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Indigenous Approaches to Infection Prevention and Control

Learning Objectives
1. Describe the role of Urban Indian Organizations in health care
2. Identify examples of culturally competent health care services for American Indians and Alaska Natives
0.5 Credit CME

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Audio Transcript

Welcome to Stories of Care, a podcast from the American Medical Association and the CDC's Project Firstline. Our guest today is Angel Galvez, CEO of the Bakersfield American Indian Health Project, serving the American Indian and Alaska Native People of Kern County. BAIHP is a collaborative partner of the National Council of Urban Indian Health, raising awareness of infection prevention and control practices and improving health equity. Along with many other Urban Indian Organizations across the country, BAIHP provides essential health services to a diverse population of American Indians and Alaska Natives.

On this episode, we discuss how Angel and his organization blended traditional native practices, cultural competency, and infection control principles in order to better serve their patients and create a welcoming, respectful and safe heath care environment.

Megan Srinivas, MD: [00:01:00] Hey, Angel, thank you so much for being here and joining us today. Can you tell us a little bit about yourself and your background?

Angel Galvez, BAIHP: [00:00:07] Hi, everyone. I'd like to greet you in my father's native language. Qi-she ne jaya' pa a'h-te pa a'h-te -- Na (hu[ ha) wa I greet you with agape love. And it's an honor to be here. A little bit of my my background. I came from working, actually, Tule River Indian Health Center. I was chief operating officer. I spent a number of years there working with the local Indians and other Indians that reside into Tulare County. After several years of working there, I came as the chief executive officer for the Bakersfield American Indian Health Center. It's an Urban Indian Health Center, one of ten Urban Indian Health Centers here in in California.

Srinivas: [00:01:50] That's all. Thank you so much for bringing your experience to the podcast today. We have so much to learn. First off, what is an urban Indian organization?

Galvez: [00:02:02] Well, that's really a good question. We get that question often. You know, what what are what is an urban Indian organization? And under Title V of the Indian Health Improvement Act, it's a establishment for health care for Native Americans and Alaska Indians who reside in rural or urban areas of the county. So there are ten in total in the state of California. And we reside in the city of Bakersfield, which is Central California, and we're in Kern County.

Srinivas: [00:02:41] Outside of California, are there a lot of UIOs as well throughout the country?

Galvez: [00:02:46] There is, yes. So I'm not sure how many, but each state, I believe, has an Urban Indian Organization establishment. And so, you know, you have places like Denver, you have places like Alaska. There are urban Indians across the entire United States.

Srinivas: [00:03:06] I'm based here in Iowa. Now, I'm really interested to see if there's a UIO near me and and learn more about them as well. So thank you for introducing this concept to us and these organizations to us. What are some of the challenges that you've seen with working within a UIO within these major cities that come from one side of the country to the other?

Galvez: [00:03:33] Well, you know, many of the urban Indians that we serve are a mixture of diverse Indians representing nations across the United States. So the easiest example that I can share with you is we we have been collecting data on the types of Indians that living that live in Kern County. And we have come up with roughly a little over 220 tribal nations represented, which tells you the diversity of the makeup of Indian Native Americans, Alaska Natives that live in Kern County. So part of that challenge is to, you know, really raise the level of quality and the embracing of the rituals and culture that exists among a very diverse group of Native Americans. And so that has been one challenge. Another challenge is that in counties such as ours, there are extremely rural communities where many of these Natives live. And so reaching them, reaching the unserved or the underserved populations of our county is also another challenge. You know, providing that transportation or providing access to care becomes difficult for those who are suffering through either chronic or severe mental illness, those who require maybe a higher level of access to care than those who perhaps come every now and then. So we have our boundary. You can drive roughly two and a half to 3 hours within our county. And I'm talking, you know, very mountain, mountain-like communities and very desert-like communities. And so two and a half to 3 hours to reach some of these populations has been a difficult challenge for us.

Srinivas: [00:05:32] Oh, wow. That's quite a large area, as well as such a diverse group of people. When you have 200 different 220, excuse me, different tribes, how do you make sure to honor each culture and understand each culture to be able to serve so many diverse groups of people?

Galvez: [00:05:53] Well, that's, that's a very important question. And I think one of the things that we did early on when I came to Bakersfield American Indian Health, was to really, really promote and advocate for community engagement and work with our community leaders who are identified as American Indian, who represent either the local indigenous populations or populations of groups that have risen, have made Kern County their home to partner together to bring to bring community engagement in a way that we haven't done it before. And so part of that planning and development has been done collaboratively with those folks that that represent those communities. And so we promote about five, we engage in five community events annually, and they're broken up based on seasons. And we did along the way, we did a lot of community assessment, community input through a community program and planning process where we would engage in community assessment via various types of funding streams that we were able to tap into, as well as focus groups to really kind of gain the input of the diverse community that I mentioned formally, to really understand what are the common themes, what are the things that our Native Americans celebrate as their culture, their traditions and their rituals? So of course, we started partnering with those who were indigenous to the region first. We have Tejon Indians, we have Tubatulabal Indians, we have Indians who have been here for generations and generations. And so we started with them because we felt to honor the land and to honor the people who were here before us, it would make sense to partner with those individuals first and hear from them. What are those? What is the cultural makeup within these communities? And there was a lot of buy in in doing it that way. And so over the course of a couple of years, we've been very well-educated in terms of what should be the cultural practices that we should embrace and that were a conduit for leading the way for the people that reside here in Kern County. So smudging is one of those things that is naturally done within the diverse communities of our Natives. And so we offer smudging as part of that practice to name a few.

Srinivas: [00:08:30] Interesting. So what are some of the other examples that you do to ensure that you're really bringing in culturally appropriate care?

Galvez: [00:08:39] Well, let me talk a little bit about smudging first and then I'll share with you a little a few examples of other cultural practices that we have embedded as part of our care. Every person that visits our health clinic is offered an opportunity to smudge. And we do this for the purpose of educating our community, as well as teaching on the significance of smudging and the importance of smudging across an accepted Native American / Alaska Native population that we serve. And so we have been given, I guess, for a lack of a or for an appropriate word, a blessing, if you will, to practice this in our clinic. And the blessing has been given by cultural leaders who are well-respected in these communities as voices of change for culture, tradition, rituals among our American Indian and Alaska Native communities. So if I can take a few minutes, I'd like to just talk a little bit about smudging and demonstrate to you. Great, great, excellent. So it's a little interactive. I want to just let everyone know that we have sacred spaces. This is my office, and in my office I have a sacred space where I keep a couple of different types of sage. We have white sage, we have thyme, we have sweetgrass, we have a few different options where each have their own unique qualities and healing rituals. And so what I'm going to do is I'm just going to engage briefly in a smudge. And you know, what you'll see here is what we offer our patients as a way to cleanse, to cleanse themselves.

Srinivas: [00:010:41] And is this offered as a patient walks into the clinic?

Galvez: [00:010:45] So patient walks into the clinic. They're offered to smudge. We have a sacred location where they can perform that. And we have we have a few trained staff to perform the smudge. One of our cultural leaders is Donna. Donna Cubit is a substance use disorder counselor, as well as a cultural coordinator who facilitates the smudge and engages with the individual or with a group of individuals on a smudge. She performs the ceremony. And so what you're seeing here is ceremonial. It's a healing ritual. And what we will do next is I will talk a little bit and offer some context. But basically what I'm doing here is I'm just smudging myself. I'm smudging and offering to cleanse myself, to prepare me for perhaps this discussion. And then I'm also I'm also purifying the air around us and I'm blessing this conference. And I'm blessing those who are listeners, those who are educators, those who are teachers, those who practice our sacred healing rituals. And so I'm going to put this down. I'm going to talk to you a little bit about so I don't overwhelm the office. There's different ways to also, you know, as you saw me lit the smudge, it's very important that that when you smudge you, you do it in an appropriate way. You know, a lot of people use lighters and they use different things. But I use wood matches. I use anything anything that that that the Mother Earth has offered. Matches, you know, are made of are the closest way of lighting as our ancestors lighted, you know, in that fashion using wood and natural resources to make fire.

Srinivas: [00:12:45] So the people who -- for those people who are only able to listen to us and can't see what's going on, can you describe exactly what you put into the smudge and exactly what you did with it and the smoke that came out in everything?

Galvez: [00:13:00] Sure. So the I was using white sage, which is which I have here. There's you know, like I mentioned, there's different ones. So there's white sage on a on a seashell, abalone. I use abalone sea shell and I have it standing on just a beautiful wood stand. I disposed my ashes in what I have purified water, water and water elements. Water is an element of our natural our natural earth. And so. When we dispose, we offer we offer the water and the ashes back to earth. At our clinic, we have a sacred site where we can dispose our ashes once we are, we once we are done. So we commonly we commonly will purify the air and the space. And I mentioned that a little earlier, not only to prepare the space for us, but to make the space healthy for us as well, both physically, spiritually and mentally.

Srinivas: [00:14:07] And you had mentioned earlier you have three examples of three different types of sage there. You utilized white sage. Does white sage. What exactly is the meaning? You said each one has a different meaning. What's the meaning of white sage compared to the others?

Galvez: [00:14:23] Well, you know, white sage could be used for medicinal practices versus blue sage could be you know, there's blue sage as well. And I just want to make the disclaimer that in many, that this is something that is perhaps defined differently across many different Native American communities. But blue sage could be used, say, for folks who are struggling with addiction. There may be struggling with certain types of addiction, and they are looking for a spiritual cleansing, for a spiritual healing, not necessarily for a traditional medicinal healing. Like white sage would be used to purify the air or purify the space, or prepare me for a blessing of whatever I am to receive, whether that be a counseling session or a vaccine or what have you. I hope that helps.

Srinivas: [00:15:22] No, that, this is all so enlightening and I'm loving learning about it. So thank you. And with the advent of the pandemic and things going virtual, not just in person, you actually extended part of that smudging to people throughout, who are listening, who are on this virtual context. Is that something that was new in the pandemic or was it something that that has been done before in history?

Galvez: [00:15:50] Well, our ancestors have left us with a lot of really good knowledge. And these practices are not new. I think for many of us, we just forgot our traditions. The pandemic certainly allowed for a new look or a new perspective, if you will. How can we use what commonly existed in the past to reach and serve our communities through this pandemic in a culturally and appropriate way? Right. So bringing those practices back into treatment, in our treatment modalities and our outreach and our engagement with our community virtually allowed for us to really appreciate and embrace the culture that once existed. And so they're not new, if you will. But I think with the with the pandemic, it has allowed us to really to really bring back the importance of traditional medicine, culture, rituals and things like what I've just demonstrated.

Srinivas: [00:17:02] Wonderful. How did, you mention that when when patients come in, they're automatically offered a smudging. How did you tie that into some of the infection control practices? I know you mentioned that the white sage for some of the people that you serve in Bakersfield has to do with infection. And I'm curious, especially in the height of COVID-19, there must have been a lot of discussion on how to combine this with some of the techniques we've learned from public health, along with some of the culturally appropriate techniques that come from so many of these tribes. I would love to hear how you explored that.

Galvez: [00:17:41] Well, as I mentioned in the beginning, when we were doing community engagement, smudging was just a way of honoring the community event. And we would rely or lean on our cultural leaders to do that. You know, they'd do a blessing and they'd smudge. And we offer smudging to those folks who attended the community event. And we realized that this was so socially accepted by our American Indian / Alaska Native people that we sort of had an eye opening to saying, well, let's ask our community, hey, is smudging one of those things that's important to you? And what we found is 100% of the time said if you didn't have this as part of this event, we would feel that culture is not being represented. And so we took that idea and we took that info. We just said, we have to offer this at our clinic. How do we do that best? And so that was sort of kind of the first start of of engaging with our community leaders or our cultural brokers, if you will, about having this discussion. And that's what led to offering that, you know, to anyone that came to our compound, our grounds, our health center.

Srinivas: [00:19:02] And you started working for the health center in the middle of the pandemic, so you really jumped right in. How did you see the pandemic impacting the relationship between the health center and patients, between the health center and the larger community, including those community leaders that that you were using to help make relationships within these different, diverse communities.

Galvez: [00:19:30] Well, at first it probably seemed a little difficult at first just because, you know, we were trying to follow all of the guidelines, the CDC requirements, the public health authority requirements or state authority requirements, and really kind of finding a medium of, you know, here's what we're allowed to do and here's what we're not. And so I think those first few months were very challenging just to get sort of kind of a good feel for what's a proper procedure, what is going to be our COVID-19 surge plan. Right. How are we going to do this well? But we knew whatever we do, we cannot lose sight of our cultural practices. How do we embed that into all of this? And it was partners like, you know, NCUIH, CCIUH, CRIHB and many other partners that helped us really shape the way for this to happen. And I think once we got a hold of that, I we felt very confident that we could roll out practices like this that would be embraced by those who came to the health center. And so naturally, I think because we were really the only urban Indian health center in our county, we don't have a tribal health center in our county. Many of our Native Americans / Alaska Native people, relied on us to really be the beacon, if you will, for everyone else. And so we were we were sort of kind of feeling the pressure that the community wants this. And, you know, we should practice this. And so are we going to be leaders in that effort? And as a consortium as well as our board of directors, we decided, yeah, let's let's lead the way. And so it's really having those top high level discussions with our board of directors to agree upon here's the things we will support and here are the things we will embed. And this is going to come through training, through, you know, through a continuity of care so that we do it well and we improve upon those processes.

Srinivas: [00:21:46] So I'm really curious that you brought in smudging to make it more, more culturally aware for your patients into your clinic. What are some of the other happy mediums that you brought in that still enabled you to follow infection prevention and control measures?

Galvez: [00:22:07] Sure. So, you know, outside of smudging, we also practice drumming. We also have an indigenous garden. It's a small garden. But when we think of infection prevention and control measures, we, of course, utilize most of the PPE that everyone else is accustomed to, you know, using disinfecting as a preventative measure to really to really make our spaces safe. And we created, in collaboration with the National Consortium of Urban Indian Health, we created a COVID-19 surge plan, which outlined all of those measures to create prevention around infection and control. I think I think the cultural practices that we engage in are more aligned with, you know, just cleansing and cleaning and washing of hands. So, you know, when we thought about how to, if we're asking people to constantly wash their hands, what is the preferred method culturally? And we said, well, let's, let's buy indigenous indigenized soaps so that our people can cleanse themselves with natural soaps. So we partnered with the few organizations that make large scale, so indigenized, Native American made soaps. And so we began to use that as part of our PPE, like when they when they get these cleansing products, they're all products that are reflective to the Native American community.

Srinivas: [00:23:56] That's really wonderful. That's such an intuitive way to tie it into the culture, to meet the times. That's really that's really cool.

Galvez: [00:24:06] Exactly. Exactly.

Srinivas: [00:24:08] You mentioned working with populations that are both indigenous or Alaska Natives as well as not. Which makes me also wonder about your staff. Are most of your staff come from these tribal populations or are most of them non-Indigenous members? Or is it, what's the breakdown that you have in your workers?

Galvez: [00:24:30] So it's about 40:60, about 40% of our staff. We don't have a very large team. We're talking about 20, 20 or so staff members for our organization. We have about 40% of our staff identify as Native American and about 60% of our staff is other ethnicities and races. About 80% of our staff are people of color. About, we have about a 50:50 male female gender staff. And our board of directors, which is a total of six, they are 100% American Indian / Alaska Native, with about 90% of no, 80% of them local indigenous generation from generation. And so we tend to think that we're very diverse and we have an equitable group. And I think that just really offers a really system of complimentary, if you will, services for the makeup of the people we serve.

Srinivas: [00:25:47] And with having so many people who are not indigenous working within your organization, how do you make sure that they understand the importance of these cultural practices, that they learn about these and are able to offer them to the patients?

Galvez: [00:26:04] Well, we have a couple of different ways of doing that. In fact, this Friday we have our all staff once a month. We have 4 hours that we closed the clinic, every last Friday of the month we take that time to provide training, essential training. H.R. and our cultural coordinator leads it. We have we have a portion of that agenda just dedicated to cultural competency. And so once a month, everyone is trained on various discussions of practices we provide here at the clinic. And that gives the opportunity for any new staff onboarding onto our team, an opportunity to really immerse themselves in in culture specific to American Indian / Alaska Native. The other way we do it is we roll out each year training plans. And we also have recorded videos by Native American organizations local to our community here in central California. And so we when we onboard a new staff, we also sit them before a 45 minute presentation about the various things we spoke about today and many other cultural, cultural inclusion in our communities that are practiced here locally. So those are just a few ways of how we how we train our staff and immerse our staff with Native American culture and community. We also have I mentioned five key events. We have spring gathering. We have gathering of Native Americans. That's coming up in October. We also have the Native, we celebrate Native American Heritage Month in November. And we have this really huge celebration where we bring our you know, we talk about rawhide and we teach youth how to drum and how to create a drum using rawhide. And we, you know, our different types of artifacts are displayed at that event as well. So we have five key community events where our community engages, but our staff are also required to attend. They're paid for, of course, when they attend. These events are usually in the weekend. But that offers another opportunity for our employees, our staff members to engage with cultural leaders, to really ask questions and learn and see firsthand how, you know, jingle dancing or drumming or smudging or blessing or presentations that relate to American Indians / Alaska Natives here locally. Really, I think that's probably like our largest way of really training and teaching all of our staff, including myself about American Indian / Alaska Native culture here in Kern County.

Srinivas: [00:29:01] Those are some amazing opportunities to really learn well, well, technically on the job, but learn while you're doing and working with this population. Maybe we need to save this episode and air it in October or November, in honor of those celebrations. But I'm also curious, I know we've talked about it multiple, multiple times throughout this conversation, but just to make sure that we get the message across and that we ensure that everyone understands why you're doing all of this. Can you explain to our listeners why it's important that we have culturally appropriate care for both our patients, as well as the health care providers, and especially if taking IPC, that is infection prevention and control, into those measures and making them culturally appropriate.

Galvez: [00:29:53] Of course. The main reason for us is, you know, we recognize that our American Indian people, our Native Americans have been resilient generation to generation. We bounced this word resiliency all over the place. But I think most people really don't understand what that means. And to us, we've taken resiliency and we've said this is how our people are resilient. These practices, these rituals, these customs, these values that exist in our American Indian / Alaskan Native communities here in Kern County is resiliency. And so we're going to see a resilient American Indian / Alaska Native population here in Kern County. It's going to be through or via these practices. And so we've made that really our model of care, is that we will be resilient generation to generation. And that actually those became sort of our ethos and our symbols that we use for our logo. Our logo has seven feathers and our logo is the medicine wheel. And there's a lot to say about all of that. And in the medicine, well, if we're talking about infection prevention and control and indigenous approaches to really improving equity in health care and the intersection of these, it's going to be through that resiliency that we're able to create among our communities because then we are better prepared to offer our youth and our children a resilient, a resilient community for the years to come. So our seven feathers is our promise to our people that we will offer health care for the seven, for the next seven generations to come. And so we're building right now, obviously, I won't be here for the for the maybe second or third generation, but someone will. This organization will. And the promise is being built right now as a foundation for all of our community to rely on that on this organization, as one of those organizations to offer resiliency across all the people we serve.

Srinivas: [00:32:09] That's truly a beautiful outlook on what you're building and where it's going. We've had such a great conversation and thank you so much for sharing so much about the culture and how you're applying it to health care in a more effective, diverse, appropriate way. Is there anything that you would like to share that we haven't touched on yet?

Galvez: [00:32:33] Well, not a whole lot. I just want to maybe caveat the final message by letting everyone know that we rely a lot on our elders and we rely on their wisdom. And our elders group here at our clinic have become an instrumental piece of all of what we spoke today. So to honor our elders, our Native Americans across not only Kern County but across the globe is something that we don't take lightly. And so I just wanted to honor our elders by saying thank you to you. And also to say that peace be with them, especially for those for those of us who have lost elders in our own communities and in our own lives with COVID-19. Thank you so much.

Srinivas: [00:33:27] Thank you. Nothing to add, that was so beautifully put. Thank you for being here today.

Galvez: [00:33:32] Thank you.

Srinivas: [00:33:36] Stories of Care is a publication of the AMA and CDC'S Project Firstline. Project Firstline is a national infection control training collaborative, working to provide all health care professionals with the foundational infection control knowledge they need and deserve to protect themselves, their patients, their coworkers, and their communities. For more information, trainings and other infection control resources, visit cdc.gov/projectfirstline and amafirstline.org.

This episode was produced in collaboration with the National Council of Urban Indian Health, a Project Firstline partner. Visit them at ncuih.org.

Audio Information

Credit Designation Statement: The American Medical Association designates this enduring material activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

If applicable, all relevant financial relationships have been mitigated.

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Enduring Material activity for a maximum of 0.50  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 0.50 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 0.50 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 0.50 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 0.50 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 0.50 credit toward the CME of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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