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Native American health left out in the cold

2011; Elsevier BV; Volume: 377; Issue: 9776 Linguagem: Inglês

10.1016/s0140-6736(11)60586-2

1474-547X

Sharmila Devi,

Health Sciences Research and Education

Striking health disparities between Native Americans and their white counterparts still persist. Some experts see training more native doctors as part of the solution. Sharmila Devi reports. Gayle Dine Chacon was the only Native American in her class at the medical school of the University of New Mexico (UNM), Albuquerque, NM, USA, several decades ago. She saw a laboratory for the first time as a teenager when she went to high school off the Navajo Nation—a semi-autonomous territory of 26 000m2, which sprawls across Arizona, New Mexico, and Utah, and is the largest land area assigned to Native Americans within the USA. Now Chacon is the director of UNM's Centre for Native American Health, and a grandmother, but she remembers clearly when she had to confront her first cadavers in medical school. Navajo beliefs can seem to clash with western medicine. Only permitted tribal members are allowed to touch and bury the dead, for example. The Navajo are also reluctant to speak directly to someone about death and illness because that could be interpreted as wishing harm on that person. So, before Chacon's first dissection of a cadaver, she sought approval from family and Navajo medicine people. “The traditional healers tell you that it's OK and that takes the burden off knowing what you have to go through”, she says. “I remember opening some huge double doors and seeing about 20 body bags lying there. It was like crossing to another, almost holy world.” Economic, educational, and health disparities continue to persist between the Native American population of about 3·4 million, and much of the rest of the US population of about 300 million. On the Navajo Nation, where about 170 000 people live amid geography ranging from arid desert to alpine forest, at least 18 000 homes have no electricity. Tourism, mining, and agriculture are the mainstays of the economy but they provide dwindling revenues and the unemployment rate is about 40%. The Navajo call themselves the Dine, meaning “the people” in the Navajo language. They and other Native Americans lost land and had conflict with immigrant Europeans who expanded westwards in the early history of the USA. Their traditional pastoral culture was almost irrevocably destroyed while US citizenship was not granted to all Native Americans until 1924. “We've had 40–50% unemployment for decades and over 50% of our freshmen [secondary school students] don't graduate—we're at the bottom of the ladder”, says Chacon. “The US has had an economic crisis where the unemployment rate is about 9%. We're always living in economic crisis.” Native Americans are the only ethnic group in the USA to have their own federal health service, called the Indian Health Service (IHS). The IHS is an agency within the Department Health and Human Services with a yearly budget of some US$4 billion and provides services to tribal peoples at 45 hospitals and more than 293 clinics in 35 states, mostly in western USA and Alaska. The data on health disparities provided by the IHS's own fact sheets are sobering. Native Americans and Alaska Natives born today have a life expectancy that is 5·2 years less than the US population of all races (72·6 years to 77·8 years, respectively). Native Americans and Alaska Natives die at higher rates than other Americans from tuberculosis (500% higher), alcoholism (514% higher), diabetes (177% higher), unintentional injuries (140% higher), homicide (92% higher), and suicide (82% higher). Suicide is the second leading cause of death behind unintentional injuries among Native American children and young adults, according to the IHS. Native Americans aged 10–24 years killed themselves at more than twice the rate of similarly aged white people, according to recent data from the US Centers for Disease Control and Prevention. Navajo had additional health problems from exposure to the deadly dust created by uranium mining—a lethal legacy that persists in the degradation of the land. Children and adults have had illnesses ranging from asthma to thyroid disease, and these problems finally led the Navajo to ban uranium mining on their land in 2005. “The American Indian and Alaska Native people have long experienced lower health status when compared with other Americans. Lower life expectancy and the disproportionate disease burden exist perhaps because of inadequate education, disproportionate poverty, discrimination in the delivery of health services, and cultural differences”, says the IHS website. “These are broad quality of life issues rooted in economic adversity and poor social conditions.” Native Americans made up less than 1% of a total of about 77 000 medical students in 2009 and the IHS faces many challenges in boosting the training and retention of health-care professionals similar to other rural communities also trying to increase primary-care services. Many young Navajo leave their land in search of education and jobs, never to return. Under the Obama administration's health-care reform passed last year, Congress reauthorised the Indian Health Care Improvement Act, which addresses the recruitment of physicians and other health-care providers though initiatives such as scholarships, mentoring programmes, and workplace support systems. “Medical students aren't exposed to the incredible kind of medical care we provide and we wish the system provided such exposure and incentives”, says Susannah Olnes, lead physician recruiter at the IHS. “We have difficulty in filling sites that are rural and remote. Most physicians are trained in large metropolitan areas and they get used to the lifestyle there.” Last year, the IHS offered 236 scholarships to train health-care professionals that each included an average of $43 000 for tuition, says Carmen Clelland, director of the health professions support division at the IHS. “We would like to see more medical school residencies and teaching on rural care”, he says. In recent years, native tribes have started to take more control over their health services under the Indian Self-Determination Act of 1975, which allows federal agencies to make direct grants to recognised tribes who can set up not-for-profit corporations to replace the IHS on tribal lands. The Fort Defiance Indian Hospital in Arizona is one such facility that has opted for direct control, having appointed its own board of directors last year. The hospital is also notable for a ground-breaking initiative to help Navajos deal with the complex and confusing process of decision making at the end of life. Under a home-based-care programme started 5 years ago, social workers and health-care professionals visit elderly and sick people in isolated communities and use poems and story-telling to introduce discussion of end-of-life care, such as do-not-resuscitate orders, living wills, and advance directives. Mitzie Begay, the programme's cross-cultural coordinator, said elderly Navajo like everyone else wanted to know what was happening to them and that all of her patients had signed advance directives that convey their end-of-life orders. “In my culture, when a person left this life, we didn't go to the funerals. Only two people buried the deceased and the others stayed at home. The White Man came in and now the mortuary takes care of the deceased”, she says. “How I usually talk to the elderly in my language is I say, ‘we come from Mother Earth healthy and we have to go in that same manner’. They say, ‘yes, this is what I want’. We explain resuscitation and they say, ‘I don't want to be pounded on like that’.” The Navajo poem that she uses reads: “When that time comes, when my last breath leaves me, I choose to die in peace to meet Shi'dy'in [creator].” “Cultures such as the Navajo endorse autonomy but their metaphysical beliefs make talking about disease or end-of-life more difficult and they are more likely to shut down”, says James Taylor, a bioethicist at the College of New Jersey, Ewing, NJ, USA. “The poem is a wonderful way to discuss such things impersonally.” Begay said that high on her wish list of additional services would be a nursing home and adult care centre so that elderly people did not have to go off reservation to get treatment. Previous initiatives have had unintended consequences, for example, a meals-on-wheels programme only increased the isolation of older people in rural areas. Susan Miller, the acting medical director of the Fort Defiance home-based programme, said she wished other white Americans knew how personally rewarding it was to work with the Navajo. “It seems we do so little and they are so grateful”, she says. “I look forward every day to coming in, it's not like a job, and I absolutely love what I do.” Chacon, meanwhile, said that she was heartened to see more Native Americans studying medicine at UNM compared with when she was the only medical student in her class. “Last year, we had nine medical students and this year we have four so that's pretty good”, she says. “There used to be no native faculty and now there are about eight of us. Students now have mentors and outside lecturers including traditional healers and I never had that opportunity.” But she cautioned that the challenges ahead remained daunting. “We don't have an educational system that will feed future health-care professionals into the system”, she says. “And there is still exploitation and glamorisation of our culture.”