“I’ve got a sad, sad case for you,” the ER physician started over the phone. After only a few months working at Gallup Indian Medical Center (GIMC), I could predict with tragic accuracy the details of the case before he said another word: young, severe liver failure, alcohol abuse disorder. My prediction was correct; in addition, 28 year old Sam had septic shock with multi-organ failure.
Sam was too confused to provide any history. His distraught father told a familiar tale. His son had developed cirrhosis by age 25 from over a decade of heavy alcohol use. Sam was told by medical providers that he would die without a new liver, and with extensive support from his large family, he was able to stay sober for almost six months, the magic amount of time after which he could be eligible to be placed on the liver transplant list. But a few months prior to our meeting in the ER, Sam’s brother died from complications from alcohol use, and this sent the patient into a deep depression. He started drinking again, and soon enough, he was in our ER with liver failure, renal failure, and very little chance of survival.
I thought I had seen severe alcohol abuse disorder in training in Boston, but nothing could prepare me for the extent and severity of the disease on the Navajo Nation. As a hospitalist at GIMC, I have routinely cared for young men and women in their 20s and 30s with severe liver failure due to alcoholic hepatitis, often superimposed on decompensated cirrhosis even at the age of 23. Never in Boston did I admit so many patients to the ICU, comatose, due to severe hypothermia and alcohol intoxication. Never before in training had I seen someone lose their pupillary reflex due to severe hypothermia. In the Gallup area, people often take their pint of liquor into an arroyo, a dry creek bed, to hide from the police at night. If they are lucky, they are found by a concerned citizen and make it to the ER. But every winter in Gallup during the frigid high desert nights, several people in these arroyos drink themselves to sleep and freeze to death.
As I write this, there is an ongoing debate about how to fund Gallup’s only detox center, which has been at risk of closing for months due to lack of funding. Who should pay for this expensive resource? The Navajo Nation? The state of New Mexico? The city of Gallup? I don’t know the answer to these difficult, politically-charged questions, but I do know that the healthcare system in Gallup (as well as the legal system) heavily relies upon the detox center.
While the detox center is a critical resource as a safety net and possible bridge to treatment, it is not sufficient to address the alcohol use epidemic that has persisted for generations on the Navajo Nation. Alcohol abuse disorder is a medical disease, but also is influenced by centuries of historical trauma. The Long Walk, forced livestock reductions, removal of children from their families and placement in boarding schools, intentional destruction of language and culture. These traumas contribute to a cycle of poverty, hopelessness, and alcohol use to cope.
Sam never woke up enough to describe which traumas influenced his alcohol use. So many others like Sam never have the opportunity to voice their stories either. And yet in my position, as a physician and as an outsider, I am trying to tell Sam’s story. This version of his story is absurdly incomplete. But I feel compelled to share so that at least the injustice of his death doesn’t become a lost story as well.
There is a concept in Navajo, hózhó, which roughly means beauty and balance. “Walk in beauty” is part of the Blessing Way Ceremony which is often done to restore balance for someone who has experienced a traumatic event, returned from war or is otherwise disconnected from his or her family and community. Although I don’t know Sam’s full story, I know that alcohol disrupted his balance with his family and community, and by the time I met him in the ER, it was too late for our medical system to help restore that balance. For Sam and patients like him, we need not only consistent funding for the detox center, but we also need access to culturally appropriate therapy, medical providers who have a shared heritage with their patients, providers who are committed to stay on the Navajo Nation for more than 3 months at time and are not outsiders. We need to find a way to help Sam’s family and families like his break the cycle and return to hózhó.