Supporting Pediatric Care for Indigenous Children

The Global Health Program launched its Indigenous Health Program initiative in 2022. Under the leadership of the Indigenous Health Director, Dr. Julia Rubin-Smith, the Program has focused on improving the health and well-being of American Indian and Alaska Native (AI/AN) children through partnership with the Indian Health Service (IHS), with a focus on the Great Plains Area. 

The IHS is the principal federal agency responsible for providing health care to American Indians and Alaska Natives and provides health care services directly through a system of federally operated IHS facilities—hospitals, health clinics, and health stations—and also funds services provided in facilities operated by tribes or others. The Great Plains Area (GPA) IHS Office, encompassing 19 federal and tribally-managed service units in North Dakota, South Dakota, Nebraska, and Iowa, oversees care for approximately 130,000 AI/AN, the majority residing in North and South Dakota. The indigenous population of this area is primarily Oceti Ŝakowiŋ (Lakota, Dakota, and Nakota). IHS has experienced a number of challenges in recruiting and maintaining clinical staff throughout the system, with particular challenges in the GPA. These challenges have led to a lack of high quality, consistent pediatric care in a number of service units within the GPA. This has a significant negative impact on the health and well-being of AI/AN children, who comprise a significant proportion of the service population: according to recent estimates, approximately 1/3 of the AI/AN population of the GPA is age 14 years or younger.^[1]

As part of an effort to address these challenges, the Indigenous Health Program has partnered with the IHS to provide pediatric care in the GPA, starting with the Cheyenne River Service Unit (CRSU) in Eagle Butte, South Dakota. Like many IHS facilities, the CRSU is a critical access hospital located on a reservation in a very rural area. The closest facility that can provide specialized pediatric inpatient services (including surgical care) is 3 hours away, and the closest tertiary pediatric facility is 5 hours away. Our presence has allowed stable pediatric patients requiring inpatient care to remain closer to home, significantly reducing the burden on their families posed by transfer to distant facilities. This innovative federal/academic partnership directly supports the GHP mission of “collaborating and innovating with local and global partners to achieve pediatric health equity and improve outcomes, through disease prevention and delivery of high-quality health services with measurable and sustained impact.”

Since February 2022, BCH has sent clinical pediatric faculty to the Cheyenne River Service Unit to provide continuous outpatient and inpatient pediatric care, and to support pediatric care in other areas, including consulting on pediatric patients in the Emergency Department. Several physicians within our group have returned to the CRSU for multiple rotations within that time. In addition to providing clinical care, BCH pediatricians have provided pediatric education to general providers (family medicine, emergency medicine, nurse practitioners) and have supported improvements in pediatric nursing care. We have also supervised pediatric residents and medical students from BCH and other institutions who have interests in global health and rural health and have completed clinical rotations at Cheyenne River, with a particular focus on AI/AN trainees and others from colleges and universities within the GPA.

In addition to our direct engagement with IHS in the Great Plains, GHP/IHP faculty are actively involved in close partnerships with other Academic Medical Centers (AMCs) providing care to Indigenous Populations in the US, including Massachusetts General Hospital, University of Minnesota, University of Utah, and the Children’s Hospital of Philadelphia, among others.

At the request of the Great Plains Area IHS leadership, beginning in July 2023, the BCH/IHS collaboration scaled up pediatric service provision to the Turtle Mountain Service Unit in Belcourt, North Dakota, with plans to expand to an additional 6 GPA service units in the coming years. Additionally, in an effort to improve continuity of care, the Global Health Program has developed a new Indigenous Health Faculty subdivision at Boston Children's Hospital to transition from short-term rotators to a job-share model, with dedicated pediatricians each spending half the year at a single service unit. The objectives of this model are to:

* Provide high quality pediatric care to children and families seeking care at GPA IHS facilities, following the concept of the “Medical Home”

* Provide consistency in presence and practice

* Support measuring the quality of pediatric care and conducting quality improvement initiatives

* Engage with community and public health projects/programs where invited

We have also engaged the expertise of multidisciplinary team members including Nursing and Child Life to improve pediatric care on multiple levels. In addition to clinical care provision, we also focus on education (including Pediatric CME, residency training, and pathway programs that support AI/AN students exploring health careers), process improvement, health infrastructure, and public health initiatives. 

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