Indian Health Service – Fort Defiance, AZ – Navajo Nation

Posted by Sefanit Mekuria, MD (a  second year Pediatric MPH resident from Kaiser Permanente, Oakland while on a global health elective in Fort Defiance, Arizona a Navajo Nation with Indian Health Service).

MY IHS EXPERIENCE-  Navajo Nation

Pre-Trip Thoughts

Ever since I heard about the Indian Health Services in medical school I knew it was something that I wanted to be a part of.  I had always been interested in International Health and when I began to read more about the Health Disparities and depressed socio-economic condition within the Indian Reservation I knew that this would also be a place I would be interested in working.  I had been through Navajo nation before and knew that it is filled with a vast amount of beautiful landscape, small towns/communities, and occasionally larger towns.  I had done more research about the Navajo Tribe once I had decided on my location for my trip.

Here is the data from 2000 Census:

• Navajo Tribe has 300,000+ declared members throughout the US (largest declared tribe in 2000 census) with 180.000+ living in Navajo Nation- 50% under the age of 5.
• The Navajo and Hopi reservations encompass an area of about 15000 sq miles (about the size of West Virginia) and is primarily in Arizona and New Mexico, but also  goes into Southern Utah and Colorado
• Many reservation-based patients will travel over 100 miles round trip for clinic and being 50 miles from nearest paved road still not unusual
• Many improvements in reservation from 1990-2000
  • In 1990 only 50% of population had running water/indoor plumbing, but due to public works projects and housing shifts in 2000 about 80% had access to clean running water supplies
  • In 1990 only 20% had a telephone, but because of cell phones and housing regionalization many residents have access to telephone services
  • 33% of Navajo families and 28% of Hopi families live below the poverty line and up to 40% of families with minor child live in poverty
  • Population still with depressed socioeconomic condition, limited economic opportunity locally and almost 40% of Navajo tribe live off reservation
  • In 2000 census 64% of Navajos and 75% of Hopi over 25 had a high school diploma or equivalent- 15% increase over the decade, but only 7% Navajos and 11% Hopi have a bachelor’s degree of higher (national average 84% with HS diploma/equivalent and 27% with a bachelors or higher)

My First week (1/14-1/21)

So I finally landed in Albuquerque (the closest airport to Fort Defiance) and was excited to get going.  I was surprised how cold it was in Albuquerque (24 degrees).  Due to my delay and snow/ice on the roads during the night I stayed in Albuquerque and then drove up early the next day.  The drive was beautiful- filled with red rocks covered in snow.  There were small towns scattered here and there with one larger town at the border (~30 miles from Fort Defiance).  I arrived at the hospital and was actually impressed with how new/large it is- built in 1999/2000.  The hospital is more like a community hospital.  It has everything you would expect a small hospital to have- ED, small Radiology department, inpatient (the pediatrics share the inpatient area with Medicine and surgery), Ob/Gyn, OR, nutrition services, health education, etc.  The one unique thing about this hospital is that it has an adolescent Care Unit for patients 13-17 with psychiatric disorder and/or substance abuse or dependence. Within this unit they do everything you would expect an inpatient psychiatric unit to do (psychiatric diagnosis and treatment, psychosocial testing, therapy, wellness activities, plus they incorporate Najavo cultural teachings, traditional culture activities, and Navajo healing interventions).  I’m hoping to work/be in this area for a couple of days or a week.  The Pediatric inpatient is small and due to respiratory season right now is mostly respiratory kids that need some small amount of support.  They also can deal with bread/butter peds- r/o sepsis, bili babies, and other stuff that aren’t high acuity. Specialty patients, patients needing higher acuity of care, or other services have to go to Albuquerque (3 hours away) or Phoenix (5 hours away)- but referrals can easily be put in.  Delivers here are run by midwives and ob/gyn (they can do C-sections and regular deliveries), so there is a well baby nursery.  If a baby needs more support they could be stabilized and transferred out.   If the mother is known to be high risk she will be flown out before delivery, if time permits.  The Pediatric Clinic runs more as an Urgent care and there is a separate Well child visits clinic.  They take appointments and walk in, so the clinic have the potential to see a lot of patients in 1 day- this is where I will be spending most of my time.  I got a quick orientation to the system (they use an EHR much like the VA system) and how the day will go.  If you are Navajo/Native in this region you get free services from the hospital.

After getting everything set up I was in the clinic seeing the pace of things, then off to the housing unit that they provided.  I was impressed with how they made a community out of volunteers, permanent staff, contract staff, families, and other employees that is right next to the hospital. The neighborhood essentially looks like a suburban subdivision.  The house that I’m staying is a 4 bedroom house with other roommates (2 nurses).  My room has the bare minimum (Bed, night stand, closet), but works perfectly for me.

On my first day I was shocked how cold it was (-18 degrees), but quickly walked the 5 minutes to the hospital (Fort Defiance has an elevation of 6000 feet, so gets pretty cold).  The next couple days warmed up to the single digits.  In clinic the patients can have an appointment or they can walk in.  Different doctors are assigned walk-in, appointments, well child visits (a different side of clinic) so there is no real continuity with patients.  Many physicians are there under short contracts for loan repayment and the few doctors that have been there for a while have some dedicated patients.  Patients check in and charts are brought back with vitals and there complaint.  You also get a sheet with immunizations record and if they are up to date.  Many people are up to date because they receive letters when they have shots due and can come in just for immunizations.  My first week in clinic was pretty busy.  For the most part I saw kids with flus, coughs, viruses.  Many tests are run in the lab pretty fast- such as rapid strep, RSV and flu.  If the lab does not run it they can send that test out.  There is a pertussis outbreak on the reservation with several of the nurses and doctors already requiring a couple of post exposure treatments this winter.  Whenever I saw the complaint as prolonged cough- I made sure to wear a mask, but sometimes it only comes out in the history.  Luckily none of the patients I tested had a positive pertussis.  There was a good amount of asthma exacerbation from Viral URI that needed treatments in clinic.  Many people run out of their medications- several families wait until worsening symptoms due to distance and transportation.  Also, many people use wood burning stoves as the method for heating their home, which can make children’s coughs worse and asthma in worse control.

During my first week it became clear that the hospital staff were like family.  Everyone lives in the community and they often have gatherings.  I was invited to several pot-lucks some with the nurses and some with a lot of the staff.  There is a Mesh of people here.  Some of the workers are locals who came back to work, some from all over the country and few even from different parts of the world just working here- either under contract, doing loan repayment, or permanent.  Everyone is very friendly and welcoming.  I also learned of the small gym within the hospital, which I’m going to try to go every day.  I met a student from Dartmouth and we went the nearest larger town Gallup- about 40 minutes away.  We did some grocery shopping and had lunch.  Over the weekend I also got a chance to go to Canyon de Chelly- a national monument located within Navajo Nation.  It has some of the ancient Native Americans ruins within the vast made of red rocks.  Driving there I got to see part of the vast Navajo nation.  I ran into several locals on the canyon who were selling handmade pottery- one women had her families story written in Navajo- she lived in a Hogan in the canyon, which is where she makes her pottery.

Week 2 (1/21/13-1/27/13)

The week started off pretty busy.  There were some emergencies and illness, so a couple of the pediatricians were away.  I worked in the walk-in clinic again and saw many patients through the day.  In clinic we saw mostly flu like illness again.  Some had asthma attacks because of this, some needed fluids.  I have also seen a good amount of gastroenteritis in the clinic as well.  Even when the child is febrile or not feeling well the Navajo children are very cooperative and patient.  I’m impressed with them and their discipline.  I learned this week that Fort Defiance went to HMO services about 1.5 years ago, so they are no longer are run by the government, but it is still an IHS hospital.  Many natives have Medicaid and whatever is not covered the hospital will cover it.  If a family or individual does not qualify for Medicaid they will still get completely free services and medications from the hospital.  The hospital bills one base fee for all visits no matter what services, procedures, or labs were done during that visit.

Through my interactions with many families and other employees I have learned that many families on the reservation live in Hogans (traditional circular houses most of them are made of wood with a stove in the middle).  I also noticed many infants in a cradle board- a wood board that they swaddle their children on.

Week 3 1/28/13-2/3/13

The week again was busy with many people with cold/cough/flu.  I did get a chance to do a couple of well child checks.  During the 9mo, 12mo, 15mo, and 24m each child gets a fluoride varnishes, so I got to apply several varnishes during the visits.  The water in the community is also fluorinated, but many people do not drink the tap water.   Dental health is an issue in the reservation.  Many children have carries, decay, or silver caps.  One of the pediatricians told me they saw sliver caps on a 9mo old.  During the week I did see one patient with a murmur that we wanted evaluated, so we referred to the Cardiologist (closest is in Flagstaff which is a 3 hour drive).  There was also one 2 week old baby in clinic for a newborn visit with seizures, but otherwise acting well in between these episodes.  Due to these we had to arrange helicopter transport to Albuquerque for further work up/management/neurology.  The clinic gets many children who come in for walk-in for physical for head start or other organizations.  During these or urgent care visits I often brought up healthy lifestyles.  There is an obesity problem on the reservation, so they do have a program for overweight children called fit families.  One of the Pediatricians runs this program, which is a 12 week program entailing nutrition education, active play, and cooking classes.  Transportation is a problem in the area so although they usually get a lot of kids enrolled; there is a large dropout rate.

Walking around the community I see many stray dogs.  Many families in the community will take in the strays and make them their pet, but there are so many still on the streets.  There have been several dog attacks in the community and one ER doctor told me that in the last 2 months 2 children have died from dog attacks.  I saw a teenager in clinic this week that had a large scar on his forehead that was from a dog attack when he was little.

I have also noticed driving around the community that there are several hitchhikers.  I was talking with one physician this week and he had told me several people have been hit while hitchhiking. You see people at night when it is pitch black on the side of the highways hitchhiking.  Sometimes they are partially in the road to get people’s attention, and the people hitchhiking maybe drunk.  When talking to the ER doctor they told me that the number one thing they see in the ER is conditions due to alcohol- drunk driving, other accidents, and people found down in the cold.  There is a large alcoholism problem on the reservation.

Week 4 2/5/13-2/7/13

I can’t believe how fast my time here has gone- It is already the end of my last week her on the reservation.  During my last week I got the chance work both in the clinic and the Adolescent Care Unit.   The clinic was very busy filled with cough/cold/flu/RSV again.  Several children did require admission for oxygen need.  The cut off for admission here is 90%- due to the elevation.  There was one teen that came in with a knee abscess after falling, which I I&D’d it.  I had gotten use to speaking English during my clinic visits, but one visit during my fourth week made me realize that I needed to make sure that everyone understood what was said.  I had a teenage patient complaining of a sore throat who had come in with his grandmother.  Most people on the reservation speak English, but some older people only speak Navajo.  I had talked with them, explained things, and asked if they had questions.  The teenager and Grandmother both said no, so I let them go.  Soon a nurse came to me and said the grandmother was complaining that she did not get any explanation for what was going on.  I was a little confused because I had explained everything, but soon the nurse told me she spoke Navajo.  I was so embarrassed and felt bad that I did not realize this.  The teenager was answering all the questions, as do many teenagers during their visits.  I immediately brought them back and got a translator to explain things.  After this visit I made sure to ensure that everyone understood what was explained to them.

Most of my week was spent in the Adolescent Care Unit.  In the Adolescent Care Unit I learned a lot about Navajo Culture and traditions.  The teens that are in treatment spend 2 weeks there mixed with inpatient treatment and traditional Navajo traditions.  You can tell the teens really enjoy learning more about their culture and find it comforting/healing.  For example, they do a blessing every morning in which they pray, sing, and burn herbs.  Once a week they do a tobacco ceremony in the Hogan, for mediation.  For the ceremony they wrap tobacco in corn husk and in doing this they are rolling their anger, regrets, or whatever they are feeling into the husk with the tobacco.  They then smoke away those thoughts.  It is suppose to help them with direction, identity and several other things depending on the tobacco.   They also do cultural teachings in the morning.  Along with these traditional teachings there are also group sessions focusing on several topics, such as anger and substance abuse.  There is also a family day when families also receive counseling and advice to help their teenager.  They have individual sessions as well with the counselor.

Each week there is also a Sweat Lodge, which I got the opportunity to participate in.  The Sweat Lodge takes about 3 hours and consists of 4 rounds.  The first round is introductions, the second round is Prayer for yourself, the third round is something you want to leave behind with the rocks- a negative way of thinking, something that has been bothering you whatever it is, and the fourth round is a positive thing for you.  After each round songs are sung.  You sit in a circle in a small circular hut around hot rocks.  With each round more rocks are added to the pit.  Once the door is closed it is pitch black in the lodge.  Water is thrown with a sage brush onto the rocks making the lodge hot and filled with steam after each person is done talking.  You can tell the girls really enjoy this.  There was something beautiful, soothing, and therapeutic about the steam from the rocks- almost like a release/cleanse of everything that may have been bothering these girls, their troubles, and what they were saying.

The next day I turned in my keys and drove back to Albuquerque for my flight to Oakland.  I can’t believe how fast my time on the reservation went.  I set out to learn more about the Navajo nation, the community, and the hospital and I feel that I have done that.  The clinic was really busy and I’m glad that I got the chance to work there/help out seeing all the patients.  I really like my experience and think that it would be a valuable experience for others.