Part 2: Exploring Healthcare Delivery at Indian Health Service, Navajo Nation (Gallup, NM)

My second and third weeks at IHS exposed me to different and innovative models of preventive health care delivery. Below, I’ve outlined the various programs that I learned about:

•    Navajo Area IHS HIV Program (HOPE): This program employs HIV Nurse specialists to assist the infectious disease physician with HIV clinic flow and to see patients independently for STD treatment, vaccinations, counseling and rapid HIV testing of partners. The HIV nurse also supervises the health technicians (pharmacists who help sort out medication distribution and adherence), and does field visits that involve home assessments, medication monitoring and community outreach for patients who are more challenging to care for. Over two days I attended a few field visits on the reservation and also participated in an outreach HIV education program at the local Gallup Adult Detention Center. This was my first time visiting patients on the reservation and it was eye-opening to see how spread out the homes were and how difficult it was to navigate the reservation as an outsider (because of the rain and mud roads and landmark-based directions). This gave me a greater appreciation for how difficult it must be for patients to seek medical care when they need it given that the reservation is so rural and relatively isolated. It was also interesting to see how the community on the reservation makes a living on their farms. Most homes had accompanying Hogans, which are traditionally used as a ceremonial space and have doors that all face east. For a few patients we visited, it was clear that they were using a combination of traditional Navajo healing/medicine man as well as antiretrovirals to treat their HIV. It was clear that the combination of these two forms of medicine sometimes posed a challenge to effective treatment of the virus. Because many of the community members lacked cell phone reception, it was sometimes hard to predict whether they would be home. The time that we were on the reservation was the beginning of the month, when people receive their paychecks and so we were told that many people on the reservation may be out in the town purchasing their month’s supply of goods. Nonetheless, we were able to visit a few homes when the patients were there and were able to review their medication adherence, provide counseling, and remind them of upcoming appointments. During our HIV awareness session at the Adult Detention Center, I was impressed by how engaged the group of 8 women were in learning about the primary, secondary and tertiary prevention of HIV and AIDS. Many were eager to get tested and share the information.

•    Navajo Community Outreach & Patient Engagement Program (COPE): This program works closely with community and tribal partners to promote healthy, prosperous and empowered Native communities. Their vision is to eliminate health disparities but providing robust community based outreach, strengthening local capacity and increasing access to healthy foods and promoting food sovereignty in tribal communities. One of the partnerships that COPE has developed is with Harvard Law School’s Food Policy Clinic, who had been working with the Navajo Division of Health over 2 years to develop Navajo Food Policy Toolkit. My visit overlapped with their visit to Navajo Nation, where they presented their work at a local Tribal Council meeting at the Sheep Spring Chapter House. During this meeting the Harvard Law School group presented their toolkit, which was a summary of all the food policy issues on the reservations. It was a large document that included sections on 1) Dine (traditional people) food ways 2) Structure of the Navajo Nation government 3) Role of state and federal government 4) Food production 5) Food processing, Distribution and Waste 6) Access to Healthy Food 7) Food assistance Programs and 8) School food and nutrition education. The tribal council was very welcoming and grateful to the group for putting together all of this research and they discussed ways to incorporate the information into local decision making. Some of the main issues they discussed were access to water, how to revitalize the agriculture practice and how to bring the processing of meat more locally onto the reservation. It was interesting to see how formally the tribal council was structured and how formally the proceedings took place.

•    Project ECHO (Extension for Community Health Outcomes): This organization provides a collaborative model of medical education and care management that aims to empowers clinicians everywhere to provide better care increasing virtual access to specialty treatment in rural and underserved areas. Currently, they run “clinics” between specialists at University of New Mexico and clinicians at IHS and elsewhere on complex conditions such as hepatitis C, rheumatoid arthritis, chronic pain, and behavioral health disorders. I was able to see Project ECHO from two viewpoints--one as the rural provider in Gallup, NM and one as the specialist at University of NM. I sat in on a “Hepatitis C Clinic” from Gallup where our Infectious Disease team discussed cases we saw and reviewed management via the teleconference. Separately, I sat in on a “Chronic Pain Clinic” at UNM where I heard cases about addiction and had a didactic lecture given by a neurosurgeon from UNM. I also sat in on a virtual workshop with prisoners around New Mexico conflict resolution. It was incredible to see how specialty care and education could be done in a way to empowers local physicians and it would be interesting to see how that model could be expanded elsewhere and applied to more specialities.

Over the course of the two weeks we spent our time outside of the clinic/hospital learning about the community. We did a homestay with one of the IHS doctors and her husband (who is a school teacher), which gave us the chance to see and hear about what it is like to live and work in Navajo Nation, first hand. Through our nightly chats with our homestay hosts, we learned about the challenges that their patients and students face in the community, including high rates of substance abuse and unemployment. However, we also learned a lot about the incredible Navajo culture, including language, food and traditions which the community is working to keep thriving. We attended local yoga classes (the doctor I stayed with teaches the class), we went on a couple of awesome hikes to Pyramid Rock and Inscription Rock at El Morro (where we saw evidence of past dwellers and travelers as far back as the 1400s-1800s), we learned about rescued wolves and stray animals at the Humane Society, and saw the local crafts at the weekend Flea Market and monthly Arts Crawl in Gallup town center. The physician community in Gallup was very tight knit--several healthcare providers were from academic institutions like Brigham and Women’s Hospital and UCSF as well as from US Public Health Commission Corps so it was inspiring to have the opportunity to hear about what brought them to IHS initially and see what has kept them doing meaningful work here for so many years. It was also great to learn about other programs, such as the HEAL Initiative that will continue to bring physicians to IHS to develop lasting relationships with the community. I hope to have the chance to return to Gallup again in the future!again in the future!