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Spring 2014
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Unseen America
A month on a Navajo reservation.
Mrs. B, a Navajo woman in her mid-60s, was brought in to our Emergency Department by ambulance. She felt unwell and had a blood sugar level that was six times the normal level. After speaking with her, I discovered that she had run out of her diabetic medications about a month ago. “I have no means of coming into town. I live about 45 minutes away.” She explained that she did not want to bother her nephews who had previously brought her in for her appointments.

I did my away rotation in emergency medicine at the Northern Navajo Medical Center, an Indian Health Service facility, in Shiprock, NM, to experience emergency medicine in resource-limited settings. It was the US parallel to underdeveloped countries, which is relevant to my future goal of helping to develop the field internationally. I also wanted to gain exposure to this unique health care system. Indian Health Services provides completely free medical care to all Navajo Indians on the reservation. This includes emergency department visits, clinic visits, inpatient stays, transfers to other health care facilities for more complicated diseases, and even free medications.

Perhaps it was the knowledge that tribe members did not need to pay anything for health services that frustrated me about Mrs. B’s situation. As I went through her chart, I noticed that she came in three months ago for the exact same reason: running out of medications. Her blood sugar during that visit was five times the normal level. She was brought in by ambulance then, too. Both of her ambulance trips, and thus the high cost of these trips to the health care system, could have been avoided if there was some way of giving her better access to this care. Access was the barrier, even with completely free health care.
Fast Food Nation
I had other realizations during my time in New Mexico. I am used to seeing obese middle-aged patients like Mrs. B. in Rhode Island. However, the number of obese adolescents I took care of in Shiprock shocked me. “Bad genetics” have been shown to play a role in this. My 10-minute drive around this beautiful town revealed another potential reason that obesity is so much more prevalent in Native American communities than the general population of the United States.

As I turned onto the main road, I became mesmerized by the gorgeous rock formation in the background that gives the town of Shiprock its name. Before I left for New Mexico, I learned about the various cultural and religious significances of Shiprock. I tried to remember the Navajo word for Shiprock, “Tsé Bit’a’í,” named after a legend of the great bird that brought the Navajos from the north to their current location. After admiring this wonder of nature in the distance for a few moments, I looked to my left and saw a Burger King, KFC, a local Chinese restaurant, and a McDonald’s. On the right was a That’s a Burger, Taco Bell, and Sonic. About half a kilometer down the road was a Subway, and a couple of kilometers up the road was a Domino’s. That was it. These were the only food options I found in Shiprock. Eating out in Shiprock means eating unhealthy fast foods. As a vegetarian, I don’t often end up at KFC for dinner, but their free Wi-Fi Internet was the best in town and I spent many of my free evenings there. I quickly concluded that investing in a fast food restaurant in Shiprock would be a very profitable venture—fast food restaurants were at the center of life on the reservation.

Thankfully, Mrs. B felt well after spending a few hours in the Emergency Department receiving fluids and insulin. She had no electrolyte abnormalities and did not get any severe complications from not taking her medications. We sent her home with a new batch of diabetes pills. I talked to her about the importance of coming to her appointments to get her medication refills. We talked about her extended family, and how she could try and rotate through nephews so that she didn’t feel like she was burdening them. She promised to come to her appointment with her primary care physician the following week. Feeling satisfied with my counseling efforts, I left the room and went to see my next patient.

Painful Lessons

As I walked in, I saw a young woman with bruises throughout her face and arms. She was clearly in shock and pain. I took a deep breath and hoped that my counseling skills would be just as good with this victim of domestic violence. It turned out that I saw at least two such victims per shift during my time in New Mexico. Despite reading about the significantly higher prevalence of domestic violence experienced by Native American women, I was not prepared to see so many women in such unfortunate circumstances. There was a powerful emotional story associated with each one. For some, this was the first time anything like this had happened. For others, holding back their tears became impossible as they told me about multiple episodes of mistreatment by significant others and sometimes, family members. I tried to listen to each story and offer as much support as I could. I tried to give them any resources that we had available. I encouraged them to report what happened to the police. I still felt that I could have done more but wasn’t sure what. I realized I needed to learn more about the issue so that I can help my future patients. As much as I loved my time in Shiprock, this experience with domestic violence was very unsettling.

I thought my month in Shiprock would simply confirm my career choice in emergency medicine, but it taught me so much more than that. I learned many lessons about access to care and the underlying cultural and societal problems contributing to health issues. I will never forget my time on the Navajo Reservation, and I expect to apply these lessons wherever I practice medicine in the future.
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