The scalpel can only cut into the biology of a person. How do you cut into their community?
In November 2019, a little under 2 weeks from me writing this blog, The Wall Street Journal published a post about how troubled doctors are finding reemployment in the form of Indian Health Services clinics. At first glance, this looks like a good thing: Doctors are getting a second chance and Indians are getting medical services, but the article quickly shows that Indians are regularly getting underperforming doctors with deadly consequences. They cite that since 2006, the U.S. government has paid out about $55 million in settlements in 163 malpractice cases at Indian Health Service hospitals and at least 66 patients in those cases died in IHS’s care. Furthermore, The Wall Street Journal looked into 171 of the doctors identified in these lawsuits and found that 3 had criminal convictions, 18 had medical licenses that were sanctioned or revoked, and 33 had multiple medical malpractice claims.
I chose to write about this topic because it’s something very personal to me. For context, I’m an Arikara Indian undergrad at the University of Washington taking a class in Contemporary American Indian literature. I’m an urban Indian and I’ve always lived in a city, so I have limited experience of life for rural Indians other than what I have read and seen when I visit my reservation. I’m a biology major and I plan on working as a physician assistant after I graduate and want to work in an IHS clinic. I want to state this because I think it’s important to be transparent with what I have to offer to the conversation. For this post, I’m applying what I have read throughout this course and others with my input as an Indian so that it can be of use to medical professionals who serve Indian communities but have little understanding of the culture they are in do more effective and conscious work.
Both medicine and interacting as an outsider with Indian communities require a unique social knowledge to interact with the people in a way to help, and hopefully not harm them. When working as a healthcare professional for Native Americans, this requires a specific understanding necessary to establish rapport, build trust, and help these communities.
Because Indians are not only different from the general population and are different from one tribe to the next context is essential in having a productive patient and provider relationship. Furthermore, I want to clarify that contexts are stories and that they are essential to Indian communities. As Daniel H. Justice discusses in ‘Why indigenous literature matters”, “stories remind us who we are and where we’re going,” “they make us human” and “are the strength of our community” Justice, Daniel Heath. Why Indigenous Literatures Matter. Wilfrid Laurier University Press, 2018. Project MUSE muse.jhu.edu/book/58046.
In this sense, context is one and the same for Indian people. Furthermore, stories are how traditions and history are passed on, how Indians think their history will shape, and most importantly, bring these communities together. By understanding the importance of and knowing the stories of a population you can know the values, fears, desires, and history and be better prepared to know what Indian patients want from you as their care provider.
Unfortunately, these are often overlooked in favor of statistics. This is understandable, in western culture we’re predisposed to working in a way that will produce the most efficient results. This is especially true of medicine as it is often urgent, hospitals and clinics are understaffed. It makes is very easy and tempting to fall into a pattern of treating patients as a list of symptoms. However, unlike manufacturing and production, it will take a while (if ever) for automation to dominate medicine because it’s an intrinsically human and intimate field. Consider this quote from the now-deceased neurosurgeon, Stanford alumni, and author Paul Kalanithi in his autobiography “When Breath Becomes Air,” “Science may provide the most useful ways to organize empirical, reproducible data, but it’s power to do so its predicated on its inability to grasp the most central aspects of human life: hope, fear, love, hate, beauty, envy, honor weakness, striving, suffering, virtue. Statistics are essential for knowing how disease-prone your patients are, but they are no replacement for what stories provide. When you take patients into your care you’re doing more than just treating their symptoms, you’re preserving their lives, passions, and involvement in their communities, and future their generations.
With that said, what contexts are especially important aside from the stories of individual tribes? If you didn’t know already American Indians have a long history of victimization from the settler colonialistic practices of the US. From disease, rape, destruction of culture, loss of land, and multiple other forms of abuse, Indian peoples carry this trauma from generation to generation. I will only talk about a few of the examples that relate directly to medicine because I’m assuming anyone interested in this blog already know about this. Regardless, I’d need a separate and larger entry to talk about the subject in any meaningful way. With that said, I will just talk about the context of why Indians have a large distrust in science, medicine, and outsiders in general.
It’s not too hard to find examples of when Indians were used, without their knowledge, for the purpose of scientific research. One example that comes to mind was back in 1990 when Arizona State University started research on the Havasupai Indians of the Grand Canyon. The original intent of this research was to look for genetic clues to the increasing diabetes rate of this poor and isolated population by taking blood samples. At this point in time, the tribe was unsure of what to do as members, including the young, were facing amputations and were forced to leave the canyon for dialysis. Diabetes has threatened to remove these people from their tribal land as the only way in and out of the canyon is by helicopter or an 8-mile hike out.
Unfortunately, the original intent was lost as one of the lead researchers, Dr. Markow, decided to prioritize the blood for schizophrenia research, and genetic evidence contradicting the tribal stories of their origin to the grand canyon. Eventually, the Havasupai found out where their blood was really going, but only after Dr. Markow and her graduate students already published their research. The tribe states they don’t know if anything came from what research for their diabetes, many members are still suffering from it, and people who donated their blood felt ashamed to be used. One of these people, Ms. Uqualla, had recruited blood donors, said “I let my people down,” when she heard that their blood was being used for other purposes. Eventually, this ended in a lawsuit and with Arizona State University staff being banned from their reservation. The Havasupai people (as far as I can find) are still facing their diabetes crisis.
One of the more wide-spread examples that have given Indians a reason to not trust science and outsiders is the forced sterilization of the ’60s and ’70s. What's more, is this one is specific to IHS. IHS was created during this time with the express purpose of providing resources to Indians on reservations. However the government service operated “...under historical assumptions that native people and people of color were morally, mentally, and socially defective... “ and “that high Native American birth rates should be stemmed” says Erin Blakemore. Furthermore, many IHS doctors did not believe that “that American Indian and other minority women had the intelligence to use other methods of birth control effectively” according to Jane Lawrence. This was all these doctors needed to feel justified in making their own decisions about what was good for Indian women. Aided by apathetic law regulation and purposefully inaccurate descriptions of procedures IHS doctors performed sterilizations without the woman having accurate knowledge or giving consent to the procedures. Women came in for procedures such as womb transplants or were told the sterilization was reversible when in reality these women would never be able to conceive. As a result, the birth rate of native women dropped from 3.7 in the 1970s to 1.8 in the 1980s. source
Keep in mind these are only a taste of the events that have contributed to a sense of betrayal and distrust that Indians have in settlers and medicine. Not only are all of these events horrible because they tell a story of when a wrong has been done, but they’re scars they are held by these communities and continue to impact the physical and mental health of Indian Communities. These scars are called “intergenerational trauma.” To reference a more well-known example, in 1870’s children were forcibly removed from their homes to be raised in boarding schools. After they were returned back to their families and had kids of their own, they practiced similar abuse that they received as children in boarding schools to their own children and these practices persisted through generations. Indigenous peoples experience higher rates of substance use and related disorders, PTSD, and suicide, all of which are directly associated with this intergenerational trauma of Indigenous peoples in some shape or form. This is something that should be a major concern for the people who are health care professionals for Indian communities especially since healthcare workers can often the few, yet regular, non-Indians that they come in contact with. Furthermore, simply knowing an objective history of these events isn’t enough in itself. Knowing the emotion and trauma is also important in fully understanding the contexts in which Indians live in. Dian Million talks about this in her article Felt Theory: An Indigenous Feminist Approach to Affect and History. She argues that the feelings associated with these events are an important part of history and present history in a more subjective sense. I'm not trying to summarize her work, but it is good for further context so I'll link it here. Because non-Indian healthcare workers can be one of the few people Indians come in contact with (especially to such an intimate degree), it’s all the more important that a good relationship with non-Indians are made for a lot of rural Indians.
So what can Non-Native health professionals do to reconcile the relationship between Indians and non-Indians? The first is to understand the contexts of American Indian relations with settlers. This is more than just knowing the history, but knowing and validating the emotions, concerns, and values of Indian people and being open to learning more about it. On a deeper level, an even better way to understand Indian cultures to engage in it. It doesn’t need to be to a point where you give up your own culture, but taking the time to do things like learning the language is great for reconciliation.
I have an example of this. Before I was born, my mom (whos white) spent some time as an in-home nurse on a Navajo reservation. Her patient was an elderly woman who spoke no English so the two communicated through her daughter. The woman resisted care from white people and her previous nurses struggled with getting her to accept their care. My mom initially faced this too until she learned enough words in the language to communicate with her on a basic level and she let her care for her. The woman grew to like my mom and once she was done caring for her, the daughter told my mom she is the only white woman her mother has ever liked. Building trust and understanding these people are essential in being a good provider for Indian People.
It’s still important to understand Indians from a medical perspective. It needs to be understood that Indians face different health problems than the general population. It is also more than just reading the statistics and knowing that alcoholism, PTSD, and depression are characteristically high for Indians. It’s looking at the practices of the community and knowing why these issues exist and knowing how your patients can live healthier lifestyles in a way that combines Indigenous knowledge and ways and medicine. For example, my family from my reservation has a history of diabetes and the diet isn’t helping, but most everyone on the reservation doesn’t want to exchange it for a diet that came from white people because of their distrust in them. A non-Indian doctor telling them to adopt their ways won’t help either. A better solution would be to encourage replacement of the current diet with options that are more similar to traditional foods.
Lastly, remember that these are people. I know I have to some degree presented a lot of ideas and culture as monolithic, but that’s not easily avoidable when this blog post is supposed to be generalized for general non-Indians who serve in an unspecified healthcare profession for some unspecified tribe. The most important thing to remember is that tribes and individuals are all unique and confusing generalities as ubiquity. Defining Indians as a monolith and not individuals remove their autonomy and is exactly the opposite of what this is supposed to do: Serve Indian people.
© Copyright Cian Wolf Fox, 2019