I initially envisioned this post as an upbeat piece of advice for graduating residents who will soon go out into the world as healers. For me, this transition was both anxiety-provoking and rewarding, so I wanted to help residents avoid the pitfalls and enjoy the pearls. Look for that piece next month because after the recent Senate hearings in early February highlighting the “horrifying and unacceptable” state of care delivered to the Native people of the Great Plains — my relatives — I felt compelled to reflect on this instead.
These health disparities and outcomes are predictable and, in many cases, avoidable. The Senate committee, after hearing testimony from tribal leaders and patients who received care on reservations, noted systemic issues at the national level such as the chronic underfunding of the Indian Health Service (IHS) and provider vacancies, as well as local problems like antiquated facilities lacking equipment, untrained or under-trained medical staff, nepotism, and — in extreme cases — malpractice bordering on criminal negligence. Of course, not all IHS sites are poorly performing; however, these issues should not be surprising to anyone who has come into contact with such IHS sites. Surely they are plainly apparent to the patients who have experienced substandard care over the past few decades. In fact, there was a similar Senate hearing in 2010 which produced action plans to address these issues. However, with high administrative turnover, varying needs and capabilities of each IHS facility, and a general lack of accountability at multiple levels, little progress was made. These negative and disheartening stories overshadow all of the good work and excellent — even innovative and cutting-edge — care taking place at other IHS sites in Alaska, Wisconsin, and, fortunately, my hospital on the Northern Navajo Nation in Arizona.
My heart goes out to the dedicated staff and health care professionals who have taken up the duty to serve these communities and strive to improve the health of Native people in spite of all the obstacles, and to the patients and families who have been promised better, but were still delivered substandard care.
None of these disparities and deficiencies within the IHS are new problems. Certain IHS sites seem to be in a state of perpetual crisis which has become routine and accepted, so care aberrations, resource constraints, and provider vacancies rarely reach the level of alarm which forces legislators or other key stakeholders to intervene.
Sadly, I think this lack of urgency is the result of mutual complacency. On the one hand are the providers, who may feel like the health care game is rigged. Without a strong economic infrastructure, secured basic necessities, and quality education, there is a fatalistic impression that there will always be disparities in health outcomes, no matter how hard they work.
Meanwhile, patients have been marginalized and disenfranchised for generations and seem to either be disillusioned or have forgotten that they deserve better. They do not demand that the rights and promises that have been made to them be kept, in ways that other U.S. citizens have come to demand and expect.
By this point, I hope you can see that the state of Native American health care on reservations is a multipronged series of problems. So the real question is how can we avoid getting bogged down in the current daily challenges established in the past, and what can we do to create a better future?
First, Congress should fund the IHS to a level that is commensurate with its needs. Doing so would allow for the improvement and updating of facilities, competitive salaries to draw well-trained health care professionals, and investment in continued professional development for those who have committed to working in IHS facilities. Adequate funding would also allow programs such as telemedicine, medical homes, and mobile health units to expand, which would consequently allow health care professionals to widen their scope of practice while limiting demand on sub-specialists and decreasing the access-burden on patients.
Second, there needs to be a stronger link between academic medical centers and medical schools or other postgraduate training programs to allow for internships and learning opportunities as a strategy for recruiting and retention. I myself am a product of one of these scholarship programs and I have seen my colleagues show interest but not clearly understand how to get involved or navigate the diverse offerings available through the Indian Health Service, the US Public Health Service Commission Core or the National Health Service Corps
Third, I see a tremendous amount of overlap between global health and the services and innovation needed in the resource-poor areas like IHS sites in our own country, and yet there is a much larger focus on global health tracks in medical schools and residency. Can we alter this perception and offer more to encourage our best and brightest doctors, nurses, and medical professionals to seek out service opportunities at home? One bit of inspiration came as I was leaving Boston, when a global health fellowship started at Massachusetts General Hospital included a required rotation at an IHS site. Similarly, for years Brigham and Women’s Hospital has been sending volunteers to IHS sites in Arizona and New Mexico that offer on-site clinical services and teaching. These programs do exist, but would have a greater impact if expanded on a larger scale across many more institutions and supported by on-site staff in these resource-poor areas. One of my early goals here at Tuba City Regional Healthcare is to create a more structured program for volunteers and trainees who want to come and serve and learn at our institution. I think the experience is incredibly valuable, especially to residents who plan on community practice, and I look forward to making this a priority during my time here. I hope others will do the same.
Fourth, we must identify, encourage, and fund young tribal members interested in public health, health care, technology, environmental sustainability, engineering, and business who make commitments to serve Native people and bring their talents back to the reservation. I was an Indian Health Service Scholar who benefited from a loan repayment scholarship, which I would not have known about if my mother hadn’t received the same scholarship and encouraged me to apply. I also ran the Four Directions Summer Research Program at Harvard Medical School, which brought Native college students from across the country together to work in labs and gain valuable real-world experience in various STEM fields. Perhaps more programs like these, where medical or other masters/doctorate level students can serve as mentors and advisors, could help open Native students’ eyes to the opportunities they have to grow personally and professionally while helping their people.
Fifth, we need a more holistic approach to health in these communities. Access to high-quality health care is only part of the picture. According to the World Health Organization, a strong economic and educational infrastructure and an ability to meet basic daily needs (food, water, shelter, and sanitation) are vital social determinants of health. There are multiple opportunities for non-profit and for-profit organizations to create partnerships to close these gaps in areas like healthful and culturally appropriate food programs, renewable energy and sanitation, affordable and environmentally conscious housing, expansion of telecommunication and Internet services, and non-traditional educational offerings and cultural exchange.
Finally, we as members of these communities cannot wait for others to solve these issues for us. Now is the time for collaboration and sharing of ideas and efforts to heal our own communities and people. I would love to see a consortium of clinical directors, health professionals, and patients come together to pool our collective resources and social capital. We are going to need each other as we try to create more adaptive and comprehensive health care systems. This may be the most difficult step, because it takes courage, imagination, and, most importantly, trust and follow-through which have been damaged over the decades through broken promises and unfulfilled mandates. It will likely take years to earn this trust back. But we need to start doing this together in small steps if we are ever to create strong, sustainably healthy, and independent Native communities. My dream is that rather than reading yet another report of the persistent shortcomings of the IHS, we can be examples of well-run, culturally competent centers of health care excellence. Maybe soon we can all live out that same dream.