Dementia in Indian Country: A Public Health Road Map


>>THANK YOU I’M GOING TO MOVE ON NOW AND
WE’RE GOING TO GO TO STARTING THE CONVERSATION ABOUT DEMENTIA
IN INDIAN COUNTRY, A PUBLIC HEALTH ROAD MAP.
ARE YOU READY TO START, LISA?>>I’M GOING TO KICK US OFF AND
THEN MY COLLEAGUES. IS DR. BLYTHE WINCHESTER ON THE
PHONE?>>I’M HERE.
CAN YOU GUYS HEAR ME?>>GREAT, GREAT.
I WANTED TO MAKE SURE YOU WERE THERE BEFORE I HANDED IT OFF TO
YOU. SO TODAY I JUST WANT TO TELL YOU
A LITTLE BIT, WE’RE TALKING ABOUT OUR NEW ROAD MAP FOR
INDIAN COUNTRY, AND I THINK THIS ALSO SHOWCASES A NICE
COLLABORATION BETWEEN SEVERAL OF THE FEDERAL AGENCIES, BRUCE AND
I YOU’LL SEE UP HERE TODAY, BUT WE ALSO HAD PARTNERSHIP WITH
OTHER FEDERAL AGENCIES THAT ARE SITTING AROUND THE ROOM TODAY
AND THIS IS REALLY, I THINK, A GOOD COLLABORATION AND SHOWS HOW
WE CAN WORK TOGETHER TO TRULY MAKE A DIFFERENCE AND IMPACT THE
LIVES AS MANY OF AMERICANS AS POSSIBLE.
SO THESE ARE NOT MY SLIDES THAT WE’RE LOOKING AT.
>>THAT ANSWERS MY QUESTION AS TO WHETHER MY SLIDES ARE UP
THERE.>>SO OUR PUBLIC HEALTH ROAD MAP
REALLY IS LOOKING AT PUBLIC HEALTH.
SO JUST AS A BACKGROUND FOR US TO HAVE A CLEAR UNDERSTANDING OF
WHAT PUBLIC HEALTH ACTUALLY IS, IS PUBLIC HEALTH REALLY DOES
BRIDGE THAT GAP BETWEEN THE ROLES THAT MANY OF US AROUND
THIS TABLE PLAY. WE REALLY HELP BRIDGE THIS GAP
BETWEEN BIOMEDICAL RESEARCH, SO WE HEARD A LOT ABOUT THE
EXCITING THINGS GOING ON IN RESEARCH A FEW MINUTES AGO, AS
WELL AS THE SERVICES THAT YOU SEE.
AND WE’LL HEAR ABOUT AS MY COLLEAGUES TALK ABOUT FROM THE
LONG-TERM SERVICES AND COMMITTEE RECOMMENDATIONS TODAY.
SO WHAT ACTUALLY IS PUBLIC HEALTH?
SO PUBLIC HEALTH DOES HAVE A ROLE TO PLAY WITHIN ALZHEIMER’S
DISEASE. PUBLIC HEALTH PROFESSIONALS TRY
TO REALLY MINIMIZE RISK AND PREVENT PROBLEMS FROM HAPPENING
IN THE FUTURE, AS OPPOSED TO WHAT CLINICAL PROFESSIONALS DO
WHO FOCUS PRIMARILY ON PEOPLE WHO ARE SICK.
PUBLIC HEALTH ALSO WORKS WITH DISPARITIES AND TRIES TO BRIDGE
SOME OF THOSE GAPS BETWEEN DISPARITIES.
SO YOU CAN SEE THE PUBLIC HEALTH WORKS FOR A VARIETY OF
POPULATIONS, ALL AGES, STAGES OF LIFE, AND REALLY TRIES TO WORK
UPSTREAM TO IMPROVE THE HEALTH, PREVENT DISEASE AND DISABILITY
OF ALL THE PEOPLE THAT WE DO SERVE.
SO WE’RE GOING TO HEAR A LITTLE MORE ABOUT OUR PUBLIC HEALTH
ROAD MAP FOR INDIAN COUNTRY. I HAVE A SERIES OF WONDERFUL
SPEAKERS TODAY THAT ARE GOING TO KEEP YOU ENGAGED BEFORE LUNCH.
SO DR. BLYTHE WINCHESTER IS ON PHONE, THEN MY FRIEND MOLLY
FRENCH FROM THE ALZHEIMER’S ASSOCIATION, CAROLYN HORNBUCKLE
FROM THE NATIONAL INDIAN HEALTH BOARD, DR. BRUCE FINKE AND I’LL
TELL YOU MORE ABOUT SOME OF THE THINGS WE ARE DOING AT CDC.
SO BLYTHE, MAKE SURE YOU TELL ME “NEXT SLIDE” AND WHEN TO CHANGE
YOUR SLIDES.>>BLYTHE, IF YOU’RE WATCHING
THE WEBCAST, IT’S GOING TO BE DELAYED, SO TRY NOT TO WATCH THE
WEBCAST.>>I’M NOT BECAUSE I’M EASILY
CONFUSED, SO THANKS. IF YOU’RE ON THE OBJECTIVES
SLIDE, THAT’S WHERE WE CAN START.
HELLO, EVERYBODY, AND THANKS SO MUCH FOR INVITING ME TO THIS AND
HELLO TO EVERYONE I KNOW THERE AND THE PEOPLE THAT I DON’T.
THIS IS VERY EXCITING FOR HE IN FOR SOMEONE AS A PRACTICING
GERIATRICIAN IT’S VERY CLOSE TO MY HEART AND IT’S WHAT I’M THE
MOST PASSIONATE ABOUT. HOPEFULLY THAT COMES ACROSS.
WHAT I’M GOING TO GIVE YOU IS SOME KIND OF GENERAL INFORMATION
TO KIND OF HELP SET THE STAGE AND PROVIDE AN UNDERSTANDING OF
WHY THIS WORK IS SO IMPORTANT. SO JUST SOME INFORMATION ABOUT
OUR ELDER POPULATION, IT’S GROWING RAPIDLY.
AND MORE RAPIDLY THAN OTHER MINORITY POPULATIONS WHICH IS
VERY EXCITING FOR ME. THERE ARE A LOT OF OUR ELDERS
WHO ARE UNINSURED, THERE IS SOMETIMES A MISUNDERSTANDING
THAT INDIAN HEALTH SERVICE SERVES AS A FORM OF INSURANCE
FOR PEOPLE BUT THAT’S NOT THE CASE.
THEY ARE STILL THE PAYOR OF LAST RESORT.
CLOSE TO 22% OF AMERICAN INDIANS AND ALASKAN NATIVES RECEIVE CARE
FROM INDIAN HEALTH SERVICE AND THERE IS SORT OF THIS LIFE
EXPECTANCY DISCREPANCY, SOMETHING WE CONTINUE TO WORK ON
FROM A PUBLIC HEALTH STANDPOINT AND AS INDIVIDUAL CLINICIANS.
SO THIS IS JUST INFORMATION AGAIN ABOUT DEMOGRAPHICS AND HOW
MANY THERE ARE WITHIN THIS COUNTRY.
THE OTHER ISSUES WE DO HAVE LOWER LEVELS OF CANCER
SCREENING, WE HAVE MORE ISSUES WITH SOME MENTAL HEALTH ISSUES,
AND OTHER ISSUES IN TERMS OF DISABILITY FOR OUR FUNCTIONAL
ELDERS AND THOSE LIVING ALONE. SO THESE ARE THINGS THAT ARE
BROUGHT UP IN MY DAY TO DAY PRACTICE AS VERY PREVALENT AND
CONCERNING AND RELATE TO DEMENTIA CARE AS WELL.
WE DO HAVE THE HIGHEST PREVALENCE OF CORONARY VASCULAR
DISEASE, I MENTIONED THE HIGH RATES OF DISABILITY AS WELL AS
CANCER, UNINTENTIONAL INJURIES AND DIABETES.
AND 22% OF US LIVE ON RESERVATIONS BUT THERE’S A VERY
HIGH PERCENTAGE WHO LIVE IN URBAN AND METROPOLITAN AREAS AND
THIS CONTINUES TO BE KIND OF A CHALLENGE IN TERMS OF MEETING
THE NEEDS OF ALL TRIBAL PEOPLE. I HAVE A COUPLE OF DIFFERENT
PICTURES FROM MY COMMUNITY, WHAT YOU’LL FIND WITH INDIGENOUS
POPULATIONS IS THAT OUR CULTURE IS WOVEN INTO EVERYTHING, YOU
KNOW, THAT WE DO SO I CAN’T POSSIBLY TALK TO YOU WITHOUT
HIGHLIGHTING OR PRESENTING. THIS IS A PICTURE OF A
TRADITIONAL CULTURAL ARTS PROGRAM THAT WE HAD THAT WE’RE
HOPING TO EXPAND TO TRY TO HELP WITH SOCIALIZATION AND COGNITIVE
FUNCTION AND THINGS LIKE THAT. SO IN GENERAL, THERE ARE LOTS OF
DIFFERENT CULTURAL CONSIDERATIONS.
IF YOU KNOW ONE TRIBE OR IF YOU’VE DEALT WITH ONE TRIBE,
YOU’VE DEALT WITH ONE TRIBE. WE ARE VERY HETEROGENEOUS WE
HAVE A HUGE VARIETY IN OUR DIFFERENT CULTURES AND
PRACTICES. RIGHT NOW THERE ARE AROUND 573
FEDERALLY RECOGNIZED TRIBES. THE ESTIMATE NOW IS THERE’S
ABOUT 175 DIFFERENT LANGUAGES SPOKEN.
THAT NUMBER USED TO BE CLOSER TO 300 AND UNFORTUNATELY BY 2050,
THE ESTIMATE IS THERE WILL BE BARELY ANY LEFT, MAYBE 20.
THERE ARE ABOUT 350,000 SPEAKERS OF THOSE LANGUAGES, BUT THAT
NUMBER WAS 15 MILLION. LANGUAGE IS STILL A HUGE
CONSIDERATION IN CULTURES AND THERE ARE TONS OF REVITALIZATION
EFFORTS IN DIFFERENT TRIBES TO TRY TO BRING THAT NUMBER UP IN
TERMS OF THE NUMBER OF SPEAKERS BECAUSE IT IS SO IMPORTANT TO
OUR CULTURE. THE HISTORICAL EXPERIENCE WHICH
I’LL SHOW ANOTHER SLIDE ABOUT IS VERY IMPORTANT BECAUSE OUR
PEOPLE HAVE SEEN LOTS OF DIFFERENT THINGS THROUGHOUT
THEIR LIFETIMES AND THIS DOES AFFECT THEIR MEDICAL CARE AND
THE CARE FOR THEIR DEMENTIA, AND I HAVE EXPERIENCED THAT MANY
TIMES, PARTICULARLY FOR PEOPLE WHO HAVE BEEN IN BOARDING
SCHOOLS WHEN THEY WERE YOUNGER, AND ESPECIALLY WHEN THEY END UP
NEEDING TO BE IN A FACILITY OR MEMORY CARE UNIT, WHEN THEY HAVE
THINGS THAT MANIFEST FROM THEIR TIME IN BOARDING SCHOOL.
ANOTHER EXAMPLE IS TRADITIONAL INDIAN MEDICINE.
IT’S IMPORTANT TO HAVE A PARTNERSHIP AND WORK TOGETHER
AND COLLABORATE WITH THOSE PRACTITIONERS AND TO LET THE
PEOPLE KNOW THAT THIS IS OKAY AND YOU SUPPORT THE USE OF THIS.
FRAMING AND CONTEXT FOR ILLNESS UNDERSTANDING IS A HUGE THING
THAT I TALK ABOUT THAT I’LL GO INTO IN THE CONTEXT OF
CAREGIVING. SO THIS IS ONE OF MY FAVORITE
SLIDES WHEN I TALK ABOUT CULTURE AND INDIGENOUS ELDERS BECAUSE IT
SHOWS AN EXAMPLE THAT’S QUITE DIFFERENT FROM THINGS THAT OTHER
POPULATIONS MIGHT HAVE EXPERIENCED IN THEIR LIFETIME
AND I TAKE CARE OF PATIENTS HERE IN THIS 1900 TO 1920 BIRTH
COHORT SO YOU CAN LOOK AND SEE EXAMPLES OF ALL OF THE DIFFERENT
THINGS THAT THEY HAVE EXPERIENCED THROUGHOUT THEIR
LIFETIME, INCLUDING ASSIMILATION AND RELOCATION, GAMING, BOARDING
SCHOOLS, ALL OF THESE DIFFERENT EXPERIENCES AFFECT THEIR MEDICAL
CARE AND THEIR EXPERIENCE OF DEMENTIA AS THEY GET OLDER.
I HAVE PATIENTS STILL IN THE PROCESS OF TRYING TO RELOCATE
BACK HERE BECAUSE OF THE SERVICES THAT WE CAN PROVIDE FOR
THEM. SO IN TERMS OF CAREGIVING, I
WANTED TO MENTION THIS SPECIFICALLY BECAUSE IT IS SUCH
A FOCUS PARTICULARLY IN INDIAN COUNTRY AND BEEFING UP RESOURCES
AND REALLY TRYING TO ADDRESS THAT NEED.
FRAMING IS SOMETHING THAT I DISCUSS OFTEN, IT’S JUST THE
IDEA OF HOW WE TALK ABOUT EVERYTHING INVOLVED IN DEMENTIA
CARE FROM OUR EXERCISES THAT WE DO IN OUR EVALUATION TO THE
DIAGNOSIS ITSELF AND HOW WE TALK ABOUT IT.
OBVIOUSLY SIMPLIFYING EVERYTHING IS IMPORTANT BUT ALSO TRYING TO
NOT INVOLVE NEGATIVE FRAMES IN THE THINGS THAT I’M TALKING
ABOUT. FOR INSTANCE, I SAID WE USE
BRAIN EXERCISE RATHER THAN TESTING BECAUSE TESTING CAN HAVE
A NEGATIVE CONNOTATION SO I’LL TELL PEOPLE ESPECIALLY WHEN
WE’RE DOING SCREENING TESTS, HI, WE DO THIS ON EVERYONE, THIS IS
A BRAIN EXERCISE SO I CAN GET AN IDEA OF YOUR BASELINE.
SO I THINK SOME OF THAT LANGUAGE IS PARTICULARLY HELPFUL IN
INDIGENOUS POPULATIONS. WE KNOW THAT CAREGIVER BURDEN,
THAT PHRASE IS NOT PARTICULARLY WELL RECEIVED SO I THINK
ADJUSTING THOSE THINGS IS VERY IMPORTANT.
THERE ARE OFTEN MANY MORE CAREGIVERS INVOLVED.
SOMETIMES I’VE HAD FAMILY MEETINGS WITH SO MANY PEOPLE WE
CAN BARELY FIT IN THE ROOM. THE MATRIARCHY IS AN ASPECT OF
SOME TRIBAL POPULATIONS WHERE THE LEADERSHIP IN THOSE FAMILY
UNITS AND IN THE TRIBE IS THROUGH THE FEMALE MEMBERS OF
THAT TRIBE AND, THEREFORE, WHEN YOU HAVE A FEMALE MEMBER OF THE
FAMILY WHO’S DEVELOPED DEMENTIA, IT CAN BE EXTREMELY DIFFICULT TO
TELL HER WHAT TO DO OR REGULATE HER BEHAVIORS AND THAT HAS TO BE
APPROACHED AS A DELICATE SITUATION.
WE DEAL WITH A LOT OF SOCIAL SITUATIONS AT HOME INCLUDING
ABUSE SO FOR OUR ELDERS WHO ARE EXPERIENCING DEMENTIA OR
COGNITIVE LIMITATIONS, THERE WILL BE PEOPLE WHO WILL TRY TO
TAKE ADVANTAGE THROUGH SCAMS AND OTHER THINGS, ALTHOUGH
UNFORTUNATELY IN SMALLER TRIBAL COMMUNITIES, PEOPLE OFTEN KNOW
WHO IS AFFECTED BY THIS, AND THEREFORE THEY BECOME EASIER
PRIME TARGETS FOR THAT, WHICH IS EXTREMELY UNFORTUNATE.
THIS IS JUST A PICTURE LESLIE TOOK OF OUR TRADITIONAL INDIAN
STICK BALL GAME. THE THING THAT I’LL END WITH IS
A FEW EXAMPLES TO FURTHER KIND OF HIGHLIGHT WHAT THE
DIFFERENCES ARE AND WHY IT’S SO IMPORTANT TO HAVE SOMETHING LIKE
THE ROAD MAP WHICH HELPS US TO HAVE THESE CONVERSATIONS AND TO
WORK WITH ENTITIES THAT AREN’T USUALLY ASSOCIATED WITH THE
PUBLIC HEALTH FORUM. IN OUR TRIBAL POPULATIONS, A LOT
OF TIMES THE INVOLVEMENT OF POLITICAL ENTITIES SUCH AS
COUNCIL IS VERY IMPORTANT IN TERMS OF PRIORITIZING, SO HAVING
THIS DOCUMENT AND THIS ATTENTION TO IT MAKES IT MUCH EASIER TO
TRY TO BRING THAT INTO FOCUS. OTHER EXAMPLES OF KIND OF
DIFFERENCES THAT I ENCOUNTER ON A REGULAR BASES AND HAVE HEARD
OF IN OTHER TRIBAL — THERE ARE OFTEN CULTURAL TRADITIONS,
LEGENDS THAT ARE STILL PROMINENT.
FOR OURS ONE IS THE PRESENCE OF LITTLE PEOPLE, SO SOMETIMES I
WILL HAVE PATIENTS WHO WILL TELL ME THAT THESE THINGS THAT THEY
ARE EXPERIENCING, IT CAN BE VERY DIFFICULT TO DISCERN WHETHER
THIS IS A CULTURAL BELIEF VERSUS A TRUE, YOU KNOW, HALLUCINATION
OR A DELUSION OF THINGS BEING TAKEN, SO IT MAKES OUR JOBS A
LITTLE BIT MORE DIFFICULT WHEN WE’RE TRYING TO GET TO THE ROOT
OF THAT. THE NEXT THING IS THAT’S JUST
NORMAL AGING, SO IN OUR TRIBAL AND IHS CLINICS, A LOT OF TIMES
THERE’S STILL QUITE A BIT OF TURNOVER OF SOME UNFAMILIAR
RELATIONSHIPS. THOUGH I SEE THIS IS HAPPENING
ALL OVER THE PLACE, I THINK HERE A LOT MORE TIMES WHEN I’M
CONSULTING ON SOMEONE OR I GET CONTACTED BY A PERSON OUTSIDE OF
THIS, MY SERVICE AREA, THAT THEY’LL SAY I TRIED TO GET
EVALUATED, I TRIED TO GET A DIAGNOSIS AND THEY TOLD ME THAT,
OH, THAT’S JUST NORMAL AGING, THEY’RE FORGETFUL, IT CAN BE
FRUSTRATING WHICH IS WHY WE FOCUS SO MUCH ON THE EDUCATION
AND TRYING TO HELP PRIMARY PHYSICIANS UNDERSTAND THE
IMPORTANCE OF THIS. I MENTIONED BEFORE KIND OF
POLITICAL INVOLVEMENT, THIS HAS HAPPENED HERE AND OTHER PLACES
THAT PATIENTS FEEL LIKE THEIR LEADERSHIP AND WHO WILL GET
THINGS ACCOMPLISHED ARE COUNCILMEMBERS SO THAT’S WHO
THEY WILL GO TO TRY TO SEEK ASSISTANCE AND RESOURCES FOR
DEMENTIA CARE, SO PART OF WHAT WE DO IN OUR TRIBAL COMMUNITIES
AND FROM A PUBLIC HEALTH STANDPOINT IS TO TRY TO APPROACH
THIS FROM A LARGER SYSTEMS STANDPOINT AND SAY OKAY, WHAT
KIND OF PROGRAMS OR RESOURCES CAN WE PROVIDE HERE THAT HOPE TO
AVOID THIS KIND OF SITUATION SO THAT THEY KNOW WHAT’S AVAILABLE
AND CAN REACH OUT AND BE INVOLVED WITH THAT AHEAD OF
TIME, AHEAD OF THEIR BEING SOME SORT OF CRISIS, FEELING THAT
THEY HAVE TO APPROACH POLITICAL BODIES FOR THAT.
I WILL TELL YOU IN INDIAN COUNTRY, THEY ARE VERY AWARE
FROM A PUBLIC HEALTH STANDPOINT ABOUT DEMENTIA AND ABOUT ITS
EFFECTS AND ABOUT EARLY DIAGNOSIS.
I’LL BE GOING TO THE DIABETES IN INDIAN COUNTRY CONFERENCE NEXT
WEEK WHERE I’M DOING AN ENTIRE PRECONFERENCE ON GERIATRIC
ISSUES AND MOST OF THOSE RELATE TO DEMENTIA.
I’M CO-PRESENTING ON DIABETES AND THE BRAIN, WHICH IT’S VERY
INTERESTING AND INVOLVES A LOT AROUND DEMENTIA.
I’M EXCITED ABOUT THIS BECAUSE A PRIORITY HAS BEEN GIVEN TO IT ON
A NATIONAL SCALE, AT LEAST 1400 ATTENDEES WHO ARE INTERESTED IN
THIS TOPIC AND CAN LEARN MORE ABOUT IT.
SO THE AWARENESS, THE SAME TARGETS AND GOALS, SO THANK YOU
FOR EVERYTHING THAT YOU DO.>>THANK YOU VERY MUCH, BLYTHE.
WE’LL TURN IT OVER TO MOLLY FRENCH.
>>THANK YOU AND GOOD MORNING. IT WAS JUST ONCE, BUT MY COLLEGE
BOYFRIEND DISCOVERED HE HAD RUN OUT OF DISHWASHER DETERGENT SO
HE GRABBED THE PALMOLIVE, DID A LITTLE SQUIRT AND AS YOU CAN
IMAGINE, THERE WERE BUBBLES EVERYWHERE, WHICH IS A MAJOR
SIGN THAT HE’D CHOSEN THE WRONG TOOL FOR THE JOB.
AND TO CARRY THAT OVER THAT LESSON ABOUT THE RIGHT TOOL FOR
THE JOB, THAT CERTAINLY APPLIES TO THE HEALTHY BRAIN INITIATIVE
ROAD MAP. SO WHAT I DO WANT YOU TO
REMEMBER IS, JUST AS DR. WINCHESTER TALKED ABOUT,
THERE IS RISING CONCERN AND AWARENESS ABOUT ALZHEIMER’S AN
OTHER DEMENTIAS AMONG TRIBAL COMMUNITIES THAT WE’RE HEARING,
AND BY AND LARGE, THE UNIVERSAL ADVICE WE’VE RECEIVED IN WORKING
IN PARTNERSHIP WITH CDC HAS BEEN THAT SOLUTIONS, THE PUBLIC
HEALTH APPROACHES NEED TO COME FROM WITHIN, AND NOT BE PROVIDED
AND SUGGESTED. THIRD, THAT THESE APPROACHES
THAT COME FROM WITHIN, THERE ARE EXISTING STRENGTHS TO BUILD ON
AND THOSE ARE VERY IMPORTANT TO HONOR.
AS YOU WELL KNOW, BEING HERE ON THE ADVISORY COMMITTEE, WE USE
THE ROAD MAPS IN OUR HEALTHY BRAIN INITIATIVE.
THESE ARE THE KEYWAY THAT WE SPARC AND GUIDE THE PUBLIC
HEALTH SECTOR. THIS IS A SECOND ROAD MAP WHICH
WAS IN 2018. IT WAS INTENDED FOR STATE, LOCAL
AND TRIBAL HEALTH OFFICIALS, AND IT DID VERY WELL WITH STATE AND
LOCAL HEALTH OFFICIALS. WITH DR. FINKE’S SUPPORT, HE
MADE SOME INTRODUCTIONS FOR US TO DIFFERENT REGIONAL INDIAN
HEALTH BOARDS, SO WE WENT AND TALKED ABOUT THE ROAD MAP WITH
THEM AND TRIED TO LISTEN TO WHAT THEY WERE HEARING AND
EXPERIENCING. WE GOT A WARM AND A POLITE
RESPONSE RECEPTION, BUT ULTIMATELY THIS WAS A LEAD
BALLOON AND IT WAS GOING NOWHERE.
SO WHICH LEADS US UP TO IT WAS TIME TO UPDATE IT.
AND WE HAD LEADERSHIP COMMITTEE WITH CDC THAT WE PUT TOGETHER,
SO DELIGHTED TO HAVE DR. WINCHESTER ACCEPT INVITATION
TO BE ON THAT LEADERSHIP COMMITTEE, AND THE LEADERSHIP
COMMITTEE DECIDED ULTIMATELY THAT, YOU KNOW, THIS ROAD MA’AM
JUST DID NOT SPEAK TO INDIAN COUNTRY.
AND THAT WE NEEDED NOT ONE BUT TWO ROAD MAPS SO THEY DOUBLED
OUR WORK, BUT IT’S BEEN A PLEASURE, SO WE DO HAVE THIS
ROAD MAP FOR STATE AND LOCAL PUBLIC HEALTH WHICH YOU’VE BEEN
BRIEFED ON. AND THEN WE DECIDED TO CREATE A
ROAD MAP THAT WAS SPECIFICALLY TAILORED FOR THE UNIQUE
STRENGTHS AND CULTURES AND SYSTEMS, AND RESPONSIVE TO THE
PRIORITIES OF TRIBAL HEALTH MEMBERS.
TO DEVELOP A ROAD MAP THAT REALLY WOULD SPEAK TO INDIAN
COUNTRY, WE NEEDED TO LISTEN AND DO A LOT OF LEARNING.
SO WE WERE VERY FORTUNATE TO HAVE THAT, MIKE SPEARHEADED THE
EFFORT, VERY PLEASED TO HAVE HIM ON MIKE’S TEAM.
HE WORKED WITH STEVE CHAPMAN AS A CULTURAL GUIDE, BUT MOST
IMPORTANTLY, THROUGH THE WORK OF A LOT OF PARTNERS HERE, WE WERE
ABLE TO LISTEN TO A LOT OF TRIBAL MEMBERS AND LEADERS FROM
THE SOVEREIGN NATIONS. AND WE DO WANT TO RECOGNIZE AND
THANK THE ROAD MAP CERTAINLY HAS BEEN A COLLABORATIVE EFFORT.
MANY, MANY LONG-STANDING AND ALSO SOME NEW PARTNERS FOR US.
ONE OF THE LONGER STANDING PARTNERS WAS THE INTERNATIONAL
ASSOCIATION FOR INDIGENOUS AGING.
THEY CONVENED TWO EARLY ONLINE SESSIONS FOR US SO THAT WE COULD
HEAR ABOUT WHAT WAS GOING ON FROM BOTH TRIBAL AND HEALTH
LEADERS AND ALSO AGING LEADERS. THEY ALSO GATHERED WRITTEN INPUT
FROM OVER 40 DIFFERENT MEMBERS, LEADERS, EXPERTS AND OTHERS.
THE THEMES THAT WE HEARD THROUGH THOSE WAS THAT KNOWLEDGE OF
ALZHEIMER’S AND OTHER DEMENTIAS, IT DOES VARY, BUT THERE IS A
GROWING SENSE OF CONCERN AND AWARENESS.
WE ALSO LEARNED THAT TRIBAL LEADERS ARE MANAGING AND LEADING
IN A VERY COMPLEX TIME. THE DYNAMIC IN WHICH PUBLIC
HEALTH APPROACHES WOULD BE DEVELOPED WITHIN INDIAN COUNTRY
ARE VERY DYNAMIC. ALSO, AGAIN, THE UNIVERSAL
RECOMMENDATION THAT IF WE WANT PUBLIC HEALTH APPROACHES TO
ALZHEIMER’S AND OTHER DEMENTIAS TO TAKE ROOT, THEY REALLY NEED
TO BE LED, PLANNED, DESIGNED, IMPLEMENTED BY TRIBAL LEADERS.
BECAUSE THEY ARE THE ONES THAT BEST KNOW THEIR MEMBERS AND
THEIR PRIORITIES AND THEIR SYSTEMS AND STRENGTHS.
ANOTHER PART OF OUR EFFORT WAS TO GO OUT AND THROUGH A LOT OF
NETWORKING AND CONVERSATIONS, IDENTIFY DIFFERENT COMMUNITIES
ALREADY USING PUBLIC HEALTH APPROACHES.
SO ONE WAS THE ST. REGIS MOHAWK REGION IN NEW YORK STATE.
THE ROAD MAP DOES FEATURE THESE BUT MORE IMPORTANTLY, SEEING
WHAT WAS ALREADY ON THE GROUND, WHAT SOLUTIONS HAD ALREADY BEEN
STARTED AND DEVELOPED HELPED US WITH SHAPING THE SUGGESTIONS IN
THE ROAD MAP. THEN WE’RE ALSO VERY GRATEFUL TO
MS. HORNBUCKLE IN THE INDIAN HEALTH BOARD, A NEW PARTNER FOR
US. THEY CONVENED AN ONLINE SESSION
SO THAT WE COULD TALK THROUGH DIFFERENT LAYOUT OPTIONS,
GRAPHICS, GET INPUT ON PRINTING MOTIFS, ALL SORTS OF DIFFERENT
ASPECTS. THEY ALSO INVITED SOME WRITTEN
COMMENTS AND SUGGESTIONS. SO WE TRIED AT EACH STEP OF THE
WAY TO LISTEN AND LEARN AND BE REASON SIEVE.
SO YOU DO HAVE — WE DID BRING SOME, THEY ARE LENGTHY LIKE THE
OTHER ROAD MAP, OTHERS HAVE RECEIVED IT IN PRINT.
THIS IS REALLY DESIGNED FIRST AND FOREMOST, DR. WINCHESTER
ALLUDED TO IT, TO BE A CONVERSATION STARTER, TO BE A
TOOL THAT TRIBAL LEADERS, HEALTH PRACTITIONERS, PUBLIC HEALTH
LEADERS CAN START TO USE THE CONVERSATION WITHIN THEIR
COMMUNITIES IN DEVELOPMENT DESIGN APPROACHES.
IT IS GROUNDED IN THE PUBLIC HEALTH INTERSPACE IN TERMS OF
BRIDGING THE GAP LOOKING AT DIFFERENT SYSTEMS.
AND THE TYPES OF STRATEGIES IN THE ROAD MAP WHICH DR. MCGUIRE
WILL TALK ABOUT MORE SHOULD SOUND FAMILIAR IN TERMS OF THE
OVERALL HEALTH SPACE OF EDUCATING AND EMPOWERING
COMMUNITY MEMBERS, USING DATA, MAKING SURE DIFFERENT WORKFORCES
ARE PREPARED AND TRAINED TO SERVE WELL.
LOOKING AHEAD, ALL OF THE ALZHEIMER’S ASSOCIATION CHAPTERS
HAVE THE ROAD MAP FOR INDIAN COUNTRY TO USE.
WE HAVE ALSO BEEN VERY EXCITED TO HAVE 10 OF OUR CHAPTERS TO
COMMIT TO A YEARLONG PROCESS, HELP US LEARN HOW TO BE MORE
EFFECTIVE PARTNERS WITH THE TRIBAL COMMUNITIES AND SOVEREIGN
NATIONS IN THEIR AREA. MY COLLEAGUES WHO ARE WITH THE
ALZHEIMER’S IMPACT MOVEMENT, ADVOCATE NETWORK AS YOU WERE
BRIEFED IN JANUARY, WORKED WITH MEMBERS OF CONGRESS AND WE ARE
SO EXCITED AND PLEASED TO HAVE THE BUILDING OUR LARGEST
DEMENTIA INFRASTRUCTURE FOR ALZHEIMER’S — IN PLACE, AND
THIS AUTHORIZES NOT ONLY COOPERATIVE AGREEMENTS FROM CDC
BUT TO STATE AND LOCAL PUBLIC HEALTH BUT VERY IMPORTANTLY ALSO
FOR TRIBAL PUBLIC HEALTH, SO WE’RE VERY EXCITED ABOUT THAT
OPPORTUNITY. BECAUSE WE WANT PEOPLE TO NOT
JUST KNOW ABOUT THE ROAD MAP FOR INDIAN COUNTRY BUT DEFINITELY TO
USE IT, WE HAVE CREATED A SPECIAL WEBSITE,
ALZ.ORG/PUBLICHEALTH/INDIAN COUNTRY WHERE THE ROAD MAP AND
EXECUTIVE SUMMARIES CAN BE COLLECTED.
THERE ARE ALSO DIFFERENT TOOLS AND HANDOUTS SO SOME OF THOSE WE
DID PROVIDE YOU TODAY IN HARD COPY, AND A LOT OF DIFFERENT
EXAMPLES, WE HOPE TO CONTINUE BUILDING THIS OUT OVER TIME.
SO TO RECAP, THERE IS RISING AWARENESS OF ALZHEIMER’S AND
OTHER DEMENTIAS IN INDIAN COUNTRY AND WE’VE TRIED TO
POSITION THE ROAD MAP SECONDLY TO AID THAT DEVELOPMENT OF
SOLUTIONS FROM WITHIN THAT THIRDLY CAN BE BASED ON THEIR
STRATEGIES. SO WITH OUR NEW ROPED MAP FOR
INDIAN COUNTRY, I DON’T THINK WE HAVE THE PRETENSE THAT THIS IS
THE PERFECT TOOL, BUT I DO THINK IT IS A BETTER TOOL TO START
THAT CONVERSATION. THANK YOU.
>>THANK YOU VERY MUCH, MOLLY. WE WILL TURN IT OVER TO
MS. HORNBUCKLE.>>GOOD MORNING, EVERYONE.
MY NAME IS CAROLYN HORNBUCKLE. I’VE BEEN WITH THE NATIONAL
INDIAN HEALTH BOARD FOR ABOUT EIGHT YEARS NOW AND I AM
REPRESENTING A NEW PARTNER TO THIS GROUP SO IF IT’S OKAY WITH
EVERYONE, I’LL JUST TAKE A MINUTE AND JUST GIVE A LITTLE
BIT OF INFORMATION ABOUT THE NATIONAL INDIAN HEALTH BOARD.
SO OUR ORGANIZATION WAS STARTED ALMOST 50 YEARS AGO BY TRIBAL
LEADERS ACROSS INDIAN COUNTRY. THE IDEA THAT THOSE TRIBAL
LEADERS HAD WAS TO HAVE AN ORGANIZATION THAT WAS DEDICATED
TO INDIAN HEALTH AND PUBLIC HEALTH IN A POSITION WHERE THAT
ORGANIZATION COULD PRESENT THE TRIBAL PERSPECTIVE WITH A
UNIFIED VOICE TO THE CONGRESS, TO THE WHITE HOUSE, TO THE
ADMINISTRATION, EVEN IN SOME AREAS AND FOR SOME ISSUES EVEN
TO THE COURTS. SO THAT WAS THE IDEA BEHIND OUR
ORGANIZATION. WE WERE CREATED AS AN
ORGANIZATION THAT WOULD SERVE ALL FEDERALLY RECOGNIZED TRIBES.
WE ARE NOT A TRADITIONAL MEMBERSHIP ORGANIZATION, WE
DON’T CHARGE DUES, THERE IS NO PAY TO PLAY FOR OUR
ORGANIZATION. WE REPRESENT EVERYONE IN INDIAN
COUNTRY AND SERVE ALL OF THOSE NATIONS EQUALLY, OR AT LEAST WE
CERTAINLY STRIVE TO. ONE OF THE THINGS THAT’S VERY
CHALLENGING AND YOU HEARD THIS A LITTLE BIT EARLIER, WE HAVE 573
FEDERALLY RECOGNIZED TRIBES. THOSE TRIBES ARE ENTIRELY
UNIQUE. I WOULDN’T SAY THEY’RE ALWAYS
DIFFERENT OR THAT THEY DON’T SHARE CERTAIN FEATURES, BUT
EVERY SINGLE ONE OF THOSE IS A SOVEREIGN NATION AND IT IS
UNIQUE, THEY HAVE THEIR OWN PRIORITIES, THEY HAVE THEIR OWN
LEADERSHIP, THEY HAVE COMMUNITY PRIORITIES, AND AS AN
ORGANIZATION INTENDED TO SERVE ALL OF THOSE NATIONS, WE DO HAVE
A DIFFICULT TASK BECAUSE WE TRY AND FIND A UNIFIED CONSENSUS
POSITION AND WE’RE NOT ALWAYS ABLE TO.
WHEN WE’RE NOT ABLE TO FIND THAT CONSENSUS POSITION, WE REPRESENT
THE VIEWS THAT THERE IS CONSENSUS ON.
NOW, YOU HEARD BEFORE INDIAN COUNTRY CARES ABOUT OUR ELDERS
AND THAT IS CERTAINLY A CONSENSUS POSITION.
SO THAT IS ONE OF THE REASONS WHY THE NATIONAL INDIAN HEALTH
BOARD IS REALLY EXCITED TO BE INVOLVED IN THIS WORK.
OUR ORGANIZATION IS SEPARATED INTO A FEW DIFFERENT COMPONENTS.
WE HAVE A CONGRESSIONAL RELATIONS DEPARTMENT THAT DOES
OUTREACH AND EDUCATION TO THE CONGRESS.
WE HAVE A FEDERAL RELATIONS DEPARTMENT WHICH WORKS VERY
CLOSELY WITH ALL OF OUR FEDERAL AGENCY PARTNERS, AND THEN WE
ALSO HAVE A PUBLIC HEALTH POLICY AND PROGRAMS DEPARTMENT, AND
THAT’S THE DEPARTMENT THAT I’M HERE REPRESENTING TODAY.
SO IN TERMS OF THE WORK WE’VE DONE ON THIS PROJECT THUS FAR,
WE HAVE REALLY TRIED TO CAPITALIZE ON SOME OF THE
STRENGTHS OF OUR WORK IN THIS SPACE AND FOR THE LAST 10 YEARS
IN THE PUBLIC HEALTH SPACE. THOSE DOMAINS OF WORK REALLY
FALL INTO ABOUT FOUR AREAS, FOUR MAJOR BUCKETS.
ONE POLICY RESEARCH THE WE HAVE NOT DONE A LOT OF THAT IN THIS
PROJECT. WE DO ALSO HAVE OUTREACH AND
COMMUNICATIONS. WE HAVE TRAINING AND TECHNICAL
ASSISTANCE AND WE HAVE CONVENING AND FACILITATION.
SO THIS PROJECT THAT WE ARE WORKING ON IN COLLABORATION WITH
CDC WITH THE ALZHEIMER’S ASSOCIATION REALLY FALLS MOSTLY
INTO THE AREA OF OUTREACH AND EDUCATION AND CONVENING AND
FACILITATION. ONE OF THE THINGS THAT YOU HEARD
FROM MOLLY IS THAT WE HELP TO GATHER SOME FEEDBACK FROM OUR
TRIBAL LEADERS, FROM COMMUNITY MEMBERS, AND FROM COMMUNITY
LEADERS. SO I SAY THAT BECAUSE IT’S A
LITTLE BIT DIFFERENT, WE HAVE ELECTED TRIBAL LEADERSHIP,
THAT’S THE POLITICAL LEADERSHIP, BUT THEN WHEREVER YOU’RE LOOKING
AT PARTICULAR ISSUES, YOU DO HAVE COMMUNITY CHAMPIONS.
AND WE LOOK TO TAP INTO THOSE COMMUNITY CHAMPIONS.
ONE OF THE THINGS THAT HAPPENS IN INDIAN COUNTRY IS OUR
POLITICAL LEADERSHIP, IN SOME PLACES IT TURNS OVER AND YOU
REALLY NEED TO MAKE SURE THAT YOUR EFFORTS ARE BASED WITHIN
COMMUNITY SO THAT YOU CAN WEATHER THOSE POLITICAL CHANGES.
NOT SO DIFFERENT FROM WASHINGTON, D.C., FRANKLY.
SO ONE OF THE THINGS THAT WE’VE DONE WITH MOLLY’S ORGANIZATION
IS WE’VE REALLY WORKED TO GATHER THOSE COMMUNITY LEADERS, THOSE
COMMUNITY CHAMPIONS, BECAUSE WE KNOW THEY’RE GOING TO BE THE
ONES WHO ARE GOING TO BE CARRYING THIS WORK FORWARD OVER,
YOU KNOW, THE NEXT 10 YEARS, NEXT 15 YEARS, BUT WE ALSO WANT
TO MAKE SURE THAT WE INFORM AND POLL FEEDBACK FROM OUR ELECTED
TRIBAL LEADERS. THOSE ELECTED TRIBAL LEADERS ARE
THE ONES THAT WILL BE SETTING PRIORITIES IN THEIR COMMUNITY IN
TERMS OF ENSURING THERE’S A WORKFORCE INTERESTED IN DOING
THIS, ENSURING THAT THERE IS PERHAPS POLICY THAT WILL HELP
PROMOTE THE WORK AND CERTAINLY SETTING THE PRIORITIES AND
COMMUNITY CONVERSATIONS. SO THOSE ARE SOME OF THE THINGS
THAT WE’VE DONE THUS FAR. WE ALSO CURRENTLY ARE WORKING ON
REALLY WORKING TO HELP RAISE AWARENESS ABOUT THE ROAD MAP
ITSELF. WE DO HAVE THREE VERY LARGE
MEETINGS EVERY YEAR. ONE OF THEM IS COMING UP IN
SEPTEMBER. WE GATHER THE LARGEST BODY IN
TRIBAL LEADERS, HEALTH PRACTITIONERS, COMMUNITY
MEMBERS, REALLY CONSUMERS OF HEALTHCARE AND PUBLIC HEALTH
SERVICES. IT’S THE LARGEST MEETING OF ITS
KIND. WE’LL BE HAVING THAT IN
SEPTEMBER AND ONE OF THE THINGS WE’LL BE DOING IN THAT MEETING
IS SHARING ABOUT THE ROAD MAP AND MAKING SURE THAT AT THAT
IN-PERSON MEETING, ALL OF THE PEOPLE WHO WILL BE KEY TO THAT
DISSEMINATION HAVE A PHYSICAL COPY, HAVE A LINK TO MAKE SURE
THAT THEIR CLINICS, THEIR OTHER DISSEMINATORS HAVE THIS
INFORMATION, AND SO THAT THEY CAN ALSO PROVIDE US SOME
FEEDBACK. IF THERE’S SOMETHING THAT MAY BE
TWEAKED IN FUTURE VERSIONS, WE WANT TO HEAR ABOUT THAT.
SO WE’RE DOING THAT AT OUR BIG MEETING, BUT WE ALSO GO TO — I
MEAN, MY SCHEDULE AND MY COLLEAGUES, WE REALLY HAVE TO
TRACK IT CAREFULLY BECAUSE ON ANY GIVEN DAY, WE’LL HAVE FIVE
OR SIX OF OUR DIRECTORS IN EVERY SINGLE PART OF THE COUNTRY AT
MEETINGS TAKING PLACE IN INDIAN COUNTRY SO WE WANT TO MAKE SURE
WE TAKE THIS INFORMATION AND SHARE IT PARTICULARLY WITH
TRIBAL LEADERS IN ALL THOSE DIFFERENT SPACES.
SO THAT’S A LITTLE BIT ABOUT THE WORK THAT WE HAVE THAT’S
ONGOING. ONE OF THE THINGS THAT WE’RE
EXCITED ABOUT ARE THE THINGS THAT MAYBE ARE NOT REALLY BEING
ENVISIONED YET BUT THAT MIGHT BE ON THE HORIZON.
SO WE HAVE HEARD IN THE WORK THAT WE HAVE DONE SO FAR THAT
YES, THE ROAD MAP IS WONDERFUL, THIS IS INFORMATION PEOPLE NEED
BUT REALLY PENETRATE INDIAN COUNTRY FULLY AND TO MAKE SURE
THAT EVERY PERSON THAT NEEDS THIS INFORMATION HAS IT AND THAT
IT IS ACCESSIBLE NOT JUST THEY HAVE IT IN HAND BUT THAT THEY
REALLY USE IT. THERE MIGHT BE SOME OTHER TOOLS
AND STRATEGIES THAT WE SHOULD EMPLOY, SO AS WE GO FORWARD,
WE’RE GOING TO BE KEEPING OUR EARS OPEN AND LISTENING TO OUR
PARTNERS, LISTENING TO OUR TRIBAL LEADS AND MAKING SURE
WHERE THERE ARE THOSE OPPORTUNITIES, THAT WE ARE ABLE
TO CAPITALIZE ON THEM AND TAKE THEM AND MAKE SURE THAT WE HONOR
OUR ELDERS IN THE WAY THAT WE’VE BEEN INSTRUCTED.
THE FIRST PRESENTATION WAS REALLY WONDERFUL IN THAT IT
PRESENTED SOME OF THOSE SNAPSHOTS INTO CULTURE, BUT I
WOULD JUST MENTION ONE OTHER THING HERE.
OUR ELDERS ARE THE PROTECTORS OF OUR CULTURE.
AND WE VALUE PEOPLE AND THOSE ELDERS ARE SO PRECIOUS TO US,
THEY ARE SUCH HONORED MEMBERS OF OUR COMMUNITY BUT THEY’RE ALSO
KEEPERS OF THAT KNOWLEDGE. AND THAT’S ANOTHER REASON WHY
THIS WORK IS SO VERY, VERY IMPORTANT.
I DON’T KNOW IF THERE MIGHT BE QUESTIONS BUT I’M CERTAINLY
HAPPY TO TRY AND ANSWER THEM.>>THANK YOU VERY MUCH, MARILYN,
AND THANK YOU FOR YOUR WORK, YOUR SUPPORT AND YOUR
PARTNERSHIP. AND WE WILL TURN IT OVER TO
BRUCE AND WE WILL HOLD THE QUESTIONS UNTIL THE END.
>>THANK YOU. I’LL JUST MAKE A FEW COMMENTS.
ONE IS, THIS SORT FOLLOWS UP ON DR. WINCHESTER’S COMMENTS.
IT WAS ONLY A FEW YEARS AGO THAT GWEN YO, DR. YO PRESENTED AT
THIS GROUP, AND THIS WAS ON WHAT WE KNOW AND WHAT WE DON’T KNOW
ABOUT PREVALENCE AND INCIDENCE OF ALZHEIMER’S IN A VARIETY OF
COMMUNITIES, AND THIS WAS A SUMMARY OF HER STATEMENT THEN
THAT, YOU KNOW — WEE LIABLE DATA AMONG POPULATIONS WHO
IDENTIFY THEMSELVES AS AMERICAN INDIAN OR ALASKA NATIVE IN THE
UNITED STATES ARE NON-EXISTENT. AND I THINK THAT’S SORT OF WHERE
WE — THAT’S WHERE WE START FROM.
THERE HAS BEEN — THERE HAVE BEEN A COUPLE OF STUDIES THAT
HAVE GIVEN SOME INSIGHT INTO THIS.
THIS IS A VERY LARGE SORT OF INSURED POPULATION STUDY FROM
KAISER IN NORTHERN CALIFORNIA LOOKING AT SELF IDENTIFIED
INDIVIDUALS, PEOPLE THAT IDENTIFY AS AMERICAN INDIAN AND
ALASKA NATIVE LOOKING AT INCIDENT CASES OVER A 13-YEAR
PERIOD. IT’S A WORKING POPULATION, IT’S
AN INSURED POPULATION, IT’S NOT A TRUE POPULATION-BASED STUDY,
BUT IT STILL GIVES SOME VIEW INTO THIS AND SHOWS IN THAT
STUDY THAT THE AGE-ADJUSTED INCIDENCE RATES WERE SECOND ONLY
TO AFRICAN-AMERICAN POPULATIONS IN NORTHERN CALIFORNIA.
THAT’S PROBABLY THE BIGGEST LARGEST GROUP STUDY THAT GAVE US
INSIGHT INTO HOW REALLY CRITICALLY IMPORTANT THIS MIGHT
BE. I’LL POINT OUT THAT — IN NORTH
CAROLINA, SHE KNOWS HOW IMPORTANT IT IS BECAUSE SHE’S
SEEING THE ELDERS EVERY DAY. I THINK FOR THOSE OF US ON THE
GROUND, WE KNOW WHAT IT LOOKS LIKE BUT THIS IS A WAY TO LOOK
AT IT AT A BROADER LEVEL. THERE’S A SECOND STUDY OUT OF
FIRST NATIONS IN ALBERTA, ABOUT A 10 YEAR PERIOD LOOKING AT
PHYSICIAN-TREATED DEMENTIA AND AGE-ADJUSTED PREVALENCE, AND I
THINK WHAT’S IMPORTANT THERE, IT’S ANOTHER SNAPSHOT BUT IT
DID — IN THAT STUDY FIRST NATIONS POPULATION HAD THE
HIGHEST INCIDENCE AND IT WAS DISPROPORTIONATELY MORE MALE
THAN OTHER NATIONS. THE IMPORTANT THING IS THIS HAD
BEEN THE VIEW THAT WE HAD HAD OF DEMENTIA IN INDIAN COUNTRY WITH
THE TOP LINE BEING U.S. ALL RACES AND THE TWO BOTTOM LINES
BEING AMERICAN INDIANS AND ALASKA NATIVE SUGGESTED
NON-ADJUSTED, AND SO THIS IS MORTALITY RATES FROM DEMENTIA
FROM INDIAN HEALTH SERVICE DATA, SUGGESTING A MUCH LOWER RATE AT
LEAST OF MORTALITY. WE DON’T BELIEVE THIS DATA TO BE
REALLY REPRESENTATIVE OF WHAT’S TRUE.
IT IS INTERESTING TO SEE THAT THE TREND LINES TRACK THE U.S.
ALL RACES SO I THINK ONE COULD SORT OF ARGUE IT’S PROBABLY A
COMBINATION OF UNDERREPORTING AND MISCLASSIFICATION AND A
VARIETY OF OTHER CAUSES. LAST THING HERE, SORT OF FOR THE
BROADER LOOK IS, WHEN WE LOOK AT POPULATION BASED RISK FACTORS,
THEY’RE HIGHLY PREVALENT IN INDIAN COUNTRY AND AGAIN
SUPPORTS THE THEORY, THE HYPOTHESIS THAT THIS IS A BIGGER
PROBLEM, WE DON’T HAVE THE DATA ON A POPULATION BASE BUT IT’S
PROBABLY A BIGGER PROBLEM THAN WE’VE OVER TIME RECOGNIZED.
IT WAS NOT ALL THAT LONG AGO THAT I WOULD GO TO THE NATIONAL
INDIAN COUNCIL ON AGING OR THE TITLE 6 DIRECTORS AND WE DO A
TALK ON ALZHEIMER’S AND THERE WOULD BE JUST A HANDFUL OF
PEOPLE IN THE ROOM AND THE QUESTIONS THEY WOULD ASK IS, IS
THIS A PROBLEM IN INDIAN COUNTRY.
I CAN TELL YOU NOW, AND I’M SURE CAROLYN CAN SPEAK TO THE
EXPERIENCE AT NIHB MEETINGS, THE ROOMS ARE FULL NOW TO
OVERFLOWING, AND EVERYONE KNOWS THAT IT’S A PROBLEM, AND I THINK
OUR DATA IS CATCHING UP ON THAT. I DO WANT TO POINT OUT THAT WHEN
WE TALK ABOUT ADDRESSING, AND I THINK CAROLYN’S COMMENTS REALLY
GAVE A GREAT FLAVOR FOR THAT, ADDRESSING ALZHEIMER’S AND
RELATED DEMENTIAS, AND TALKING ABOUT THE INDIAN COUNTRY OR THE
INDIAN HEALTH SYSTEM, IT’S MOSTLY TRIBAL, MOSTLY TRIBALLY
OWNED AND OPERATED. THE INDIAN HEALTH SERVICE DIRECT
SERVICES ARE A SMALLER PART OF THAT.
THE MAJORITY OF THIS IS TRIBALLY OWNED AND OPERATED.
THE INDIAN HEALTH DELIVERED SERVICES, WE LOOK TO TRIBAL
LEADERS TO SET THE PRIORITIES FOR THIS WORK.
IT’S A VERY COMPLEX ENVIRONMENT, RIGHT, WITH BOTH TRIBES AND
ELECTED TRIBAL LEADERSHIP, THERE’S THE NIHB AND THE
REGIONAL HEALTH BOARDS THAT PROVIDE POLICY AND PUBLIC HEALTH
SUPPORT, THERE’S TRIBAL EPIDEMIOLOGY CENTERS THAT
ACTIVE, OWNED AND OPERATED BY THE TRIBES.
THERE ARE A VARIETY OF OTHER TRIBAL ORGANIZATIONS ACTIVE.
THERE’S UNIVERSITIES, WORKING WITH TRIBES, THROUGH GRANTS AND
OTHER MECHANISMS TO DO RESEARCH IN THE AREA.
SO THERE’S A LOT GOING ON IN INDIAN COUNTRY, AND I THINK
SOMETIMES TO RECOGNIZE THERE’S A NUMBER OF WAYS IN, THERE’S A
NUMBER OF WAYS IN WITH THIS METHOD.
IT’S ONE OF THE REASONS THAT THE ROAD MAP WILL BE A POWERFUL TOOL
FOR US BECAUSE KNOW WITH YOU HAVE SOME COMMON LANGUAGE TO USE
AS WE LOOK AT ALL THE WAYS IN. ON THE RIGHT SIDE THERE ARE THE
FEDERAL PROGRAMS THAT ALSO HAVE A LARGE PRESENCE IN INDIAN
COUNTRY. IHS IS ONE OF THEM BUT NOT THE
BIGGEST NECESSARILY. TRIBES HAVE REALLY GOOD, WORKING
RELATIONSHIPS WITH SAMHSA, WITH CMS, WITH CDC, SO THERE’S A
NUMBER OF WAYS AND EVEN THROUGH THE FEDERAL SYSTEM.
I DID WANT TO TAKE A MINUTE AND JUST SAY NOW NARROWING THE FOCUS
TO INDIAN HEALTH, THINKING IN TERMS OF THE ROAD MAP, WHAT ARE
THE AREAS OF CONCENTRATION THAT WE SEE IN OUR PORTION OF THE
SYSTEM, AND I THINK THAT WE WILL BE TALKING WITH TRIBES ABOUT.
FOR THE TRIBES WE SERVE, THROUGH DIRECT SERVICES BUT ALSO THE
TRIBES WE WORK WITH OWNING AND OPERATING THEIR OWN HEALTH
SYSTEMS. YOU’VE SEEN THIS BEFORE BECAUSE
THIS SHOULD BE IN THE PLAN, IN THE NAPA PLAN.
INCREASING AWARENESS IN THE COMMUNITY, IN PART IN ORDER FOR
THAT AWARENESS TO DRIVE CHANGE, RIGHT?
WE NEED THE IHS BENEFICIARIES WHETHER THEY’RE SERVED THROUGH
TRIBAL OR IHS PROGRAMS TO BE DEMANDING OF US, AND DEMANDING
OF TRIBAL LEADERSHIP, MORE ATTENTION TO ALZHEIMER’S AND
RELATED DEMENTIAS. OBVIOUSLY THERE’S A LOT TO BE
DONE IN WORKFORCE COMPETENCY. BLYTHE DID A GREAT LITTLE STUDY
AT THE CHEROKEE INDIAN HOSPITAL SHOWING THAT THIS IS NOT JUST
ABOUT INCREASING KNOWLEDGE BUT ALSO ABOUT INCREASING CONFIDENCE
IN THE USE OF THAT KNOWLEDGE, ESPECIALLY IN PRIMARY CARE, AND
I’VE SAID A MILLION TIMES OUR PRIMARY HEALTHCARE SYSTEM.
I WOULD JUST POINT OUT, IT’S ALSO ABOUT THAT CONTENT IS NOT
JUST KNOWLEDGE ABOUT ALZHEIMER’S BUT ALSO THE CONTENT OF HOW TO
TALK ABOUT IT IN COMMUNITIES. I DON’T KNOW IF CAROLYN
MENTIONED THIS AS BLYTHE MENTIONED, IT PART OF THAT
CONTENT THAT WE NEED TO BE WORKING WITH.
WE ALSO NEED TO BE THINKING ABOUT SYSTEM COMPETENCE.
I’LL HIGHLIGHT TWO AREAS, ONE IS AROUND CAREGIVER SUPPORT.
WE’VE TALKED ABOUT THAT I A LOT. THE SECOND IS AROUND — AND IT
CAME UP EARLIER TODAY — THAT NOTION OF CARE NAVIGATION OR
CARE MANAGEMENT, ABOUT SUPPORTING, ABOUT BUILDING
BETTER SYSTEMS IN THE DELIVERY OF CARE FOR FAMILIES AND
INDIVIDUALS. ADDRESSING ALZHEIMER’S.
INTO URBAN THAT SLIDE AROUND RISK FACTORS POINTS OUT THE
ISSUE THAT THIS IS — THAT DIABETES, GOOD DIABETES CONTROL
IS AN IMPORTANT COMPONENT OF DEMENTIA PREVENTION OF
ALZHEIMER’S, ALZHEIMER’S PREVENTION.
I DIDN’T INCLUDE A SLIDE BUT THERE’S BEEN SOME REALLY
INCREDIBLE DATA PRODUCED BY THE CDC AND IHS IN THE LAST YEAR
ABOUT THE IMPACT OF THE SPECIAL PROGRAM FOR DIABETES FOR INDIANS
AND OF SOME CLINICAL INTERVENTIONS IN TRIBES AND IHS
DELIVERED SERVICES ON THE RATES OF END STAGE RENAL DISEASE, AND
I THINK IT’S A MODEL FOR HOW WE CAN SORT OF THINK ABOUT HOW DO
YOU BUILD, THIS GOES BEYOND — BUT HOW DO YOU BUILD INTO A
PRIMARY CARE SYSTEM THE TOOL SET TO ACTUALLY MAKE GENERATIONAL
CHANGE IN ILLNESS AND DISEASE. AND FINALLY I COULDN’T HELP BUT
POINT OUT THE NEED TO LOOK AT MEASUREMENT AND I’LL
SAY THAT WHETHER THE MEASURES IN INDIAN
HEALTH REALLY STARTED OUT LOOKING AT HOW WE’RE GOING TO
START LOOKING AT THIS IN A MEANINGFUL WAY, IT’S A CHALLENGE
AND AN IMPORTANT ONE. THE LAST THING IS JUST — AND
IT’S MUCH BIGGER THAN INDIAN HEALTH, IT’S REALLY INDIAN
COUNTRYWIDE, IS AVAILABILITY OF LONG-TERM SERVICES.
HOME AND COMMUNITY-BASED PRIMARILY BUT ALSO
FACILITY-BASED CARE. I’LL TURN IT BACK TO LISA.
>>THANK YOU. I’M GOING TO GIVE YOU A BRIEF
OVERVIEW OF THINGS CDC IS DOING IN SUPPORT OF THE ROAD MAP AND
IMPLEMENTATION OF IT AS WELL. SO MOLLY GAVE US A GREAT
OVERVIEW OF THE ROAD MAP AND INDIAN COUNTRY AND HOW IT REALLY
IS TAILORED TOWARDS TRIBAL HEALTH LEADERS AND REALLY THE
PLAN IS WE’RE TRYING TO LEARN, PLAN AND START RESPONDING TO
ALZHEIMER’S DISEASE AND DEMENTIAS.
YOU SEE THE ROAD MAP, THE EXECUTIVE SUMMARY PLACED AT THE
COUNCILMEMBERS’ SEATS AND WE HAVE PLENTY OF HANDOUTS IN THE
BACK, AND THE DISSEMINATION GUIDE.
SO IF YOU WANT TO HAVE NEW STORIES, SOCIAL MEDIA, ET
CETERA, ARE SOME WAYS TO THINK ABOUT OR DISCUSS OR DESCRIBE THE
CONTENT OF THE ROAD MAP, THAT THIRD DOCUMENT ON THE RIGHT-HAND
SIDE HAS THAT AS WELL. SO THESE ARE THE CATEGORIES OF
THE STRATEGIES WITHIN THE ROAD MAP AND THESE DO CORRESPOND TO
THE 10 ESSENTIAL SERVICES OF PUBLIC HEALTH WHICH IS THE
LANGUAGE THAT PUBLIC HEALTH PRACTITIONERS DO SPEAK, ACT AND
USE TO GET THEIR WORK DONE. SO I’M GOING TO HIGHLIGHT A
LITTLE BIT OF THE DIFFERENT TYPES OF ACTIVITIES OR ACTIONS
WITHIN EACH OF THOSE ESSENTIAL SERVICES AND ALSO SOME OF THE
DIFFERENT TYPES OF MATERIALS OR THINGS THAT WE HAVE AVAILABLE TO
SUPPORT THE UTILIZATION AND IMPLEMENTATION OF THIS NEW ROAD
MAP. SO THE FIRST ONE OF THOSE
STRATEGIES IS EDUCATING AND EMPOWERING COMMUNITIES.
SO WE REALLY WANT TO GET THAT CONVERSATION GOING SO THAT IS
OUR THEME, GETTING PEOPLE TALKING, GETTING PEOPLE THINKING
SO THESE ARE THE ACTION ITEMS INCLUDED IN THE STRATEGY.
THESE MATERIALS HAVE ALSO BEEN PLACED AT THE COUNCILMEMBERS’
SEATS. SO THESE ARE ACTUALLY PULLOUTS
FROM THE ROAD MAP, BUT THESE ARE SOME OF THE ONE PAGERS,
CO-BRANDED — AND PARTNERSHIPS DEVELOPED BETWEEN ALZHEIMER’S
ASSOCIATION AND CDC OF INFORMATION THAT WE THINK IS
REALLY IMPORTANT TO GET SHARED. SO WHAT ARE SOME OF THOSE
WARNING SIGNS? HOW DO YOU GET A CONVERSATION
GOING AND HOW DO YOU START THAT CONVERSATION IN YOUR COMMUNITY,
AS WELL AS OTHER PROGRAMS THAT ARE AVAILABLE WITHIN INDIAN
COUNTRY THAT SHOW SOME OF THE OTHER RELATED ACTIVITIES SUCH AS
DIABETES AND OTHER HEALTH PROGRAMS THAT ARE RELEVANT AND
CONNECTED. HERE ARE SOME RECENT THINGS WE
HAVE DONE THE A CDC. ONE ON THE LEFT-HAND SIDE IS A
BLOG THAT’S PART OF THE CDC.GOV FEATURE SERIES WHICH EMPHASIZES
SOME OF THE RACIAL AND ETHNIC DISPARITIES IN THE PREVALENCE OF
ALZHEIMER’S DISEASE AND THEN ON THE RIGHT-HAND SIDE, CDC
PUBLISHES WEEKLY EMAILS CALLED “DID YOU KNOW.”
SO WE IN THE MAY FEATURE GAVE SOME STATISTICS FOR AMERICAN
INDIAN ALASKAN NATIVE COMMUNITIES I’LL SHOW YOU IN
JUST A SECOND AS WELL AS THE ROAD MAP.
SO DATA IS IMPORTANT. SO HOW DO WE KNOW IF WE’RE
IMPROVING, HOW DO WE KNOW IF WE’RE MAKING THE NEEDLE, HOW DO
WE KNOW WHAT THE ISSUES ARE WE NEED TO ADDRESS OR SOLVE WITHIN
OUR COMMUNITIES? AND DATA IS ONE OF THE WAYS WE
CAN DO THAT. SO THROUGH CDC’S BEHAVIORAL RISK
FACTOR SURVEILLANCE SYSTEM, ACTUALLY THIS ALL STARTED AT
THIS MEETING WITH BRUCE FINKE SAYING, LISA, DO YOU HAVE ENOUGH
DATA TO DO THIS? AND ANSWER IS YES, WE DO.
SO WITH OUR SUBJECTIVE COGNITIVE DECLINE, SO THIS IS PEOPLE
EVALUATING THEIR OWN MEMORY PERFORMANCE.
SO IN THE PAST YEAR, HAS THEIR MEMORY OR THEIR CONFUSION GOTTEN
WORSE? AND SO THIS INFOGRAPHIC IS — I
CANNOT SPEAK. THIS INFOGRAPHIC IS DATA OF
EXCLUSIVELY AMERICAN INDIANS AND ALASKA NATIVE ADULTS.
SO REPRESENTING 49 STATES, D.C. AND PUERTO RICO.
THESE ARE ALSO AT THE SEAT OF THE COUNCILMEMBERS AND IN THE
BACK OF THE ROOM AS WELL. WE ALSO HAVE INFORMATION ON
CAREGIVING, AND THIS IS CAREGIVING, PEOPLE WHO ARE
PROVIDING CARE TO SOMEBODY. THESE ARE FOR ADULTS 18 YEARS
OLD AND OLDER, AND THEY COULD BE PROVIDING CARE TO SOMEBODY FOR
DEMENTIA, THEY COULD BE PROVIDING CARE TO SOMEONE FOR
ANY REASON SUCH AS CANCER OR SOME OTHER CHRONIC HEALTH
CONDITION. SO ONCE AGAIN, THIS IS DATA
EXCLUSIVELY FOR PEOPLE WHO ARE CAREGIVERS WHO ARE AMERICAN
INDIAN AND ALASKA NATIVE. SO STRENGTHENING THE WORKFORCE.
ANOTHER ONE OF THOSE IMPORTANT ESSENTIAL SERVICES OF PUBLIC
HEALTH. SO WE TALK ABOUT STRENGTHENING
THE WORKFORCE, WE’RE TALKING ABOUT STRENGTHENING THE
WORKFORCE OF ALL DIFFERENT TYPES OF PEOPLE, SO THE NOT JUST
HEALTHCARE PROVIDERS BUT PEOPLE WHO ARE WORKING WITH,
INTERACTING WITH HEALTHCARE PROFESSIONALS VERY BROADLY.
AND SOME OF THE WAYS THAT WE HAVE DONE THAT IS IN PARTNERSHIP
WITH APTO AS WELL AS IA SQUARED. SO WE HAVE DEVELOPED A SERIES OF
COMMUNICATION MATERIALS THAT REALLY ARE EMPHASIZING THAT
CONNECTION BETWEEN SOMEBODY’S HEART HEALTH AND MAINTAINING AND
PRESERVING THAT HEART HEALTH AS A WAY TO MAINTAIN THEIR BRAIN
HEALTH AS WELL TOO. SO THERE’S A SERIES OF POSTERS
AND FLYERS THAT CAN BE USED AT CLINICS, HEALTH FAIRS, WE HAVE
RADIO PSAS, VIDEOS, A PROVIDER GUIDE WHICH HAS BEEN WIDELY
POPULAR. I DO HAVE SOME OF THOSE
MATERIALS WITH ME BUT THEY’RE ALSO AVAILABLE ON OUR WEBSITE
AND ASTO’S WEBSITE. WE HAVE A CONTINUING EDUCATION
COURSE ON BRAIN HEALTH THAT IS NOT DESIGNED SPECIFICALLY FOR
AMERICAN INDIAN AND ALASKA NATIVES BUT IT DOES EMPHASIZE A
LOT OF THOSE CARDIOVASCULAR DISEASE RISK FACTORS THAT WAS
DESIGNED AND DEVELOPED IN COLLABORATION WITH AMERICAN
COLLEGE OF PREVENTIVE MEDICINE THAT BECAUSE IT WAS DEVELOPED BY
CDC FUNDING OR GOVERNMENTAL FUNDING, IT IS FREE TO ANYONE
WHO WANTS TO TAKE THE COURSE, WHETHER YOU’RE ELIGIBLE WITH
CONTINUING EDUCATION UNITS OR NOT.
IF YOU’RE ELIGIBLE, YOU CAN GET THOSE FOR FREE AS WELL TOO.
ACPM JUST RELEASED A COMPANION WEBSITE OF TOOLS AND RESOURCES
HIGHLIGHTING RESEARCH TOOLS AND PROVIDERS AS WELL AS MATERIALS
THAT CAN BE GIVEN TO PATIENTS. SO CDC IS ACTIVELY ENGAGED IN
TRYING TO PROMOTE THE HEALTH AND WELL-BEING OF AMERICAN INDIANS
AND ALASKA NATIVES, SO THIS SLIDE ILLUSTRATES SOME OF THE
DIFFERENT TYPES OF PROGRAMS AND ACTIVITIES WE HAVE GOING ON
WITHIN OUR AGENCY. MANY ARE VERY AWARE OF OUR
DIABETES PROGRAMS BUT THERE ARE OTHER PROGRAMS AS WELL TOO AND
I’D BE HAPPY TO SHARE MORE OF THAT INFORMATION WITH YOU.
SO NEXT STEPS. SO IF WE’RE MOVING FORWARD WITH
THIS ROAD MAP, I’M SO EXCITED ABOUT THE ENERGY AND THE
EXCITEMENT THAT WE’RE HEARING ABOUT IT.
WHEN MOLLY AND I TOOK ON THIS PROJECT TWO YEARS AGO, YES, TWO
YEARS AGO, WE WERE ENVISIONING AN EIGHT PAGE, 10 PAGE, 12 PAGE
DOCUMENT. NEEDLESS TO SAY, IT HAS GROWN A
LITTLE BIT. THERE WAS A LOT MORE WE NEEDED
TO INCLUDE AND WANTED TO INCLUDE FROM ALL OF THAT LISTENING AND
LEARNING WE HAVE DONE. IT’S BEEN A VERY, VERY
INFORMATIVE EXPERIENCE FOR US AS WELL AS A GREAT WAY THAT WE HAVE
FORGED MANY NEW PARTNERSHIPS WITH THIS.
SO THIS IS NOT IT FOR US. WE DIDN’T JUST DEVELOP A BOOK
AND STOP. SO WITH SOME FUNDING THAT WILL
HOPEFULLY BE PUBLICLY ANNOUNCED ONCE IT’S AWARDED IN AUGUST,
SOME OF THE THINGS WE’RE DOING AT CDC IS WE’RE INTEGRATING
BRAIN HEALTH MESSAGING INTO — THINGS ABOUT QUITTING SMOKING,
THINGS TO REDUCE OBESITY AND OTHER HEALTH CONDITIONS.
SO WE ARE WORKING WITH PARTNERS TO GET BRAIN HEALTH MESSAGES
INTEGRATED INTO THOSE EXISTING MESSAGES AND COMMUNICATIONS
PROGRAMS. THE OTHER THING WE’RE TRYING TO
DO AS WELL OR TRYING TO AWARD IS WE’RE REALLY GOING TO BE WORKING
WITH OUR PARTNERS TO GET MEETINGS AND GET ACTION — OUT
INTO COMMUNITIES, ESPECIALLY TRIBAL COMMUNITIES, TO TRY TO
STIMULATE STRATEGIC CHANGES INTO ENVIRONMENTS.
IF YOU GO TO OUR WEBSITE, YOU WILL SEE AT THE TOP THE ROAD MAP
FOR INDIAN COUNTRY. IF YOU DO NOT GET OUR
NEWSLETTERS, PLEASE SIGN UP, THERE’S A LINK THERE AS WELL.
AND I THANK YOU VERY MUCH AND I’LL LEAVE THIS SLIDE UP SO YOU
CAN FIND OUT WHERE TO GET ALL OF OUR MATERIAL FROM THE
ALZHEIMER’S ASSOCIATION AND FROM CDC.
SO I THANK YOU TO THE NAPA COUNCIL FOR ALLOWING US THIS
OPPORTUNITY TO SHARE THE WORK THAT WE’RE DOING, AND WE’RE
READY FOR QUESTIONS.>>GREAT.
THANK YOU VERY MUCH FOR YOUR DEEP DIVE AND VERY GREAT
PROGRESS. AND WE’LL JUST TAKE ABOUT TWO
QUESTIONS. THAT’S ALL WE HAVE TIME FOR.
>>>>GREAT QUESTION.
CAN YOU SAY MORE ABOUT THE PSAS AND HOW THEY’RE THE SAME
OR DIFFERENT FROM ONES THAT ARE PREPARED OR PLANNED NOT FOR
INDIAN COUNTRY? JUST VERY CURIOUS ABOUT THE
CULTURAL DIFFERENCES AND HOW THAT WAS INCORPORATED INTO THE
PSA FOR INDIAN COUNTRY.>>HOW IT WAS DEVELOPED IS THERE
ARE ACTUALLY TRIBAL MEMBERS AND USING MESSAGES CULTURALLY AWARE
OF THE SO USING LANGUAGE THAT IS COMMUNICATING THE MESSAGES THAT
PUBLIC HEALTH WOULD WANT TO GET ACROSS IN WAYS THAT ARE
APPROPRIATE. SO THEY’RE VERY SHORT, SOME OF
THEM ARE 30 SECONDS, SOME ARE ABOUT A MINUTE AND THERE’S FIVE
OF THOSE.>>AND THE GOALS ARE TO INVITE
PEOPLE TO COME IN FOR COGNITIVE SCREENING OR —
>>THE GOAL — SO THOSE PSAS, THAT IS ALL THROUGH THE ASTO
COLLABORATIVE OF THE CARDIOVASCULAR RISK FACTORS TO
PROMOTE BRAIN HEALTH. SO THAT IS THE MESSAGING ON
THOSE. GOOD QUESTION.
>>OTHER QUESTIONS?>>NOT A QUESTION BUT A COMMENT.
I JUST WANT TO SAY THANK YOU FOR ALL OF THIS WORK.
IT’S INCREDIBLY ELEGANT AND REALLY SPEAKS TO HOW ONE WOULD
ADDRESS POTENTIAL BARRIERS AT POINT OF CARE AND WHERE IT
MATTERS, AND BRUCE MENTIONED THE KIDNEY, IMPROVING OR PREVENTING
PROGRESSION OF KIDNEY DISEASE AND DIABETES.
THAT’S EXACTLY — WE ARE VERY INTERESTED IN WHAT WE CAN LEARN
FROM THAT, NOT JUST FROM DISSEMINATION AND SPREAD ACROSS
INDIAN COUNTRY, BUT WHAT ARE THE LESSONS LEARNED THERE AND BEST
PRACTICES THAT MIGHT BE APPLICABLE TO A BROADER
AUDIENCE, SO JUST WANT TO SAY THANK YOU FOR THE WORK.
>>I JUST WANT TO SAY DITTO TO YOUR EXPRESSION HERE.
IN A WAY IT’S LIKE A LITTLE MINI STUDY OF 500-PLUS NATIONS, ALL
WITH ITS OWN LANGUAGE AND CULTURAL BELIEFS AND SO FORTH,
AND SO IN TERMS OF A MODEL FOR DISSEMINATION AND IMPLEMENTATION
THAT’S IMPORTANT, AND ALSO IT MAY HAVE BEEN CAROLYN, OR
BLYTHE, I THINK, WHO MENTIONED A POSSIBLY DIFFERENT CULTURAL
MANIFESTATION OF SYMPTOMS, SO SYSTEMATICALLY IDENTIFYING THEM
AND COLLECTING THAT INFORMATION, BEHAVIORAL AND PSYCHOLOGICAL
SYMPTOMS AND OTHER DISEASE PRESENTATION, I THINK WOULD GO A
HUGE LONG WAY BECAUSE WE HAVE HERE A VERY CRITICAL MINI
EXPERIMENT, IF YOU WILL, THAT HAS LESSONS NOT ONLY FOR INDIAN
COUNTRY BUT ALSO FOR THE LARGER POPULATION.
THANK YOU. THANK YOU VERY MUCH FOR COMING
AND PRESENTING.

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