do you have any statement you’d like to make?
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STATEMENT OF HON. KENT CONRAD, U.S. SENATOR FROM

NORTH DAKOTA

Senator CONRAD. Just very briefly, Mr. Chairman.

First of all, I want to thank you very much for holding this hearing. I especially want to welcome Dr. Ludtke and appreciate the

work that he did on this survey. It is really sobering to look at the

statistics that are revealed here. When compared to the general

U.S. population, Native elders are almost 20 percent more likely to

have experienced a stroke, 50 percent more likely to have experienced congestive heart failure, more than 40 percent more likely to

report asthma, and perhaps most stunning of all, 170 percent more

likely to be afflicted by diabetes.

All of us have known before this survey was done that these statistics would probably be alarming. And they are. When it comes

to life expectancy in the Aberdeen area, which includes my home

State of North Dakota, we have the lowest life expectancy of any

area for Native Americans, 64 years compared to nearly 77 for the

general population.

Mr. Chairman, these statistics cry out for action. This is going

to require a dedication of resources and a commitment of effort.

Unfortunately, we see in the President’s budget that there is not

that commitment. And it is, I think, deplorable. But it’s not just

the President’s responsibility. Fundamentally, the responsibility

lies right here in the Congress of the United States. We have the

obligation to dedicate the resources to make a meaningful difference. And there has been a failure to do so.

Mr. Chairman, I hope this hearing will be the beginning of a

change in the level of attention and the level of commitment by the

Congress to address these issues, and once and for all, to make a

meaningful change.

I also want to thank Mr. McDonald for his contribution to this

study. I’m also pleased that Fred Baker, the chairman of the

Mandan, Hidatsa and Arikara Elders Organization is here to share

with us some of the experiences of Native elders in North Dakota.

I’d like also, Mr. Chairman, just briefly, to recognize two other people who are here today, Alan Allery, the Director of the National

Resource Center on Native American Aging, and Dr. Mary Wakefield, from the Center for Rural Health in North Dakota. Dr. Wakefield is my former chief of staff, and she has made a tremendous

contribution to these issues, not only in North Dakota, but here in

Washington. I know of no one with greater credibility to speak on

these issues than Mary Wakefield. I am so pleased that she has

gone home to North Dakota to make a contribution at our Center

for Rural Health there.

Let me say, Mr. Chairman, if I could, that you and the vice

chairman have been outspoken on the need to make a difference

on these issues. We appreciate your leadership. I think we’ve got

to find some way to convince our colleagues that more of the same

just isn’t going to get the job done. I don’t know what it’s going to

take to put a focus on these issues in a way that moves our colleagues.

I was just at one of our reservations over this break. We had terrible fires break out on the Standing Rock Sioux Reservation, more

than 40,000 acres burned. While I was there for an emergency
17

meeting, with people who had lost their homes as well as with the

leaders of the reservation and Federal officials who were part of

the response team, it really struck me once again, as I left that

hall, a young woman came up to me and said, Senator, something

has got to be done. We are having suicide on this reservation

among young people in numbers we have never seen before. She

said, there is a sense of hopelessness and despair, a sense that

there is no future. Now, that is a condemnation of what is occurring. And we have an obligation to respond.

I thank the chairman, and I thank the witnesses as well.

The CHAIRMAN. I thank you very much, Senator.

If I may ask a question of Mr. McDonald, you have accumulated

much data. Do you share this with the Federal Government?

Mr. MCDONALD. The descriptive statistics from the study are

posted on our web site underneath the research icon. So the numbers are available to the general public. Those statistics are from

the aggregate data file.

The CHAIRMAN. Do you know whether the Federal Government

is making use of that?

Mr. MCDONALD. No, sir; I’m not aware.

Mr. LUDTKE. Can I respond to that? These are being shared as

widely as we can. They are submitted to the Administration on

Aging. Each publication is submitted to the Administration on

Aging . They have been shared with the Indian Health Service, and

Dr. Finke has used them. So we are making every effort to get

them to the appropriate agencies.

The CHAIRMAN. Senator Conrad said we cannot do the same

thing for the same problem year after year. But since we are not

experts in this field, can you tell us what we can do? We are awaiting your suggestions.

Mr. LUDTKE. I think there are a number of things that we can

do. When we work with some of the tribes or State organizations

and they receive our data, they would like to carry it forward, and

they look to us for assistance. We’re frankly equipped to give some

of the information and the data, but not the counsel on how to develop long term care programs. I think we could develop a concerted effort to assist people in developing long term care programs

on reservations. I think we could develop demonstration projects

that are unique and culturally compatible with reservations. And

these could be tied to our research and educational efforts. I think

these are possibilities for responding that would, I think, have a

short start time and produce great results.

The CHAIRMAN. Have you looked into the possibility of submitting such a request to the Government?

Mr. LUDTKE. We have only talked about it. We have considered

it if we could find the vehicle, we would submit.

The CHAIRMAN. There is your vehicle right there. [Laughter.]

Mr. McDonald, have you looked into the possibility of what Dr.

Ludtke has stated?

Mr. MCDONALD. We’ve talked about it a little bit within the office, but as far as going further with it, we’re still in that process

of thinking of what could be developed first, before seeking assistance for that.
18

I’d like to maybe have Alan comment on that. He’s the director

of the Resource Center.

Mr. ALLERY. Just a brief comment. We are going to be meeting

with some Federal agencies this afternoon to discuss possibilities

further. But the Indian Health Service is the primary health care

provider for American Indians. And certainly, additional support

for health promotion activities would make a huge difference in the

health status of elders.

The CHAIRMAN. Well, my concern is that, as a member of this

committee, we have been giving these impassioned speeches year

after year about the dismal health conditions in Indian country.

And it is the same every year. Some day, I hope we can give

speeches saying that we have done something about it. And there

isn’t much we legislators can do unless we know what to do. And

no one has suggested to us what we can do, other than add 10 percent or add 5 percent. And even at that, we are not aware, or we

are not certain what it will accomplish.

But apparently, you people have some scientific data that could

be put to use. If you come up with a pilot program of sorts, I can

assure you we’ll look at it very seriously and put it on the right

vehicle, as you say.

Mr. ALLERY. We would like the opportunity to translate the research into action by working with various groups on model

projects, including specific tribes, perhaps, in North Dakota and

other States that would develop some models, some ideas that others could replicate.

The CHAIRMAN. Mr. Vice Chairman.

Senator CAMPBELL. Thank you, Mr. Chairman.

This by the way, is tremendously informative. Probably also predictable. I might say, Senator Conrad mentioned something maybe

along the line I was talking to, that we’ve got to really get ahead

of this curve, this population growth. We’re not putting enough resources in it, but I don’t know if we’ll ever be able to put enough

resources in it, because the underlying problem is growing faster

than even the resources that are available. Before Senator Conrad

came in, we talked about the population growth and the baby

boomers were mentioned and the post-baby boomers, the boomers

of the baby boomers.

And I’m not a scientist or a doctor, but I think in mighty simple

terms. I envision this problem like the shape of a pyramid. You

have the traditional number of people, and this is pretty well, I

think, alluded to in your study, traditional number of people, X

amount at that apex of the pyramid. Then you have the adults that

are on the reservations now, or Indian people, nationally growing

at a huge rate. Then you have the youngsters. I mentioned before

Senator Conrad came in that on the Cheyenne Reservation, 75 percent are under 25 years old.

Well, if we have that kind of a growth rate, and I imagine on

many reservations it is the same, if you envision that pyramid I

was talking about, and turn it over, that’s where we have the problem. The apex is down at the bottom now, and we have a number

of people that are elders down there that have existing problems

and that we have got to deal with. But as you go higher on that

inverted pyramid, the base is getting bigger and bigger, and the
19

baby boomer and the post- baby boomers is where the real problem

is going to be in another 20 or 30 years.

I don’t know how we get ahead of that, because it’s just not going

to be resolved by more resources from the Federal Government.

Somehow, we’ve got to get to the underlying problem of unemployment, lack of opportunity, all the things that reservations face now

that are somewhat similar to the things we would see in developing

countries. It’s something we simply have got to not just continue

to play catch-up with, but try to get ahead and recognize the problem we’re going to face in another 20 years. It’s going to be huge

compared to now.

Senator Conrad mentioned the suicide rate. I don’t know if that

was in the study or not. But I’m told on some reservations that almost half the teenage girls try to commit suicide before they are

out of their teen years, and about a third of the boys. I’m not sure

if that’s a valid number or not, but I know having been out to reservations a lot, it’s higher than the national average. And I’d like

to know a little bit about the problems that people are facing that

are related to suicidal tendencies. We’re talking primarily with seniors here, so maybe somebody could deal with that, if you could.

Was there anything done in the study that related suicide to bad

health in seniors, the elders?

Mr. MCDONALD. No; we had nothing on the mental health.

Senator CAMPBELL. Nothing on that.

Mr. MCDONALD. No; and I think what you’re seeing with the

elder population is that when we talk about suicides happening on

the reservation areas, that tends to be with the younger population. With the older population, I think at least for my people, is

that we don’t kill ourselves.

Senator CAMPBELL. Well, we shouldn’t, and traditionally they

didn’t. But they are now. A lot of young people are now. I know

some tribes traditionally, they felt that suicide for men was not a

way you could go to the next world, you would lose your way to the

next world if you did that. And it was an absolute no-no. They

might have died a lot of ways, but they didn’t kill themselves. But

they are now, as you know, youngsters are. It’s non-traditional, but

it’s happening.

So you don’t have any, really anything to compare suicide rates

for Indian elders with the national population?

Mr. MCDONALD. No; and from our discussions with the tribe that

we’ve been working with over the past few years, this is not an

issue that has come out of the focus groups that we’ve had or other

groups.

Senator CAMPBELL. Have you found any, in your study, any concrete suggestions you could give the committee on improving lifestyle habits to reduce some of the statistics you have in here?

Mr. ALLERY. One of the groups that we worked with in Minnesota, the groups of tribes in Minnesota developed a wisdom steps

program, which encompassed almost all elders in all the tribes in

Minnesota. And in working with the National Resource Center,

they were able to parlay their elder needs assessment into a

$250,000-grant from the Share projects at the University of Pennsylvania. Their progress has been substantial. The last session that

I went to, they had over 400 elders exercising, walking at least 2
20

miles a day. So that was, that’s kind of how the National Resource

Center works with many groups. We depend on the tribes to take

the initiative. And we work closely with them and the data is actually theirs. They can use it for planning their own projects and developing programs that meet the needs of their elders.

Mr. LUDTKE. Could I followup on that for just one comment?

Senator CAMPBELL. Yes.

Mr. LUDTKE. In the data we have questions that reflect on lifestyle issues. They weren’t included as part of the report this morning, but it’s very interesting to observe that the Native elders exercise more than the general population. The Native elders drink far

less than the general population. But in the area of diet, they have

greater problems.

As we looked at the lifestyle comparisons, we were kind of stricken with the notion that they seemed to have relatively good lifestyles, yet relatively poor outcomes. We’re left with the conclusion

that that had to revert back to diet, and the very thing you were

talking about earlier.

Senator CAMPBELL. Well, we’ve got to try to help, because it’s the

right thing to do. But I also happen to think those elders are one

of the most valuable resources that tribes have. Because those

youngsters that are in that population boom, one of the problems

they’re having is relating and finding and learning about the old

ways. The elders are the key, they’re the link. If we lose them, I

think we’ve lost something that is just simply not replaceable.

Thank you, Mr. Chairman.

The CHAIRMAN. Your discussion on suicide reminded me of a trip

that I took to Alaska for the first time 10 years ago. At that time,

I was advised that the suicide rate among young men between the

ages of 19 and 23 was 14 times the national norm. I think that is

unacceptable.

Senator Conrad.

Senator CONRAD. I’d like to go back to the question of what can

be done. In your analysis, did you do any separation based on economic circumstances for the health of elders? In other words, did

you look at different income categories and then look at how that

might relate to health?

Mr. LUDTKE. We haven’t. There is a great deal of analysis yet to

be done. We struggle to find the time to get the information back

to the tribes to this point, so we haven’t done extensive analysis.

One observation on the economic variable is that there’s not a

great deal of variability. My guess is that as we apply that, we’ll

find the absence of variability on that income variable, that a large

percentage of the population is below the poverty line.

Senator CONRAD. The two of you have spent more time with this

data than anybody else. Are there things that you observed, are

there things that kind of tickled your fancy, if you will, as you

looked at this data as to clues that might make a difference?

Mr. MCDONALD. I think somebody was talking about commodities earlier. I was raised on commodities, too, as you can tell. But

one of the things is that the highest thing, Dr. Ludtke mentioned

already, is the higher rates of exercise for Native elders. So they

exercise at higher rates, but they also have higher rates of BMI,

or they are more likely to fall into overweight and obese categories.
21

Therefore, the only thing I could think of that would otherwise

affect their higher BMI would be the nutritionals. So I think there

would have to be something to provide better nutrition and also

maybe continue exercising, for those who already are, and maybe

increase exercise for those people who aren’t.

Senator CAMPBELL. Would the Senator yield for a moment?

Senator CONRAD. Yes.

Senator CAMPBELL. You asked a question about different socioeconomic backgrounds for elders. From my own experience, you

rarely find an elder with much money, because it’s not a traditional

thing to accumulate money. If anything, they give it away. They

have giveaways, they do things to share it. So you don’t have much

individual wealth among elders anywhere, Indian elders. Not that

I know of. But that doesn’t mean the tribes can’t accumulate some

wealth through different kinds of opportunities, and provide some

of the programs that the elders need.

Thank you.

Senator CONRAD. In terms of diet, did you make observations

with respect to dietary differences between the elders and the Indian population and elderly people in other populations? Is there

some clue there as to what they’re consuming that is different from

others in healthier populations?

Mr. MCDONALD. Somebody talked about Alaska, and they are

still eating much of their traditional foods, like fish and wild game

and that type of thing. And what we’re seeing is that that region

tended to have lower rates in some areas.

Senator CONRAD. Lower rates of?

Mr. MCDONALD. Of chronic disease.

Mr. LUDTKE. The information that we gathered on nutrition was

relatively scant and survey data often tends to be scant, we often

ask one or two questions. What did happen was that we were triggered to look at nutrition as kind of a key variable. So if we have

an opportunity to do a second generation instrument, we plan to

expand that significantly.

We think this is an area that needs attention. We think health

promotion needs to be directed at nutrition. We think nutrition and

low incomes are at odds with one another. It’s very difficult to have

a nutritious diet if you don’t have an adequate income. It’s difficult

to buy fresh fruits and vegetables. And people will end up on processed foods, which are less healthy.

Senator CONRAD. Thank you.

The CHAIRMAN. Thank you very much. Like the first panel, we’d

like to submit question to you for your consideration and response.

On behalf of the Committee, I thank you very much.

Our final panel consists of the executive director of the National

Indian Council on Aging of Albuquerque, Dave Baldridge; and the

chairman of the Mandan, Hidatsa and Arikara Elders Organization

of the Three Affiliated Tribes of North Dakota, Fred Baker.

Mr. Baldridge, welcome, sir.

STATEMENT OF DAVE BALDRIDGE, EXECUTIVE DIRECTOR,

NATIONAL INDIAN COUNCIL ON AGING

Mr. BALDRIDGE. Thank you, Mr. Chairman. I believe that over

the time I’ve been in this business I’ve heard you make some of the
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most eloquent statements about Indian country since Chief Joseph,

probably, so it’s a great honor to have you listen to us this morning.

I know you need no one to tell you anything about the Federal

trust responsibility or that nowhere are the disparities in minority

health care so great, nowhere is the mandate to the Federal Government so compelling as with the well being of Indian elders.

Today we’re glad for this chance to bring your attention to a few

of them.

First, long term care. The need for long term care services in Indian country is great. It continues to grow. And while it’s recognized that there is no national overall policy regarding long term

care for the Nation’s elderly and disabled, it’s also true that billions

of dollars in Federal and State funds are spent on long term care,

particularly for nursing home and home and community based

services under Medicaid. It’s important to understand that there

are virtually no funds available to Indian country for long term

care.

States have the ability through Medicaid waivers and CMS has

the authority to approve requests to establish Indian only waivers

especially for home and community based long term care services.

We understand that no further legislative authority is necessary,

yet States are not seeking these waivers and we hope this committee could provide leadership in working with tribes and receptive

States to put such waivered services in place.

We’re also extremely concerned that senior health insurance

counseling and assistance services, SHIP program, is still not available for older Indians. Such funding is provided to all States, but

inexcusably, there’s no counterpart for Indian country, no analog.

Despite our repeated requests, we’re not aware that CMS or DHHS

has addressed this issue. Perhaps the Committee could help us inquire of CMS.

Of the issues that elders face, those not related directly to their

health are generally legislated through the Older Americans Act.

I would like to talk to you about some issues that are certainly related to long term care, such as elder abuse. Title VII of the Older

Americans Act, the vulnerable elder rights protection, was created

in 1992. It includes subtitle B, which authorizes a program to assist Indian country to prioritize and carry out elder rights activities. Yet funds have never been appropriated, although they have

been appropriated for States for similar purposes. These programs

seldom reach Indian elders. Tribe have little or not access to the

agencies, departments, ombudsmen or other programs that are

available to States. Further, tribes have no additional source of

mandated Federal funding for elder protection activities.

So we request that you not overlook basic protections like this

that are available to most of the Nation. A demonstration grant

program for Indian country of a million dollars would begin to address this very serious issue.

I would note on the side that our elders are living longer, but

they’re living longer with the amputations and the blindness and

the renal failure that go with the diabetes. That’s putting extraordinary burdens on their family caregivers. And we know that 90

percent of care for elders is given by adult children in homes and
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communities. So we think that may be a factor in abuse and that

long term care is certainly related there.

Title VI, as you’ve heard this morning, is an especially important

program in Indian country. The 238 programs funded there are a

primary source of services provided to reservation elders. Since

1980, title VI funding has been so inadequate for most of the years

that its services have never really been ‘‘comparable to those provided under title III’’ as the OAA often indicated. Nevertheless, this

program still is the cornerstone of Federal Services, including diabetes and health education for our elders. Current funding for

projects ranges from about $71,000 to a top end of $174,000 per

program. But we need an immediate increase of more than $30

million nationally to keep title VI directors able to deal with their

great responsibilities.

That’s related to title IV of the Act, research and demonstration

grants. This title has historically provided annual training for our

title VI program directors. However, since 1995, these activities

have not been funded. The reality is that title VI remains without

a national infrastructure, no paid staff, without a national training

program at any level, without the capacity for regional or national

meetings, and even without the capacity for its estimated programs

to communicate with each other, its 238 programs.

We urge you to sponsor a capacity building initiative directed by

NICOA, hopefully, to engender skill building, communication,

greater economic self sufficiency for title VI programs. We request

the sponsorship of $600,000 for training title VI directors, so badly

needed, and developing their capabilities to better serve our elders.

And I’ll conclude, we’re very proud of some of our partnerships

and projects with diabetes, which is front and center for all of us.

We’re connecting some tribes through a project with the Administration on Aging with the United States Renal Disease System, so

they can look at ESRD. For CDC, we’re conducting a grassroots diabetes education program for Indian elders. As the NIH recently

published in the New England Journal of Medicine its DPPS study,

showing that interventions really make a difference in diabetes, we

are creating an atlas of diabetes for CDC, we are in the fifth year

of an interactive atlas of Indian elder health for the IHS. These

data projects are being extremely productive.

So thank you again.

[Prepared statement of Mr. Baldridge appears in appendix.]

The CHAIRMAN. Thank you very much, Mr. Baldridge.

Mr. Baker.

STATEMENT OF FREDERICK BAKER, CHAIRMAN, MANDAN,

HIDATSA AND ARIKARA ELDERS ORGANIZATION, THREE AFFILIATED TRIBES, NORTH DAKOTA

Mr. BAKER. Thank you, Mr. Chairman and honored members of

the committee. Thank you for allowing me to speak before this distinguished group regarding the concerns of the Indian elders of

North Dakota, and in particular the elders of the Mandan, Hidatsa

and Arikara Tribes.

My name is Frederick Baker. I am chairman of the Mandan,

Hidatsa and Arikara Elders Organization, an organization that

was officially chartered and sanctioned by the Three Affiliated
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Tribes Business Council to represent the concerns of our elder population and provide some direct services. I have been appointed to

the Governor’s Committee on Aging of the State of North Dakota.

The elders of the Fort Berthold Reservation are those folks who

are 60 years and older. We were born between the years 1905 and

1942. Our oldest member is 97 years old. There are approximately

573 of us that are in this age range; 307 of us live on the Fort

Berthold Reservation, 74 live outside the reservation but in North

Dakota, and 192 of us are sharing the virtues of North Dakota with

other States. [Laughter.]

Mr. BAKER. As an age group, we have endured and survived

great change. Most of us were born in dire poverty. Most of us saw

family members die from causes of the frustrations of poverty, such

as alcohol, despair, poor to non-existent health care. Most of us are

products of off-reservation boarding schools. Many of us were given

a one way ticket to urban communities, such as Los Angeles, Chicago, Dallas, with virtually no preparation of urban survival skills

and very limited financial resources. Many of us still bear the scars

of that experience.

Our age group also went to war in defense of our country. Many

of us walked the jungles of the South Pacific, landed at Normandy,

defended the frozen ridges of Korea, and saw the monsoons of the

Mekong Delta. Many of us returned maimed in body and sometimes in spirit. Many of us were returned for burial.

Without question, the most devastating event for us was the Garrison Dam. It was almost as devastating as the smallpox epidemics

of 1781 and 1837. Prior to the Garrison Dam, we were settled in

communities such as Independence, lucky Mound, Nishu, Shell

Creek, Elbowoods, Beaver Creek. We were raising our own food,

just like we had been for centuries. Beef replaced the buffalo as our

major protein supply, and we proved to be excellent cowboys. The

River, Missouri, and its bottomlands provided us good soil for our

gardens and crops, shelter for ourselves and our livestock, timber

to build our homes. But especially, it allowed us to practice our cultural traditions. These traditions helped us to be independent and

develop our own systems of caring for ourselves and one another.

We didn’t need social programs. We took care of our children, our

elders, our ill. We had our own system of law and order.

The Garrison Dam changed all that. We were forced to move

from the bottomlands up into the hills, where the quality of the

land was such that it was very difficult to raise gardens. It took

many more acres to raise livestock. Our homogeneous communities

were broken up and replaced by isolation. We did not have access

to capital, except the meager amounts of credit that was offered

through the Bureau of Indian Affairs. Most of this credit was just

enough to get one into serious difficulty.

Unfortunately, many of our people died in the process of relocating from the Garrison Dam. Many of us turned to alcohol, and ourselves and our families suffered as a result. Terms like unemployment, welfare, foster care, spouse abuse, child abuse, elder abuse,

alcoholics, alcoholism, juvenile delinquency, low rent housing became part of our vocabulary. Our languages are in danger of being

lost, and we get confused between poverty culture and Indian Culture.
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We have never had the mental health resources to deal adequately with the problems that were posed to us through the Garrison Dam.

Despite these difficulties, some members of our age group were

the first in their families to earn a college degree, to enter professions such as education, nursing, social work, medicine. We face

many of the same problems today. Among those are inadequate

medical care, poor or substandard housing, lack of specialized home

health care, elder abuse issues, inadequate transportation, and our

reservation is large, and because of the Garrison Dam, we’re scattered, large traveling distances, inadequate meal service. Our written testimony will more clearly document these problems.

Let me highlight just a few things. The average health care expenditure in the United States is approximately $3,500 to what at

Fort Berthold is $1,300; 75 percent of our elders have some type

of a depression problem. A lot of it is caused by people who as a

result of diabetes feel that their quality of life is over. All of North

Dakota is seeing a return of elders who are seriously or terminally

ill. Hence, the drain on the already limited Medicaid resources is

critical.

Set-aside for Indian reservations for meal sites under title VI of

the Older Americans Act only is enough to meet a part of the

needs. At the present time there are six communities in Forth

Berthold, one is being served through title VI, the other five are

being served by what resources we can muster as a tribe. Housing

is badly needed for elders, and especially assistance is needed repairing homes. Many elders live in very crowded conditions, because their children or grandchildren have no housing, and therefore move in with them. Our elders will not ask their children or

grandchildren to move out.

Elderly abuse is rampant and needs to be addressed. And Social

Security is something that we are trying to deal with and also

needs to be addressed. We are receiving a lot less than the national

average, because of some issues regarding reporting and so forth.

Thank you for your time. I would be glad to answer any questions that you may have.

[Prepared statement of Mr. Baker appears in appendix.]

The CHAIRMAN. I thank you very much, Mr. Baker.

Mr. Baldridge, can a Native American elder residing in an urban

area have access to State social services, or does he have to rely

upon American Indian Alaska Native type programs?

Mr. BALDRIDGE. We know that probably 50 percent of Indian people, including elders, are now urban. We understand from the Seattle Urban Indian program that they are seeing third generation

urban Indians. Yet we know less about this population than any

Indian population or probably other minority population in the

country. They tend to not live in ethnic neighborhoods. They tend

to be transient, they tend apparently to have frequently substance

abuse or alcohol problems.

So in answer briefly is, I think they fall through the cracks very,

very frequently. But they do rely on State programs and of course,

the non–ITU services that are available in cities. I don’t know that

the Indian Health Care Delivery System reaches them much at all.
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The CHAIRMAN. You indicated that the title VI moneys are inadequate. About how much more would you suggest is needed?

Mr. BALDRIDGE. In 1992, we had $14 million. Currently I believe we are at about $27 million. One of the staffers from the House

side back a few years ago estimated that it would take $30 million

just to get original title VI programs back to their 1980 levels of

service; $35 million would, I think, make a huge dent in the ability

of these programs to serve their elders. Many of them still are able

to provide only a few communal meals a week, and very few home

services or supplemental services. It’s a very pale shadow of the

services available through area agencies on aging.

The CHAIRMAN. Well, I can assure you I will look into that, because I must confess, I have no idea how much the Government requested for this program. But I would gather it must be much,

much lower than $35 million.

Mr. BALDRIDGE. I believe we’re at $27.5 million or so right now.

And certainly more money is at the top of our list of needs.

The CHAIRMAN. Mr. Baker, do you have any suggestions as to

what we as Members of Congress can do?

Mr. BAKER. Well, I think first of all, some of the things that

we’re trying to do is try to access or have our people access those

programs that are available that don’t come through the normal Indian programs, so to speak. Because we are citizens of the State

of North Dakota and as such, have the right to those programs. I

think a lot of tribes, a lot of people do not think that they’re entitled to those programs. So we’re trying to do that.

Obviously, there is a need for more funding. One of the things,

I think there needs to be some type of Congressional action, perhaps, regarding elderly abuse in terms of its programs to try to

deal with elderly abuse. I think it’s one of those issues that is kind

of quietly not mentioned, yet it exists in many ways. So I think

those are perhaps some issues that might be addressed.

The CHAIRMAN. In your presentation, you remarked that many in

your generation put on the uniform and participated in the wars

of this Nation. I think we should recall that in the last century, on

a per capita basis, more native people put on the uniform to serve

our country in every war of the last century than any other ethnic

group. That is saying a lot. More Indians per capita served than

German-Americans or Italian-Americans or Chinese-Americans or

Japanese-Americans. And I have said many times, couple that with

the fact that you have given up much of your land suggests to me

that you have already paid your dues. The least we can do is to

make certain that you receive what you are entitled to.

Mr. Vice Chairman.

Senator CAMPBELL. Thank you, Mr. Chairman.

Let me ask Mr. Baldridge a question or two, but I wanted to say

to Mr. Baker first, I thought your testimony was poignant. Depressing. Absolutely true. It needed to be said. I just wish more

people here of our colleagues in the Senate could have heard your

testimony.

You mentioned elder abuse. I was talking to one of my staff here,

that I had an elderly gentleman at home, at Northern Cheyenne,

tell me one time that he doesn’t turn his lights on a night time because he’s afraid somebody will know he’s there and come and beat
27

him up. That’s just a tragic kind of a thing to know about. Yet at

the same time, that certainly wasn’t a traditional value of Indian

people anywhere. Elders were always respected and trusted and

learned from and revered. But I suppose it’s on the rise because of

poverty and lack of opportunities and so on. So we have this dichotomy, this strange relationship between what Indian people believe

and want to believe from a traditional standpoint and sometimes

what is actually happening. I just wanted to mention that.

But I wanted to ask Mr. Baldridge a couple of questions. Three

out of five, as I understand it, three out of five Indian elders are

living at or below 200 percent of the poverty level. But more tribes

are trying to develop their economies, certainly some of the gaming

tribes have had some success. In the Great Lakes region, some of

them have had great success, too. I have visited them.

Have you seen any increased resources from those successful

tribes that have gone toward elder care?

Mr. BALDRIDGE. Yes, sir; I can. One comes to mind, certainly,

Sandia Pueblo, which just went into debt enormously for a new casino. Yet with their gaming revenues over the last decade, they

have developed a very fine clinic. They’re putting all of their tribal

members, including elders, through secondary education and higher education at no cost. And their health care has improved enormously because of that.

Other Pueblos around Albuquerque, with successful gaming operations, have created partnerships with hotel chains to create resort

golf course, and it’s interesting that our seemingly more business

wise tribes are developing initiatives with States and private industry that are benefitting not just the elders but all the tribal

members. So we’re really encouraged by those tribes that are gaming.

Senator CAMPBELL. I have talked to a number of them, and I

don’t know of one single tribe I’ve talked with that has gaming that

has not dedicated a portion of their new-found income towards senior programs. And I’m gratified that that is actually happening.

Some in fact have even broadened it. I live with the Southern

Utes in Colorado. They are negotiating with the county to build a

huge hospital and health care facility that will take care of everybody, not just Indian people. So they have been, in most cases, I

think, very, very generous with some of the new money that the

successful tribes have made.

Statistics from the IHS indicate Indian youth are the most likely

to commit suicide. I may have mentioned, asked this earlier about

suicide, I did, in fact, I think. But I asked it of another panel. Do

you have any comparative statistics to deal with Indians or non–

Indian comparison in suicide?

Mr. BALDRIDGE. What little data we’ve seen from IHS seems to

indicate that once Indian people reach the age of 75, their longevity

is much greater than that of other races. I believe that we see low

suicide statistics for elders as well.

However, I visit from my tribe a medicine man, Crosson Smith,

and I asked him, what’s the greatest problem we face as Indian

people. He said, we’re losing our kids. It’s what you all have said

to us. Indian teens, with 17 to 19 times the alcohol and substance

average of the Nation, suicide 7 or 8 times, we’re winning some
28

battles with the medicine, but we’re losing our kids. And it’s a challenge for our elders and all of us.

Senator CAMPBELL. All the more reason we need to take care of

them.

Several tribal groups have submitted testimony that they are

being shut out of operating elder care facilities because the IHS

doesn’t fund it. They can’t get direct reimbursement from Medicare

or Medicaid for such facilities. And the states won’t license a facility for the tribes so they can get different reimbursements from the

State.

Do you have any comments on those issues?

Mr. BALDRIDGE. Yes, sir. I believe South Dakota, we often see,

is the worst case State, where there is a more than 10 year moratorium on building nursing homes. The tribes there very desperately

want and deserve nursing homes on their own reservation lands.

Yet the State I think says, gee, we’re sorry, it’s a Federal problem,

but we have this moratorium, even though it’s self-imposed. It’s

very much, I think, a critical situation for those tribes, a longstanding one, and one that CMS has made some effort to resolve, but

it’s a very difficult, as usual, interface between Federal policy and

State regulatory authorities.

Senator CAMPBELL. In that case, even if you found all the money

you couldn’t get a license, because they have a moratorium on it.

Mr. BALDRIDGE. Exactly. It’s a very difficult situation.

Senator CAMPBELL. Thank you for your testimony.

Mr. Chairman, thank you, I have no further questions.

The CHAIRMAN. Senator Conrad.

Senator CONRAD. Thank you, Mr. Chairman.

First of all, I’d like to welcome Mr. Baker here. He is a very valued and respected member of the Three Affiliated Tribes of North

Dakota and a very respected member of our State. And I thought

your testimony was outstanding. I thought you could have focused

on the disaster that the Garrison Dam has been to the Indian people, not only of the Three Affiliated Tribes but of the Standing

Rock Sioux Nation as well. Because it dramatically altered the way

of life of the people. And the compensation that has been forthcoming, while welcome, has not been sufficient to reverse the damage

that was done. So I think, Mr. Baker, you put the focus right where

it belongs.

Let me ask you, if you could wave a wand, if you could come here

and say, these are the things that must be done, what would be

the list that you would give this Committee.

Mr. BAKER. Wow. I guess several things. One is probably some

type of a way to go back, if we can go back, I look at it as probably

going forward, to incorporate the traditional cultural values that

we had with the attempt to become a part of the modern day society, through some type of language preservation, cultural preservation program of some type. I think that’s the basis for a lot of our,

perhaps the problems that have to do with respect for elders, the

respect for ourselves.

Somewhere along the line, because of the things that have happened, I think we’ve lost respect, to some extent, for ourselves, and

probably lost confidence in our ability to deal with the issues. I

think that’s one of the things that I would somehow, and I think
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maybe some of these other things would kind of fall into place. Certainly we need some type of an increased health care facility, those

kinds of issues need to be addressed. Certainly employment, although we’re trying hard to do that, employment issues, trying to

find some type of way. Also some way to help our people to be able

to leave successfully and become part of the rest of the community

and still maintain their Hidatsa, Arikara and Mandan affiliations.

Senator CONRAD. Okay. Mr. Baldridge, if I could ask you the

same kind of question, if you had the ability to dictate outcomes

here, what would be the things you would point to? What are the

things that would leap to your mind as to things that need to be

done?

Mr. BALDRIDGE. If this committee, sir, could help us find some

creative new solutions to home and community based care in Indian country that would be at the top of my list, along with a single other consideration, that’s the empowerment of our title VI program. These directors need help so badly and training so badly,

and it’s not available for them. They could be a real force in helping us deal with public health issues for our elders. We’ve got to

lift them up and really help them get on their feet and be more viable.

Senator CONRAD. How much of this is related to resources? To

put it bluntly, how much is related to money?

Mr. BALDRIDGE. It seems that poverty is the thread that ties everything together in Indian country. Certainly I believe that’s the

case in this. But there’s been no training money available to them

since 1995, I believe, through Title IV of the OAA. It’s just a stopper right there. That’s very resource related. Some of the other, the

seeking for demonstration programs to deal with new ways of community home based care is not so directly resource related, but certainly some demonstration projects need to be coordinated.

Senator CONRAD. What would your answer to that question be,

Mr. Baker? The question of money, if you were to try to assess,

what could be done that would really make a difference, how much

of it is related to money being provided to have programs?

Mr. BAKER. Well, I think they’re probably of somewhat equal

value. I think there certainly needs to be a lot of thought given to

innovative ways to deal with the program. Sometimes money is a

rather simple solution, or probably a quick fix attempt. So I think

they are kind of equal value. We definitely need money to do

things. On the other hand, I think it’s the ideas or the attempts

at programs. One of the things we’re trying to do as an elder organization, is to try to talk to the elders, give them a place, have a

forum to discuss some of these issues and say, now what can we

do.

Senator CONRAD. All right, thank you. Thank you both for not

only excellent testimony here today, but I know in the case of Mr.

Baker, thank you for a lifetime of involvement in the community.

The CHAIRMAN. Before we adjourn, I would like to make an observation. I believe I have visited more reservations than any other

chairman of this. And I have noted one common thread in most of

my visits. Most tribes for good reasons want to show their very

best. So they guide me through all the developments, the new

buildings. I have yet to see one of the dilapidated buildings. They
30

show me the new houses, the new apartments. In fact, in order to

see the worst conditions, I have to ask that I see where the asbestos is leaking from the school building and such.

It is the same with wealthy tribes and poor tribes. They want to

show that they have done something. I would suggest that when

members of Congress come to reservations to visit, show them the

real world. I think they will understand the situation much better.

I have had some of the best meals in poor reservations, and I do

not know why they do that. But they want to extend their hospitality and show what friendship is like. But if they are poor, show

us that they are poor. If there are buildings that are dilapidated

and school buildings are filled with asbestos, we should know about

it.

So with that, I thank all of you for your testimony. This hearing

is adjourned.

[Whereupon, at 11:57 a.m., the committee was adjourned, to reconvene at the call of the Chair.]
(31)

APPENDIX

ADDITIONAL MATERIAL SUBMITTED FOR THE RECORD

PREPARED STATEMENT OF HON. MARIA CANTWELL, U.S. SENATOR FROM WASHINGTON

Mr. Chairman, I thank you for the opportunity to speak concerning Native American Elder Health Issues.

I am especially interested in the findings from this hearing because I represent

29 federally recognized tribes, with 25,000 tribal members.

The committee is well aware that Native Americans experience significant disparities compared to whites for many health indicators, and while the mortality rate

for American Indians and Alaska Natives is higher than for all races in the United

States, life expectancy is almost 6 years lower.

While life expectancy is certainly an important indicator of population health status—the quality of one’s life is also important. This morning’s testimony tells us

that Native American elders are 78.7 percent more likely to experience congestive

heart failure, 17.7 percent more likely to report high blood pressure, 17.5 percent

more likely to have experienced a stroke, 44.3 more likely to report asthma, and 173

percent more likely to be afflicted with diabetes.

Diabetes complications, especially end-stage renal disease and lower-extremity

amputations are major causes of morbidity and mortality among older Indians. Diet,

sedentary lifestyle and obesity are risk factors for the development of diabetes and

its complications—factors we can prevent or control.

And we know that heart disease—one condition, at least, which can be somewhat

mitigated through prevention and treatment—is the No. 1 cause of death in Native

Americans over the age of 45.

1 think it is no great leap to ask if we actually funded the Indian Health Service

at more appropriate levels, would the health status of our tribal elders not be better?

While the IHS is tasked with providing full health insurance for the American Indian and Alaska Native population, it is so underfunded that patients are routinely

denied care. The budget for clinical services is so inadequate that Indian patients

are subjected to a ‘‘life or limb’’ test. Unless their condition is life threatening or

they risk losing a limb, their treatment is deferred for higher priority cases; by the

time they do become a priority, the treatment required is generally more costly and

there are often no funds left to pay for it.

Finally, I also want to add that as Congress continues to consider Medicare reimbursement issues, we need to make Indian-specific policies and procedures to ensure

that its billing requirements insure that Indian health program receive fair reimbursement for services provided.

Again, thank you, Mr. Chairman for convening this hearing.
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