Friday, September 11, 2015

Gallup. NM part 2


Contrary to popular belief, although “Native” Americans populated the Americas long before Europeans and other immigrants, Native American history is also one of immigration and migration throughout the North American and South American continents.

Over 1000 years ago, the Athabascans crossed the Bering Sea from the Eurasian landmass and settled parts of Western Canada and Alaska. Through cultural, linguistic, and genetic research, it was recently discovered that the Navajo are descended from the Athabascans and most likely branched off in the 1300-1400s when they migrated to the American Southwest. Other Athabascans diverged and became present-day Apaches.

Traditionally hunter-gatherers, the Navajo learned from neighboring Pueblo tribes how to farm and cultivate the land. Over time, they fended off threats from the Spanish but eventually were defeated by US forces including Colonel Christopher “Kit” Carson in the mid 1860s. This defeat culminated in the widespread deportation of Navajo people away from their homelands to Ft Sumner from 1864-1866 that came to be known as the “Long Walk” and the signing of treaties that led to the formation of Navajo Nation. It is purported that this was one of the first exposures of the Navajo people to tuberculosis. By 1912, 10% of Navajo had TB, and TB was responsible for 50% of all illness seen among the Navajo.

The Navajo word for TB is “jei di,” which literally means “disappearing heart.” There is a commonly held perception that TB can be caused by contact with wood that has been struck by lightning. Navajo Medicine asserts that TB or jei di can be cured by the shooting way ceremony to achieve harmony.

By 1953, almost a century after the “Long Walk", TB incidence was 100x higher among the Navajo than among the general US population. Around this time, a brave lady named Annie Wauneka led a public health campaign to educate her fellow Navajo about the dangers of TB and to correct misconceptions surrounding the disease. She taught Navajo medicine men about TB, pioneered a model of directly-observed therapy for TB, and encouraged Navajo to complete their TB treatment.

Today, tuberculosis still plagues the Dine at a rate many times that of the general US population. As you may know, tuberculosis is a curious disease in its ability to remain latent for many years before reactivating during times of sickness or immunosuppression. TB is called the “Second great imitator” due to its protein manifestations.

It is estimated that as many as 1/3 of all those who suffer from diabetes mellitus on the reservation have latent tuberculosis and are at risk for reactivation and transmission. As such, it is increasingly common for all those with DM to be screened for latent TB with a PPD or a serum quantiferon test.

Although TB rates and mortality have fallen drastically thanks to efforts by Annie Wauneka and others, TB is still a disturbingly common occurrence among the Navajo. While working with an infectious disease physician in Navajo Nation, I had the opportunity to meet and care for a kind lady on immunosuppressants for her rheumatoid arthritis who presented with severe hip pain. Although the thought was that she likely had a labral tear or her pain was a manifestation of her pre-existing RA, her joint was tapped and was positive for TB. She was treated with a 4 drug regimen, and before I left her pain had significantly improved.

For context for those reading, during my 6 year general medical training in the United States, although tuberculosis has been on the differential many times, I have never cared for a patient with newly diagnosed tuberculosis. I have read and seen patients with TB in India and southern Mexico but not once in the United States. By and large, it is a disease of poverty and affects the most vulnerable both from a medical and societal perspective.

In my next post, I hope to speak more about structural factors that affect health in Navajo Nation.

Post 3

“Next to the mountain. Literally right at the foot of the last mountain to your left.” That’s where she lived. Ms. G was a 60yo lady with diabetes, HIV, and a big heart. While here in Navajo Nation, I’ve had the opportunity to see amazing medicine in the clinic but also outside the clinic. In fact, when you think about it, most of what affects health doesn’t happen within the fours walls of a hospital or doctor’s office, but in a person’s home, among their family. As such, home visits can be a powerful lens for understanding how people live and how their environments contribute to their health in both positive and negative ways.

Yesterday, I was fortunate to travel with HIV community health workers to visit the homes of patients with HIV and make sure that they were being cared for and had their medications. For patient with HIV, adherence to anti-retroviral medications of 95% or greater is essential to rendering the HIV viral load undetectable. For many diseases, adherence of >70% is a victory, but for HIV high adherence means life or death. As such, ancillary support from social work, nursing, and family can be essential.

After traveling for 1.5 hrs and missing her home multiple times (there are many mountains on the reservation), we arrived at Ms. G’s humble abode - a 2 bedroom converted trailer home. Ms. G profusely apologized for missing her appointment and not answering the phone, but because of the rain and the unpaved roads on the reservation, she was afraid she would get stuck in the wet clay and so was unable to get to her appointment. Regarding the phone, she did not have a landline, and her daughter needed her only cell phone.

In speaking with the CHW, I found that this scenario was not uncommon. ~80% of the roads and driveways on the reservation are unpaved, and only 60% have access to landlines with fewer having access to internet and cell reception. More disturbingly, 9% of households do not have access to clean drinking water and sanitation.

The infrastructure that I take for granted in Boston is feeble at best on the reservation, further exacerbating the poverty and poor health that plague this community. Sadly, the Navajo Nation suffers from unemployment reaching over 50% by some estimates with yearly income 1/3 of the general US and rates of intimate partner violence as high as 39%. In this setting, health and healthcare often take a back seat to food, nutrition, housing, and other goods.

Ms. G was ever the gracious host, offering my companions and I a drink and making us feel welcome in her home. On the kitchen table, I was impressed to see a strict food diary with blood glucose levels and a medication dispenser organized by her daughter. Of course, this victory was hard won and over the past 2 years, Ms. G had been hospitalized for complications related to diabetes and come close to death many times. The CHW was able to re-schedule her appointment using a cellphone, schedule labs that had been missed due to the rain, and provide her with a more organized medication dispenser.

As a medical doctor, I am trained to interpret numbers, look for signs and symptoms, examine the body, and come up with a diagnostic and treatment plan. All too often, the most important elements of a patient’s daily life (i.e. rain, poor infrastructure, no cell phone, domestic violence, economics hardships) are left out of the plan to the detriment of the patient and society’s health. In these cases, we physicians re-double our efforts to treat patients in the ways we know how, but never are we trained to think about the big picture, to think about how access to clean water or to telephones can make an outsized impact on health. It is here that the CHW and the home visit really shine and add impact to a medical team.

In my next post, I’ll talk more in depth about innovative care delivery models in Navajo Nation.

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