To Improve Indigenous Health, Expand Community Health Aide Programs

“He’s not breathing normally,” the woman said to the camera that was streaming live beside a patient who appeared to be in his mid-20s.

“Can you get an oxygen saturation reading on him?” asked the emergency department attending physician who I was sitting with, hundreds of miles away in Kotzebue, Alaska.

The scene unfolded in real time on a computer screen in front of us at the Maniilaq Health Center in Kotzebue, one of the eight Native Alaskan-owned and operated hospitals in the state. On the screen, the patient appeared pale and inconsistently responsive. As a third-year medical resident working at Maniilaq, I was learning more about what health issues face communities like these in rural Alaska.

The woman on the screen grabbed the pulse oximeter and applied it to the young man’s index finger.

“I’m getting a reading of 84%; the waveform looks good, so I think this is a fairly accurate read. Should I go ahead and give oxygen through the nasal cannula?”

The woman on the screen is a Community Health Aide (CHA). First recognized and funded by Congress in 1968, the Community Health Aide Program (CHAP) in Alaska has developed an innovative way to deliver care to Native Alaskans living in remote, rural areas throughout the state.

Indigenous Peoples’ Day, to be celebrated on October 14 this year, is a good reminder of how crucial it is to ensure healthcare access for these communities.

Today, many see CHAP as a key component of the overall Alaska Native Healthcare system, which serves 229 federally recognized tribes living across nearly 600,000 square miles of land. Through the program, CHAs participate in a series of trainings at CHAP training centers throughout the state in order to recognize and respond to problems that may warrant professional medical attention.

The aides are chosen by their community in an effort to provide not only high-quality but also culturally competent care, and typically have conversational familiarity with the community’s local language. Those wanting to become health aides are required to have at least a sixth-grade education and must complete a 4-month long series of trainings where they learn requisite clinical skills and knowledge.

In conjunction with trained health professionals — including nurse practitioners, physician assistants, and physicians — CHAs are the first providers to treat a wide range of medical problems, from emergent ones (like de-oxygenation in a poorly communicative patient) to chronic ones (like performing routine check-ups on patients with diabetes or high blood pressure).

The program has been so successful that this paradigm has expanded to other aspects of healthcare in the state, such as dentistry. Even more recently, Alaska’s legal system has adopted this approach — and other states are following suit. California, Indiana, Mississippi, Pennsylvania, and Massachusetts are just a few examples of states that have invested in programs to bolster community health through CHA-type initiatives to reach under-resourced patient populations. Meanwhile, HHS recently announced a $75 million investment to ensure adequate access to healthcare for rural Americans, so hopefully there will be a burgeoning supply of innovative delivery care models across rural America.

Some of the groups most in need of such innovative healthcare delivery models are other Native American Nations across the lower 48 states. It is true that 86 out of the 100 identified most-marginalized communities in the U.S. are rural. However, one quarter of those marginalized rural communities are made up of predominantly Native peoples. In fact, Native Americans are the only U.S. minority group that has a higher percentage of their members living in rural areas than urban areas.

To be sure, Indigenous groups across the country have their own unique culture and needs, so a homogenous solution cannot be uniformly applied to these communities. That is why CHA programs would work so well for Indigenous peoples across the U.S.: the programs source from their own communities and are overseen by Native leadership. This ensures local cultural competency and delivery of high-quality care that is informed by each community’s needs.

With a centuries-long history of colonization and subjugation, Alaska Natives and Indigenous peoples have high levels of mistrust in U.S. government institutions, most notably the Indian Health Service (IHS), which is the federal entity responsible for providing healthcare to all the Indigenous Nations residing within the 50 states. However, if IHS were to work toward a common goal with Indigenous Nations to establish a national CHAP across the lower 48 states, this may help improve trust. While current IHS leadership is reportedly in favor of expanding the CHAP program, solidifying support and plans is urgent.

It is critical for policymakers, healthcare providers, community advocates, community leaders, and funders to support policies and programs that will implement innovative healthcare solutions for Indigenous Nations across the country, leading to better health outcomes for all.

Victoria Kliewe, MD, is a third-year internal medicine resident on the primary care track at Massachusetts General Hospital and a Public Voices fellow through The OpEd Project with Massachusetts General Hospital.