The 24-year-old woman who came into the Oklahoma City Indian Clinic in early November 2005 was pretty depressed, and for good reason: She weighed 324 pounds, smoked, and had blood pressure of 158/114 mm Hg. She also had very poorly controlled blood sugar, with a hemoglobin A1c reading of 10.5%. She had been diagnosed with diabetes at a previous health care provider but seemed not to be paying attention to the diagnosis.
The clinic staff enrolled her in its diabetes program, known as BRAID (Being Responsible American Indians with Diabetes). She was given prescriptions for twice-daily metformin and for insulin, and she was told to test her blood sugar three times a day. She also began a series of five diabetes education sessions.
Less than a year later, her picture had brightened considerably. Her weight had dropped to 282 pounds, she had quit smoking, and her blood pressure was down to 132/82 mm Hg.
But the most dramatic improvement was in her blood sugar: Her hemoglobin A1c (HbA1c) was 5.7%. Her daily metformin dose had decreased from 2,000 mg to 500 mg, and she was off of insulin completely.
Such success stories are often cited by backers of the federal government's Special Program for Diabetes in Indians (SPDI), of which BRAID is a part. SPDI, an Indian Health Service (IHS) initiative, was first authorized by Congress in 1997 and renewed in 2001 and for several years thereafter. The program gives money to Native American tribes and private contractors who provide diabetes treatment and prevention services. It is funded through fiscal year 2008, then it will come up for reauthorization.
But SPDI faces a stiff challenge. American Indians and Alaska Natives have an age-adjusted diabetes rate of 16.3%, the highest among all racial and ethnic groups in the United States. In some native communities, as many as 60% of adults have diabetes. Among Native Americans aged 15–19, the rate of diabetes increased 128% from 1990 to 2004, according to the IHS. Almost all of the cases are type 2 diabetes.
In February, the Senate Indian Affairs Committee held an oversight hearing on the SPDI program. Several witnesses testified to the great successes the program has had, especially in the areas of diabetes awareness, nutrition programs, and exercise.
But committee member Rep. Craig Thomas (R-Wyo.) was having none of it. He wanted to know only one thing.
“How effective have we been?” he asked Dr. Kelly Moore, clinical specialty consultant to the IHS division of diabetes treatment and prevention.
Dr. Moore cited improvements in blood pressure and blood sugar control, noting that the Native American community “has seen a decline during the SPDI program in A1c levels from 8.9% to 7.9%.” (See box.) She admitted that data from 2004 indicated that diabetes has been increasing among Native American youth, “but we've had more efforts directed toward screening for diabetes, which would also increase our rates. And it will take decades to reverse the epidemic of type 2 diabetes we're seeing in our population.”
IHS director Charles Grim, D.D.S., also defended the increase. “We don't know what the rate of increase would have been if we didn't have this program,” he said. “We believe the rate would have been higher [without it].”
Dr. Biron Baker, a family physician who worked for the IHS in North Dakota for 3 years, testified that medication options for IHS diabetes patients were problematic. “In the IHS, we see older insulin preparations, older oral medication preparations, and things being done we don't think work any more,” he said.
Dr. Baker recommended to the committee that the IHS make it a priority to hire and retain competent administrators and medical staff. He also estimated that the IHS is currently funded at about 40% of the needed level.
“I don't usually advocate throwing money at a problem, but this is where I make an exception,” he said.
Dr. James Brosseau, director of the Altru's Diabetes Center in Grand Forks, N.D., testified about another problem: access to clinic care.
“Many patients are frustrated with a lack of service on evenings and weekends, long waits to see the doctor, and then the sense that you are just given a prescription and are sent out the door,” he said. “We have to change the way we deal with chronic disease. A 10-minute visit is not going to work for a person with diabetes.”
Despite these problems, many SPDI providers keep working to make a difference. Dr. Musarat Saeed, an internist at the Oklahoma City Indian Clinic, has been with the clinic for 12 years and spends 2 full days each week seeing diabetes patients.