Charles W. Grim
Former
Director of the Indian Health Service
The
following profile was based on an interview with Dr.
Charles Grim in July, 2007. In September, 2007, Dr.
Grim decided not to seek another term as Director of
the Indian Health Service (IHS), so he is no longer in
that position.
Charles W.
Grim, Cherokee, DDS, MHSA, is the first dentist to serve as
Director of the Indian Health Service (IHS). Dr. Grim is an
Assistant Surgeon General, and holds the rank of Rear
Admiral in the Commissioned Corps of the United States
Public Health Service. He administers a nationwide, 4
billion dollar health care delivery program, providing
preventive, curative, and community health care to
approximately 1.9 million American Indians and Alaska
Natives (AI/AN) living on or near reservations in both
rural and urban areas.
The IHS delivers health services through a system of IHS,
tribal, and urban operated facilities and programs that
includes 48 hospitals, 272 health centers, 11 school health
centers, 11 youth regional treatment centers, and 154
health stations, and 162 Alaska village clinics. The IHS
also contributes to the support of urban Indian programs,
which offer services ranging from community health to
comprehensive primary health care.
Grim oversees a workforce of approximately 15,500
employees. The clinical staff consists of approximately
2,600 nurses, 900 physicians, 90 physician assistants, 500
pharmacists, 300 dentists, 80 physical therapists, 120
social workers, and 70 psychologists. The staff also
includes other allied health professionals, administrators,
and clerical staff. Together they take care of 9.8 million
outpatient visits, 3.2 million dental visits, and 60,000
inpatient admissions annually.
Unlike most traditional health care systems, care is not
limited to hospitals and clinics. Nurses and community
health representatives do outreach work in the community.
Also, approximately 400 engineers and 150 sanitarians care
for the environment and try to make sure that there is
clean water, sewage disposal, and safe health care
facilities.
Leading
Causes of Death Linked to Behavior
Grim points out
that the leading causes of death for AI/AN people have a
behavioral component. Heart disease and diabetes, for
example, are impacted by what people choose to eat or not
eat and whether they choose to exercise. Grim also argues
that many of leading causes of death could be prevented if
people choose to have a lifestyle that promotes health and
prevents disease.
In the early years of the Indian Health Service, some of
the most pressing health problems were acute illnesses
linked to environmental pollutants and contagious diseases.
Now Grim notes that chronic conditions, such as heart
disease, diabetes, and cancer, are the leading causes of
death. Asthma, depression, renal disease, dental caries and
other chronic illnesses are also placing growing demands on
the health care system.
3 Initiatives for Today’s Health Care Needs
Grim said that in the middle of the last century the
greatest achievements in reducing health disparities were
through increased medical care and public health efforts,
including massive vaccination programs and bringing safe
water and sanitation facilities to reservation homes and
communities. Given the nature of today’s health problems,
Grim, with the support and input of Tribes, launched three
interconnected health initiatives: (1) health promotion and
disease prevention, (2) the management of chronic care and
(3) behavioral health.
The
health promotion and disease initiative includes
developing and sharing programs that are effective in
helping individuals and communities take responsibility for
their health by exercising, eating right, taking advantage
of medical screenings, and avoiding risky behaviors. These
programs are most effective when they are developed at the
local level where people can draw on traditional and local
foods, activities and other resources.
Grim hopes that good programs will reduce health
disparities. For example, he notes that research has shown
that moderate changes in diet and exercise, can delay or
even prevent the onset of diabetes. He also thinks that
programs that help people modify or eliminate health risk
factors, such as obesity, sedentary lifestyles, smoking,
high-fat diets, and hypertension, can reverse the
increasing rate of cardiovascular disease.
The goal of the
chronic care management initiative is to
restructure Indian health clinical programs to more
effectively manage chronic diseases in Indian Country by
linking community-based primary prevention programs with
patient-centered secondary prevention efforts. Primary
prevention programs can identify people who are at risk for
developing diabetes, enabling them to make needed lifestyle
changes and alerting providers to monitor these at-risk
people. One-third of people with diabetes do not know they
have it. Screening provides an opportunity for secondary
prevention because early detection enables people with
diabetes to make lifestyle changes and start any
appropriate medical interventions.
Currently 14 sites within IHS are piloting new approaches
to the management of chronic care in partnership with the
well-regarded Institute of Healthcare Improvement. Grim
says, “We are committed to developing patient and
family-centered care processes that apply across multiple
chronic conditions.” The projects are addressing the
underlying causes of poor health, rather than just the
symptoms.
The
behavioral health initiative addresses the
fact that one-third of the demands made on health
facilities in Indian Country relate to mental health,
alcoholism, and substance abuse. Programs included
methamphetamine intervention, suicide prevention, and
family safety and protection. “We need to focus on
screening and primary prevention in mental health,
especially for depression, which manifests itself in
suicide, domestic violence, and addictions,” says Grim who
adds, “We know that mental health issues, such as
depression, can make chronic disease management more
difficult and less effective.” Grim says that in addressing
behavioral health issues, effective behavioral health
techniques can be used side-by-side with tribal traditions
and customs. Behavioral health techniques can also be used
in the treatment of some medical conditions.
Health
Professionals and Business People Are Needed
Improving the health of AI/AN people requires the services
of many people. “There’s a critical need for dentists,”
says Grim. “The vacancy rate is 34%. The vacancy rate for
nurses is about 17%, which means there are about 500 nurse
vacancies. We consistently run a 10% vacancy rate for
pharmacists, physicians, and behavioral health
practitioners.”
Grim says that people with expertise in
telemedicine/telehealth are greatly needed, so that
high-quality primary care, emergency care, and specialty
medicine can be brought to more remote communities.
Business people are also needed. “We are a 4 billion dollar
agency,” says Grim. “We have hospitals with multi million
dollar budgets, so we need people who have good
administrative skills.
As the Baby Boomers retire, IHS, like other government
agencies, anticipates loosing many employees, including
people in leadership positions, so the need for health
professionals and business people is likely to increase.
Opportunities
The need for health professionals and business people
translates into opportunities for people who would like to
participate in providing high quality health care to AI/AN
people. Grim says, “Once people begin working with us, they
have a huge number of opportunities. We have hospitals and
clinics from the tundra of Alaska to the Everglades in
Florida and every place in between. We even have a health
clinic at the bottom of the Grand Canyon. We have hospitals
and clinics in 35 states.
“People can cross over. For example, if they are a health
professional and they want to get involved in information
technology or administration, they can do this.
“We’re a broad public health organization. We don’t just do
hospital and clinic care,” declares Grim. There are also
opportunities for people to work in homes and communities
and to care for the environment.
American Indians and Alaska Natives in IHS
In the early
days of IHS, few AI/AN people were in professional and
management positions. Now American
Indians and Alaska Natives make up 70% of the total
workforce. Almost all of the people in the highest levels
of leadership are AI/AN. AI/AN people hold 87% of the
administrative positions, 95% of the technical/clerical
positions and about 38% of the health professional
positions. AI/AN people
are in a unique position to
provide culturally-sensitive care, so more of them are
always needed.
Support
Provided to Students and Health Professionals
The Indian
Health Care Improvement Act of 1976, created a scholarship
program to support the development of AI/ANs as health
professionals. Since its inception, more than 8,000 AI/AN
students have been supported through the program.
Grim says,
“There are 400 to 500 people in the pipeline at any given
time. The unique thing is that we pay for pre-professionals
(undergraduates) as well as students in professionals
programs.”
Grim points
also to the summer student extern programs and to the
CO-STEP program. For information on all of these programs,
explore the Indian Health Service website <</span>
http://www.ihs.gov/>.
Advice for Future Health Professionals
Grim advises students to do well in math and science and to
find a mentor in their field. He said that IHS wants to
reach students earlier in the pipeline, even as early as
elementary school.
Journey
Grim,
a descendent of those who walked the Trail of Tears, grew
up in the small town of Cushing, Oklahoma. As a boy Grim
witnessed the generosity of his parents (Ruth Grim and the
late Charles Grim) toward family, friends and their church.
Grim says that his parents’ example contributed, at least
indirectly, to his choosing to become a health professional
– a caregiver. He also says that his parents’ confidence in
him was always a source of strength and pride.
“I knew fairly early on that I wanted to go into the health
professions,” says Grim. “I just didn’t know which one to
choose. I asked my local dentist if I could assist him on
weekends or during the summer. He agreed, so I acted like a
dental assistant and saw what the work was like. I did the
same thing with my optometrist and with a physician and a
pharmacist. I shadowed them and, when it was possible, I
did some work. In the end I liked the atmosphere of the
dental office.”
Grim knew that he needed to do well in high school and
college in order to be accepted into and complete dental
school. In his current position he is aware that some
Indian youth are not successful in making this journey
because when they leave home (sometimes for the first
time), they can lose touch with their family, friends, and
culture. “I was lucky,” says Grim. “I went to school
relatively close to home. I did my undergraduate work and
dental training at the University of Oklahoma, so I could
drive home in an hour and a half.”
Thanks to Grim’s hard work and the support he received from
family and friends, he received his DDS in 1983.
Beginning
Work with the IHS in Oklahoma
At the
confirmation hearing for Grim’s second term as Director of
IHS, he told the Senate Committee on Indian Affairs, “I
draw my strong sense of heritage and culture from my
family. From early in my life I envisioned working for the
Indian Health Service as an important way to help Indian
people. Upon my graduation from dental school, my aunt, Ms.
Dorothy Snake, also encouraged me to work for the IHS as
part of my National Health Service Corps educational
scholarship payback requirement.
“My first assignment with the IHS was at the Indian Health
Center in Okmulgee Oklahoma. Working there was like coming
home and fulfilling the dream I had as a teenager to help
Indian people. I knew then, and I know now, just as
strongly, that working for the Indian Health Service is
part of my life. I cannot imagine being as satisfied or
having such a sense of reward working anywhere else.”
After a
two-year clinical assignment at the Claremore Service Unit
in Okmulgee, Grim was appointed Assistant Area Dental
Officer in the Oklahoma City Area Office. As a result of
his successful leadership and management of the complex
public health dental program, in 1989 he was appointed
Acting Area Dental Officer.
Back
to School
At this stage in his career, Grim had experience both in
directly caring for patients and in administration. “I had
been practicing clinically long enough to know that I
wanted to be in administration as opposed to doing purely
clinical work,” he says. “The agency recognized my
potential. I applied for a long-term training slot in
administration. I was selected and sent off to school.” For
two years Grim attended the University of Michigan where in
1992 he earned a master’s degree in health services
administration.
Albuquerque
In 1992, with his new capabilities and credentials in
health service administration, Grim became Director of the
Division of Oral Health in Albuquerque Area of the IHS.
Next, as Acting Service Unit Director for the Albuquerque
Service Unit, he was responsible for the administration of
a 30-bed hospital with extensive ambulatory care programs
and seven outpatient health care facilities.
Later as Director for the Division of Clinical Services and
Behavioral Health for the Albuquerque Area Grim was
responsible for working with all health-related programs at
the area level. Then Grim assumed even more administrative
and fiscal leadership opportunities as Acting Executive
Officer for the Albuquerque Area, one of three top
management officials for the two-state region.
Phoenix
In April 1998, Grim transferred to the Phoenix Area IHS as
the Associate Director for the Office of Health Programs.
In that role, he focused on strengthening the Phoenix
Area's capacity to deal with managed care issues in the
areas of Medicaid and the Children's Health Insurance
Program of Arizona.
Even Great Responsibility
Next Grim was
first Acting Director and then Director of the Oklahoma
City Area Office. In this position he managed a
comprehensive program that provides health services to the
largest IHS user population - more than 280,000 American
Indians from 37 tribes in Oklahoma, Kansas, and a portions
of Texas. Health care is provided through direct care,
contract care, and tribally operated facilities.
Director,
Indian Health Service
In 2002,
President George W. Bush appointed Grim as Director of the
IHS. The next year the Senate unanimously confirmed this
appointment. In 2007, his appointment was confirmed. Grim
was nominated to serve for another four years but chose to
withdraw his nomination.
Among Dr. Grim's honors and awards are the U.S. Public
Health Service Commendation Medal (awarded twice),
Achievement Medal (awarded twice), Citation, Unit Citation
(awarded twice), and Outstanding Unit Citation. He has also
been awarded Outstanding Management and Superior Service
awards by the Directors of three different IHS Areas. He
also received the Jack D. Robertson Award, which is given
to a senior dental officer in the United States Public
Health Service (USPHS) who demonstrates outstanding
leadership and commitment to the organization.
Dr. Grim is a
member of the Commissioned Officers Association, the
American Board of Dental Public Health, the American Dental
Association, the American Association of Public Health
Dentistry, and the Society of American Indian Dentists. Dr.
Grim was appointed to the commissioned corps of the U.S.
Public Health Service in July.