Charles W. Grim
Former Director of the Indian Health Service
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
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.
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.
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.
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.
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.