Letter from Kayenta
I live among the red rocks of the Southwest and the "red men" who are native to them. The Navajo Reservation is a desolate place with a jarring juxtaposition of primitive and modern. Wooden shade houses, crafted from a ramshackle accumulation of piñon logs, offer respite from the searing noontime sun. Hogans, the traditional Navajo dwellings, mounded from the vermilion clay, stand together with groups of weather-beaten trailers. Suddenly the barren terrain is broken by fields of steel pylons, embattlements hoisting thick ropes of power lines to rescue a few clusters of homes from the isolating darkness of nightfall.
I never expected to find myself living here. But after graduating from Harvard Medical School and a pediatrics residency at the Boston Children's Hospital and Boston Medical Center in 2001, I wasn't ready to settle down, even though I was married and pushing 30. My family and friends had long expected me to choose a prestigious but comfortable job, close enough to a medical mecca to be academic and challenging, far enough away to afford the home life motherhood would demand. On the other hand, after working exhausting, stressful hours as a medical student and resident, all the while envying my nonmedical friends their comparatively carefree lives, I wasn't ready to leap into a grueling fellowship and pediatric subspecialty. I wanted a little adventure. So, my husband, Carlos, who is also a pediatrician, and I chose to work for the Indian Health Service (IHS) on the Navajo Reservation.
Both our families were a little confused by our choice at first. "Will this advance your career, or will this be a setback?" Carlos's father asked when we first broached the idea. "What will you eat?" asked Carlos's brother, a lifetime Los Angeles resident who eats almost exclusively in restaurants, when he learned that our town boasted only fast food. "You want to do what?" my mother asked. It was difficult for our families to envision usafter 30 (combined) years of solid accomplishment and academic achievementstriking out on a path that, however professionally challenging and personally stimulating, did not necessarily fit into the progression of easily recognizable success that a prestigious fellowship would offer.
On the reservation, Carlos and I are two members of a staff of 11 physicians working in a remote clinic that offers routine outpatient care as well as emergency facilities in a small six-bed emergency department. We are the only medical facility in a 70-mile radius, so we see a range of patients, from critically wounded trauma victims to those with mundane colds and viral illnesses. In addition to the children Carlos and I trained to care for, we also treat grownups and elders and pregnant women. We work closely with our colleagues who are trained in internal medicine and obstetrics to ensure that we provide high-quality care to all our patients.
All IHS physicians sign an initial contract of two years. If we decide to stay, we choose to renew our contracts year by year. Our patients are accustomed to getting to know a new physician every couple of years, and they rarely identify a primary-care physician as their own. The IHS offers challenging and rewarding work, but not necessarily a luxurious lifestyle. We can't own our own homes, but instead live in the prefab homes or, for the lucky ones, in a newer double-wide (trailer, that is) that the government provides. Our Boston friends laughed when they heard that our rent went down this year to less than $200 per month as our house devalued by one more year. We are lucky to have a small grocery store right in town, but must drive more than two hours for basic shopping or to service our cars or to eat out in a restaurant that doesn't offer collectible theme prizes. It's hard to imagine building a permanent life here, often hundreds of miles from family. Our Navajo community has internalized this pervasive transience and approaches us with hesitation, protecting themselves from inevitable loss. Many of the physicians as well are already planning the next step within months of their arrival. Some of us stay for the long term, but most do not.
My experiences at Harvard did not prepare me for the challenges I would face in dealing with patients here. The nearly 250,000 Navajo are spread across a reservation larger than West Virginia. Navajo traditions are intact, and most of our elders do not speak English. Nearly 70 percent of our patients do not have a phone, and 50 percent live without running water or electricity. The "ve-hicle," or "chitty," typically a 4 x 4 pick-up capable of navigating the unmarked dirt roads that criss-cross the reservation, is highly valued. Recently, we failed to resuscitate an elderly man whose family first noticed that he was unresponsive two hours earlier. The family first had to drive eight miles to reach their nearest neighbor with a phone to alert 911, and then the ambulance had to cover more than 40 miles over unmarked roads to retrieve the patient. The man had already been without a heartbeat for at least one hour by the time the ambulance arrived at the clinic.
The Navajo have an ambivalent relationship with our Western traditions and lifestyle. Initially, I was astonished that many of the Navajo do not experience the lack of amenities as privation, but rather take pride in sustaining their ancient nomadic ways. They still often describe their permanent homes as "camps," hearkening back to an era when clans moved from the desert highlands in the summer to graze the animals and farm the more fertile lowlands. Of course, this view is not universal. One mother of seven children said to me, "I just need to get that running water and 'lectricity." I have learned that this struggle to maintain the kernels of the ancient traditions while still embracing the comforts of modern living contributes to tension among the Navajo and creates dissension when trying to create a vision of the future.
One of the pediatric nurses has managed to bridge modern living and the traditional culture. She lives in a hogan without running water or electricity. She wakes every morning at 5:30 to start the fire and haul the water. She goes for a quick run before preparing breakfast for her family. She then spends the day administering vaccines and teaching parents to use car seats before returning home to re-start the fire and prepare dinner. Her mother-in-law also lives in a hogan. When she was discharged from the hospital on oxygen earlier this winter, Sally had to keep reminding her not to use the oxygen when the fire was burning: "It's hard in the cold with no fire. She complains, but what can I do?"
Back in Boston, I worked in a primary-care clinic that served many recent immigrants. I had to counsel Haitians that Gripe Water, which often contains alcohol and is used to treat colic, is not a great choice for babies. Many Central Americans insisted on over-feeding their infants because in a culture of starvation, obesity is a symbol of health and success. An African mother asked me to circumcise her newborn daughter so that she would have no trouble finding a husband when she returned to her homeland. But these families had come to America to fulfill dreams of an easier and more successful life. Often I had the opportunity to serve as a cultural interpreter as they struggled to understand life in this country. They wanted to know what I had to offer, and they invariably felt that it was an advantage over what their native lands could provide.
The Navajo, in contrast, never asked for the white doctors. The earliest Western doctors clashed with the Navajo. The doctors fought to enforce their own modern traditions and to terminate the influence of the traditional medicine men. Since then, more tolerant viewpoints have prevailed and we have achieved a sometimes uneasy balance between the modern and the traditional ways. Still, the government has chosen the medical structure and the range of services to provide. Approval for new facilities must come from Washington, far removed from the red lands, and the process can be so lengthy that by the time the facility is built, it is already out of touch with the current demands of the people. The Navajo clearly resent this and are working to establish their own medical system and wrest control from the government. These tensions, sometimes present and palpable in the clinic, sometimes not, depending on the particular patient, make practicing in this land challenging and occasionally frustrating. My pediatric patients must come to me in clinic to receive the mandated vaccines and legally required Western treatment for critical medical problems. Some want what I have to offer and accept advice willingly, even eagerly. Others would prefer not to have to come in the first place.
The most challenging and troubling conflicts come over the care of children. In the Navajo Nation, we live in a bit of a legal never-never land. The Nation is largely self-governing, determining its own laws and subject only to federal laws. Except when the Arizona state laws take precedence. (To make the situation more complicated, the Nation spans three different states.) The rules seem desultory, irrational, and improbable at times, difficult to navigate always.
I am currently the medical liaison for the child-protection team. On the reservation, the department of social services is under tribal jurisdiction. The caseworkers are all traditional Navajos, fluent in both languages and fluid with the old traditions as well as the modern ways. They must be able to interpret any household, to assess the traditional values and compare them against a modern standard. In a recent team meeting, we discussed a family who was charged with neglect for failing to bring the 13-year-old to school. The family had had multiple written agreements, documented by the social worker, to ensure that the child went to school. Yet despite these measures, the family had as of yet failed to comply with any of our requests. In the midst of the heated discussion about how drastic our censure should be to ensure that the child would receive an education, the caseworker in charge silently raised his hand.
"Why does a kid have to go to school anyway?" he asked. "Why isn't it okay to just follow his grandfather around and learn the traditional ways? He has to learn things. He has to memorize stuff. Why isn't that good enough?"
The room was silent.
"I mean, I'm asking because I want to know what to say when the parents ask. Parents ask this kind of thing all the time. I want to know what I should say."
At the time, I was angered by the question. These people were selected by the tribe to ensure that all children received appropriate care at home. Why couldn't he understand the importance of a well-rounded education? But as I thought about the issue further, the question seemed legitimate. Who is to say that my Western education has more value than his Navajo traditions? The reality is that most of these children will not move off the reservation, they will not pursue jobs demanding a Western-style education. But I believe that the children must be given that choiceto pursue the future or to preserve the past or some combination in between. This choice would be impossible without any formal Western-style education. The state-mandated answer, and the answer I still believe in, was unequivocally that this child has to go to school, or at least pass the state examinations. The question exposed the entrenched cultural differences between our two communities, even when we try to work together for the good of a child.
There is a deep-seated suspicion among the Navajo that the government is using IHS physicians to practice and experiment on them. Among a small subset of the population, this belief is unwavering. Our group of doctors has struggled for many years to decide how to handle the case of a child whose father has consistently refused a potentially life-saving procedure. The child has a large hole in her heart that allows the blood to flow unevenly, overloading her lungs and shortchanging her body. While young, she will most likely not feel the effects of this imbalance. But the chronic overflow will put her into heart failure by the time she is an adult and will probably kill her by middle age. The father will not permit the surgery because he is convinced that the surgeons want to practice on her, opening her chest and then stitching her back up without actually performing the lifesaving procedure. We have allowed the family to defer the surgery because the girl has several more years before correction is critical for her survival. We bring them in yearly to readdress the issue, and we are hopeful that finally this year we may have broken the impasse.
Sometimes, just when I become frustrated and feel that I will never be able to negotiate a meaningful relationship with the ancient traditions, I find a moment of understanding. At 15 months of age, Jimmie Calamity hadn't quite lost the thick shock of fuzzy hair that most Navajo infants sport before it changes to the finer, flatter coif of early childhood. He sat in his mother's lap, wearing an Old Navy T-shirt with a sweatshirt, jeans, and a pair of miniature Nike sneakers. His mother wore jeans and a sweatshirt. When I asked what brought Jimmie in to the clinic that day, his mother held him a little closer and looked at me defiantly. "He was in the hospital for wheezing," she said. "He just got out."
As I looked back at her toddler, I noted the snotty nose and the coarse, congested breathing. I thought I heard a faint whine to his breaths, but even so, he was smiling and giggling in his mother's lap. "Bronchiolitis," I thought. We were in the thick of the winter-long season of the viral pneumonia that plagues young children. "How has he been since you went home?" I asked.
"Well, he was pretty sick in the hospital," she said. "But I went to a medicine man and had a ceremony, and since then, he's been much better. He's been in and out of the hospital with this wheezing, and none of you doctors could tell me why this was happening, and you couldn't fix him. Now he's much better since doing my own kind of medicine." She set her jaw, clearly testing how I would respond to this.
"I'm glad the medicine man was helpful," I said. "Why did he think Jimmie was having these problems?"
"Well, I don't know if you can understand this, but he made everything right. Not just the body, but everything." She began to relax a little as she spoke, loosening her grip on her son and slouching down a little more comfortably in her chair. "My grandmother passed on when I was still pregnant with Jimmie. Jimmie was always moving in my belly, and the medicine man explained that the spirit of my grandmother was trying to take him for herself. There was also a lightning storm, and it cast a spell on the weakest person in the household to make him ill, and being the baby, he's the weakest person," she explained. "The medicine man did a ceremony to make everything all right again."
I was glad that she found her traditional methods helpful in a way my Western medicines couldn't be, but as I put my stethoscope to the baby's chest, I heard coarseness and prominent wheezing. He still needed my medicines, and I was afraid that the healing ceremony had been so effective in the mother's opinion that she would stop using the medicines I had to offer. I explained to her again that while I believed that the health of the spirit and mind contributed to physical illness, my tradition of medicine attributed Jimmie's breathing difficulties to inflammation deep in the lungs. Our medicines were directed at alleviating the inflammation and opening the airways.
"Oh yes," she said. "I've been giving him the pink antibiotic three times a day for the ear infection. He has two more days left. And I give him the breathing treatment at least twice a day. They seem to work. He already finished the other liquid medicine they gave him."
"Excellent," I said. The mother looked fully at ease now. "It sounds like you have done a great job for him, and he seems to be getting better. I would expect him to be all better within the next week. If he is still having trouble or getting worse, please bring him back to see us. Otherwise, we'll see him at his next well-child appointment." I left the room feeling healed from the experience, and I think she did, too.
Ellen L. Rothman, M.D. '98, is author of White Coat: Becoming a Doctor at Harvard Medical School, based in part on essays she wrote as a medical student; some of those essays were featured in the March-April 1996 Harvard Magazine. Names and some personal details were changed in this article to protect the privacy of her patients.
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