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!

Community Health Workers and Home Visits in Navajo Nation

“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.

The Navajo Experience with Tuberculosis

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.

Part 1: Exploring Healthcare Delivery at Indian Health Service, Navajo Nation (Gallup, NM)

My first week at Indian Health Service (IHS) in Gallup, New Mexico was incredibly diverse. I spent the first couple days in clinic, where I learned about the detection and management of the most common diseases in the community--namely, diabetes, obesity, rheumatologic illnesses, alcohol dependence, and depression. Unfortunately, nearly all the patients I met had an underlying diagnosis of diabetes and obesity, likely due to a combination of genetics, an increasingly sedentary lifestyle, and lack of access to healthy food (more on this in my next blog post). I also learned how the PCP diagnoses and treats rheumatoid arthritis (including how to differentiate between general non-active RA and a flare) and ankylosing spondylitis. Since there is no local rheumatology specialist, the PCP is responsible for managing this on his/her own. The PCP I worked with also taught me about the use of Naltrexone in alcohol dependence, which I had previously never prescribed during my residency training in Boston. I also met several patients who were successfully treated with Naltrexone and were doing a lot better. Finally, regarding depression, there were a number of patients I met who had undergone physical and/or verbal abuse from their family members as children and as adults, usually in the context of alcohol abuse. I learned about the stigma of getting therapy in the community, which made me realize how important and needed it is to integrate behavioral health with primary care.  

I spent the second half of the week doing a mixture of inpatient medicine and ID/tuberculosis clinic. On the inpatient side, I took care of a young man who was admitted overnight for fever, headache, jerking movements and diarrhea. He had a history of coccidio-meningitis and resultant syringomyelia status post VP shunt and so meningitis was on the differential and he was initially treated for both bacterial and recurrent coccidio-meningitis. Serotonin syndrome was also on the differential since he was on a number of pain medications for his neuropathic pain (including a high dose SSRI and SNRI), so we discontinued these potentially exacerbating medications. Ultimately however, his CSF studies from the lumbar puncture were benign and his stool study came back as c.diff positive so he was treated for c.diff and sent home. I am glad that ultimately the patient had an identifiable and treatable source of his fevers and it was fascinating to think through his case as it progressed in the hospital. It was fun to present his case during ICU and infectious disease rounds at Gallup Indian Medical Center and get the input from the team of physicians and other healthcare providers.

In tuberculosis clinic I learned the nuances of how to treat latent TB infection as well as active TB and how to monitor for drug side effects. I took care of patients who had been recently hospitalized for extrapulmonary TB and were undergoing treatment, and I also initiated treatment in a patient who is a healthcare worker who had a positive ppd. It was interesting to learn about how common TB is in the population and about the process of contact investigation once someone is diagnosed. We also learned about TB reactivation in immunocompromised patients, namely in rheumatoid arthritis and diabetes, which are very common on the reservation. Finally, we learned about the history of Hantavirus, which was first recognized by Bruce Tempest in 1993 at Gallup Indian Medical Center.

Indian Health Service and Navajo Nation

5/9/15

It is a Saturday morning in early May here in Gallup, NM, and as I sit down to write this post, I am staring at a flurry of snow outside my window and a blanket of white upon the town. In Boston, the snow often cloaks and transforms the city, but here in Gallup, the snow only shades the imperturbable land and sky. Indeed, what struck me most when I came here was the vastness of the land, of the sky, of the history. It is overwhelming and humbling at the same time. 

Gallup is located squarely in the Navajo Nation, a tribal sovereign nation of close to 200,000 people who identify themselves as Navajo. It is bordered by other culturally and linguistically distinct tribes, the Zuni and the Hopi. 

Much like the land, the people here are enduring and have weathered storms in the past - from rival tribes, to colonization by European powers, to subjugation at the hands of the United States, to more modern threats including pollution from coal and uranium mining and now substance abuse, HIV/AIDS, and diabetes. 

Through it all, Dine, or "the people” in the Navajo language have persevered.

There have been bright spots in Navajo history, from the heroic role of code breakers in WWII to the establishment of the sovereign nation of Navajo to the retention and active use of Navajo language and traditions in everyday life.

The Indian Health Service and its hub in Gallup has pioneered a number of incredible innovations along the way to better service its constituents including the use of community health workers, the active treatment of HIV/AIDS, Hepatitis C, and Tuberculosis, and the implementation of telemedicine to enhance care.

Over the next few blog posts, I hope to explore Navajo history and culture and highlight my clinical experiences.

Stay tuned.

Promoting Best Anesthetic Practices in Ho Chi Minh City: Part 2

Today concludes my second and final week in Vietnam (read about Part 1 of my adventure here!). 

Our Monday morning started off with a healthy patient having a significant facial reconstruction procedure for injuries sustained in a motorbike collision.  Using an arterial line and an experimental noninvasive cardiac output monitor from our home institution, we reviewed management of hypotensive anesthesia to control blood loss during procedures on highly vascular areas.  Minimizing blood loss during surgery is of particular concern at Rang Ham Mat hospital, since access to blood products for transfusion can take considerable time.  We were able to see some of our post-operative patients who were still in the hospital and discussed aspects of PACU care, focusing specifically on strategies to reduce airway swelling.

Later that week we were offered the opportunity to visit the Heart Institute in Ho Chi Minh City, hosted by the head of the anesthesia department B.S. Quy.  Roughly half of the surgical cases here are adults having mostly valve procedures, and the other half children undergoing repair of congenital heart lesions.  As a resident in anesthesia who is planning to do fellowship in pediatric cardiac surgery, I jumped at the chance to spend a day with the cardiac anesthesiologists.  The afternoon of our visit I had the fantastic opportunity to participate in the case of a one year-old child undergoing total repair of Tetralogy of Fallot.  In keeping with last week’s theme of the incredible efficiency of the Vietnamese surgical services, the entire case from incision to dressing was less than three hours, with a cardiopulmonary bypass time of only 65 minutes.  The child did extremely well and was extubated uneventfully by the next morning.  This efficiency is coupled with a remarkably low mortality rate: B.S. Quy explained that after reviewing their practices and making careful improvements, their mortality rate for total repair of Tetralogy of Fallot was now less than 1%.

Jamie placing a central line under careful supervision by B.S. Quy.

I concluded my week by giving a talk on one-lung ventilation in pediatric patients at the 2015 Asia Anesthesia Summit.  With an audience of around 300 anesthetists, it was the largest lecture I’ve given as an anesthesia resident.  I was fortunate enough to have the help of a Vietnamese translator, who translated my lecture in real time over hundreds of wireless headsets provided to the audience members.  I had also sent my lecture slides in advance to be translated as well—looking up at my slides and seeing them in Vietnamese with a little disorienting!  My attending Dr. Denman also gave an excellent talk on best practices in perioperative fluid management.  The conference hosts were extremely appreciative of our participation in the conference and delivered us back to the hotel with armloads of flowers and gifts.

Jamie presenting at the 2015 Asia Anesthesia Summit in Ho Chi Minh City.

These two weeks have raced by, and I have had an amazing trip.  I am so grateful to have had this incredible opportunity not just to do interesting cases, but to really participate in a different medical system.  I hope by working with Vietnamese anesthetists and residents that I have taught them as much as they have taught me.