The Only Nation is Humanity

     My time in Whiteriver has finally come to an end, and I have learned so much from this experience that I will bring with me.

    My last couple of weeks I spent working in a variety of clinics ranging from Family Medicine to high-risk OB/prenatal care, from Pediatrics to Internal Medicine. I truly saw the full spectrum from a 3 day-old newborn infant to an 80 year-old man with metastatic cancer. I learned how to manage rheumatoid arthritis and ankylosing spondylitis (yes, it does exist!) where there is no Rheumatologist and care for an open fracture of the distal finger where the nearest Orthopedic surgeon is 2 hospital transfers away. I witnessed the devastating effects of substance use rooted in personal and historical trauma and the hope and joy that accompanies one's faith in something larger than oneself. In all of these things, I re-discovered the beauty of medicine and caring for others- I was reminded of why I chose to become a physician in the first place.

    Yesterday I had the opportunity to work in Cibecue, a rural town of ~2,000 people on the White Mountain Apache Indian Reservation. Cibecue is over an hour drive from Whiteriver, so I joined the group of workers in a large van that carpools daily from Whiteriver to Cibecue. The area just saw a large snowstorm, so the drive was exceptionally beautiful- scattered with frosted trees and bushes, snow-capped mesas and alpine mountains, snow-powdered red rock, and wild horses roaming around. When I arrived at the Cibecue clinic it reminded me of the free stand-alone clinics that I've worked at both on the Navajo Nation in Arizona and in rural areas of Central and South America. Most of the people living in Cibecue do not have any means of transportation, so having a clinic there with doctors who can provide full-spectrum care is necessary. 

    The patient encounters I had that day comprised everyday Family Medicine issues, but most unique was getting to know the patients beyond their medical conditions. I met one man who was a bull-riding judge who had been hired to judge at many national competitions. He is known for his handmade belt buckles, especially in Canada where most of his buyers are. He talked to me for 20 minutes about his experience and reiterated to me one important lesson he learned in his work- to never sacrifice one's integrity for something or someone. I also encountered a woman who, like me, graduated from the University of Arizona- a fellow Wildcat as we say. She has a doctorate degree in Education and works at the local school in Cibecue. She acknowledged that she isn't using her degree as one would expect, but she is passionate about educating the children of her ancestors and that's what is important to her. She always knew she wanted to return to where she grew up. And then there was another man who works at the Apache Sunrise ski resort who after I had said I was visiting from Colorado told me he had worked at the Eldora ski resort in Colorado for more than 10 years! We talked about our mutual interest in skiing and our love of the mountains.

   "Patria es humanidad," or in English, "the only nation is humanity." This is a phrase that is written in Mountains Beyond Mountains, a book I am reading that follows the life of Paul Farmer and his international work in Haiti. Call it coincidental, but I think this phrase stood out to me after all of these patients I met yesterday. Despite all of the cultural and language differences that could separate us, the physical borders and mountains that could divide us, and even the doctor-patient gradient that could further distance us, I was reminded of what we share in common: our humanity. I have learned that many of the challenges that have come with providing care to people different from myself rise from the failure to recognize this common humanity. There will always be inevitable barriers when caring for people different from myself, things that can't necessarily change like language, culture and tradition, history. But when recognizing one's humanity is at the forefront of that interpersonal encounter, I firmly believe that these barriers are made easier to overcome. This is what the Apache Indians have taught me.

    When I was writing my first blog post, I asked myself why I came to Whiteriver to do an elective rotation, and I didn't really know the answer at that time. I could easily come up with a list of self-serving reasons: to improve my medical knowledge and experience providing rural and full-spectrum healthcare or to scope out potential options for my future career. I remember when I initially came to Whiteriver I assumed that maybe I wouldn't be well-perceived by the Apache Indians after dropping in for one month only to leave and move on to different things. And though this still might be true, I was surprised by how many patients and staff appreciated my coming to Whiteriver. They explained that they need people who understand their experience and care about improving the health and well-being of a people who have been forgotten for too long. The only way to know their experience is to learn from them and see that experience for oneself. It's the first step. I still don't know if this is where or whom I'm called to serve. I have had the privilege to get a small glimpse into the lives and experience of the Apache people, and for that I am grateful. I hope that I have also shared some of that experience with you so that they, and their story, won't continue to be forgotten.

A look over the White Mountain Apache Indian Reservation

COVID or Rocky Mountain Spotted Fever (RMSF)?

     Two weeks have passed since starting my rotation in Whiteriver, and I have learned more these 2 weeks than I have in some of my previous 1-month or longer rotations! Many people say that providing medical care to American Indians on the reservation is similar to providing care in underserved international settings or, as some say, "global health in your own backyard." I have seen this first-hand, evidenced by new pathology and infectious diseases I haven't encountered before, unique barriers to care and social determinants of health that rarely exist elsewhere in the US, and interesting genetic differences among American Indians here in the White Mountains. Above all, I have learned that the medical training and knowledge I have received is not always applicable to the patient encounters here- working here requires a significant degree of humility, eagerness to learn, and adaptability.

    COVID is making a smoldering come-back here in Whiteriver, where back in the Spring, Apache Indians were hit hard and fast by this disease. It was inevitable after re-opening the local casino and re-instituting group gatherings. Luckily, the healthcare community here is prepared. Last week I had the opportunity to participate in the high-risk COVID home visit program run by a group of public health workers, nurses, and contact tracers. I was on a team with one public health nurse and one contact tracer. We were given a list of 10 COVID-positive people to see that day, hopped in a 4WD mid-size SUV, and hit the dirt roads that would lead us to their homes. We checked each person's oxygen level, evaluated him or her for symptoms of severe respiratory illness, and asked about recent contacts. As we drove from home to home, the contact tracer called each contact, adding them to the list of people to be tested later that day, giving them instructions to self-quarantine until their results came back. We came back to the hospital at the end of the day and everyone shared the list of new contacts. On the white board in front of me was a map I've never seen before- clusters of names with locations and dates. From this one could see who was infected, exposed and when and where. I couldn't even try to comprehend it, but everyone else knew exactly what was going on.

    One of the women we visited had just returned from a 5 month stay in the Phoenix area or "down in the valley" they say here. No one wants to go down to the valley- people are afraid, skeptical.  And this woman's story explains why. She was infected with COVID back in May. As soon as the local hospital realized her medical needs exceeded the services it could provide, she was transferred to Phoenix, a 4-hour drive, for intensive care. There, she remained ventilated for almost two months. When she "came to," she was afraid and alone. Her family is poor and had no means of transportation to visit her, and she had no idea where she was or what had happened. She was then transferred to a long term acute care facility where she went through intensive rehabilitation for 3 months. She talked about how she was treated like a second-class citizen at times, as many American Indians (especially those with substance use disorders) are treated by non-Indian healthcare workers. Two times during her stay she had coded and required transfer to another two hospitals for acute management- she thought there was no way she would survive, especially without her family to support her. After a 5-month fight against COVID and its consequences, she returned to Whiteriver, welcomed by a parade of family and community members waving signs and balloons as she entered her home for the first time in almost half a year. She explained that the most feared part of going down to the valley is knowing that you may not ever come back home, because by that point you are either too ill to make it through, or you won't have the strength or courage to survive without the support of your family and your community. Nevertheless, she survived and felt blessed to have the opportunity to tell her story- she said she owed it to God and to her family who was with her in spirit every day. She told me if she could share with people only one thing about her story and experience with COVID, she would say (paraphrased), "take this disease seriously, wear your mask, and do your part so others don't have to go through what I went through or lose their lives."

    Not everyone who has suffered from COVID has had a similar outcome, including the heartbreaking case of a 30 year-old woman who developed a debilitating MCA stroke, leaving her paralyzed on one half of her body and unable to carry out daily functions. But the support system here for COVID is robust with a specific pulmonary rehabilitation program designed by one of the local physical therapists, high-risk home visits and contact tracing like I described above, home delivery of pulse oximeters and aspirin for those at risk for hypoxia and blood clots, and availability of remdesivir for anyone admitted to the hospital with COVID.

Below is a picture of one of the members of the team I worked with and one of the patients we visited in the community (picture from news report from Arizona Republic).

See link below for the recent news report here: 

https://www.azcentral.com/story/news/local/arizona-health/2020/10/18/robust-contact-tracing-saving-lives-apache-tribal-members-coronavirus/5712555002/ 

***

    I have learned a lot about Rocky Mountain Spotted Fever in my time here. It's endemic to the area with a prevalence greater than 150 times the national average. But this startling statistic is not due to its endemicity; rather, it's due to the large amount of stray dogs carrying the fleas that transmit this bacteria. RMSF is deadly if left untreated, and the risk of mortality increases the longer one waits to be treated. For this reason and due to its high prevalence here, anyone with a persistent fever for longer than 48 hours receives empiric doxycycline, one of only a select few antibiotics that is successful at treating this disease. We are frequently taught in medical school to avoid doxycycline in children and pregnant women, but everyone gets it here. (As an aside, the evidence has not shown any deleterious effects with doxycycline but only tetracycline). The reason the 48 hour mark is used is because survival drops from the 90% range to the 70% range after day 2, and after day 5, the survival rate is less than 50%. It's so prevalent and serious that on every transfer summary for patients being sent to another hospital, the following statement is at the top of the page: "this patient is coming from a community with high prevalence of RMSF- recommend starting doxycycline if patient has a fever for more than 2 days." 

    In addition to COVID and RMSF, a variety of other conditions run rampant with higher prevalence on the Apache Indian reservation compared to most areas of the US, including: necrotizing fasciitis, MRSA infection, myocarditis from strep pharyngitis or the classic "strep throat," autoimmune diseases like dermatomyositis and lupus, and coccidioidomycosis (an endemic fungal infection).

    My experience thus far has been very informative and eye-opening to say the least, and I look forward to my next two weeks here and learning more about the complex and diverse human condition. 

Getting to Know the White Mountain Apache Tribe (WMAT)- Whiteriver, Arizona

        After a long and grueling drive down from Greeley, Colorado to Whiteriver, Arizona (about 12 hours), I was greeted with tall pine trees, cool mountain air, a multicolored sunset, towering cliffs, and distant tree-covered mesas. I was reminded once again that Arizona is more than a flat, arid desert with spiky green cacti. Only minutes before arriving, I even drove by some large blue lakes, painted aspen groves, and a cluster of wild horses. It wasn't difficult to understand how sacred this land is to the Apache tribe- I instantly felt grateful to have the opportunity to live and work in this space. 

        The emotions were mixed, however. Though I had lived in Arizona for more than 8 years, it didn't feel like I was "coming home;" instead, it felt a bit foreign. As I drove through the tribal land, I found myself contemplating why I chose to come here in the first place and what I hoped to learn during my time here. No, I still haven't figured out the answers to these questions, but perhaps in a few weeks I will have some answers.

        My first day was mostly filled with orientation- meeting new people, learning my way around the hospital (known as Whiteriver Indian Hospital, a subset of the larger Whiteriver Service Unit), learning how to navigate another EHR, etc. Among the most interesting things I learned about the White Mountain Apache are: there are about 17,000 tribal members in total. The entire area, however, also includes people from Hopi and Navajo tribes, though these tribes make up a much smaller portion. The Apache revolve around a matriarchal system, where one's clan or kinship system is passed on from the mother's side. The four clans are: bear, butterfly, eagle, and roadrunner. What significance these animals have I still have yet to learn. An individual's upholding of native traditions and assimilation to the surrounding American culture is quite heterogeneous among the Apache, differences largely noticeable among younger and older generations and among those who have lived outside the reservation and those who have not. 

        For example, it is common for Apache people to not use direct eye contact when engaging in conversation, especially when interacting with those older than you. I noticed this today as a patient and her partner looked and talked toward the ground the entire postpartum visit. I was prefaced ahead of time that to many of the Apache, it is disrespectful to look into another person's eyes- I was instructed to focus on one's ear or forehead when it was apparent that the patient was not maintaining eye contact. This isn't true for everyone, however, especially most of the hospital staff. I was grateful that I was made aware of this ahead of time, or I might have jumped to conclusions. In our medical culture, we are taught that avoidance of eye contact is associated with difficulties with social interaction and autism spectrum disorder. In the Apache culture, one is taught that to avoid direct eye contact is to show utmost respect for the person with whom you are speaking. How easy it would be for a misunderstanding of one's culture to affect the doctor-patient relationship.

        I learned that in Apache tradition, women carry their newborn infants on cradleboards. I embarrassingly admit that when I first saw these beautifully crafted "baby carriers" hanging on the wall of the birthing center, I thought they were oversized shoes (or old-fashioned snow shoes). I was taught that a baby is placed in the cradleboard, sinched tightly with the lace straps on either side, and carried around like one carries a lunchbox (not on one's back, as I mistakenly assumed again). I have attached a photo of a cradleboard below.

        I also learned about the Sunrise Dance from a patient today- a dance to signal the "coming of age" of a woman in Apache culture. I likened it to the Mexican Quinceañera in my mind. Traditionally, this is a multi-day event celebrated by many people, the greater "family" of Apache, to help welcome a girl to womanhood. The physician with whom I was working asked the patient if she was going to have a Sunrise Dance for her daughter- she was unsure. In the early 1900s, the Apache began to be introduced to outside religious presence, initially in an effort to encourage Apache Indians to assimilate and relinquish native practices that did not conform to those of Christianity. The patient when on to explain that because her daughter attends a Lutheran school, that if she chose to have a Sunrise Dance for her daughter, her daughter would be required to leave the school for good. She went on to explain that she is a Christian as well, so this was a difficult decision. I began to feel a little uneasy being a Christian myself, mostly because I couldn't imagine how difficult it might be to have to decide between one's tradition and one's faith, and for her daughter- to have to leave one school for another if she had chosen to follow her native tradition. She stated some churches tried better to incorporate native practices within the framework of the faith- the example she gave was the local Catholic Church that used traditional Apache baskets for the tithe collection and Apache drums as people walked up for Communion. I appreciated her openness and honesty about the subject and wished I could have learned more. I don't mention this story to point fingers, but to reflect on the reality of this divisiveness. I would like to imagine a circumstance where both worlds could exist harmoniously- I think I will likely encounter this divisiveness again when balancing patients' adoption of allopathic medicine and traditional Apache medicine.

        I think that's all for today!