I lived in Los Angeles for several years and the Navajo Reservation is a mere 10 hour drive; I have never been. I have visited post-Soviet Armenia, the Himalayan region of Northern India, rural Ghana and pre- and post-earthquake Haiti; but I had never driven 10 hours to visit my neighbors. Now as a pediatrician in the HEAL Fellowship, I was asked to spend half the year on the Navajo Reservation, which I accepted with enthusiasm.
The last six months have, like most new experiences, proved enlightening. Each time I have the opportunity to bear witness to something wholly unknown to me, my world view evolves. Think of a time you were exposed to something entirely new and how it might have changed your perspective. It might seem I benefit the most from these experiences, but I have come to realize that to bear witness can be powerful if I share what I have seen. It allows me to educate others, as I have been educated by my Navajo neighbors. If I did nothing else as a physician on the reservation, bearing witness and telling part of their story is an important outcome, possibly the first actionable step towards bringing about change.
I feel both troubled and humbled here. It’s a special place that values tradition, but that didn’t stop the industrialized world from having an impact. For nearly 40 years, from the 1940s to the 1980s, unregulated mines extracted uranium from Navajo lands and the now-abandoned mines have led to uranium contamination of water, with potential adverse health consequences. Now must drive a distance to obtain potable water rather than drink potentially harmful tap water that contains uranium and other heavy metals. The first time I drove my 15 year old car to get water there was a storm; while the rain beat down, the cracks in the dimly lit, neglected roads filled with water, making the roads even more dangerous to drive. I had to laugh because I didn’t feel as if I was in the United States of America in that moment. All this for potable water!
I get to laugh because I am fortunate that my old car is fairly reliable and I have money to purchase potable water. Many living on the reservation do not have these same securities. Many don’t have the amenities that we assume all Americans have. Some do not have electricity, running water, electric heat, or indoor plumbing. They must chop their own wood to prepare for winter or pay for the wood when the nights get bitterly cold. When seeing my patients, I ask the children with severe constipation if they have an outhouse, believing it may be contributing to their medical condition; almost invariably the answer is yes.
A young girl came into the pediatric clinic with her mother and I sensed there might be social issues, which is not uncommon. I asked the mother to step out of the room; the 11 year old shared the events from her time in foster care, where for 6 months she was physically and emotionally abused by her foster brother and foster parents. Her eyes welled up but I was moved by how composed she remained while bravely telling her story. She was given a comfortable space to speak with a specialist who wanted to listen and offer comfort, which she appreciated.
I share this story not to make you feel sad, but to point out certain details. Her story depicts several striking gaps in our system for protecting children. From the pediatrician, to her social worker, to the school system, these gaps resulted in unnoticed foster abuse that lasted 6 months. While this system is extremely overwhelmed on the reservation, the problem is not unique. Many urban areas in the US are equally overwhelmed and inundated with child protective service referrals. Without placing blame on any one part of the system, this is just one example of how we, as a system, failed this child.
Another young girl, recently taken away from her mother by her grandmother due to neglect, arrived in the clinic for general pediatric care. Immediately it became clear that this 7 year old was the height of a 3 year old and that she had several signs and symptoms of panhypopituitarism, a condition in which growth hormone, thyroid hormone and other important hormones are not produced. She was extremely short for her age, her movements were slow, she talked very little and she was developmentally delayed. She had a serious brain injury from presumed physical abuse at 3 years old. She survived, but her current condition was a long term complication from her injury. Normally she would be monitored closely after such a serious injury, especially one that resulted from abuse. However, no one took her to follow up appointments. Did the school system, knowing that she was developmentally delayed, not appreciate or seem alarmed by her obvious short stature and other signs and symptoms? Again, what gaps resulted in the system failing this child? While she has a long road ahead, she now has well established care, has started treatment, her energy is significantly improved, and she is visibly interacting more with peers, teachers and family.
These simple observations of life on the Navajo Reservation offer a sense of the complexity of this community. This beautiful land and its people are a highly valued part of our humanity within the United States. However, in some sense, this is a land and a people neglected. Their needs demand more human resources in the way of physicians and nurses; addressing current living conditions which do not always meet the standards of a secure environment; and access to safe, clean water and food. Navajo youth face many social challenges which affect their development and potential, in a community grappling with issues of alcoholism and abuse, with minimal support to address these issues. By relentlessly telling these people’s stories, and even our own personal stories, providers working within this community can increase awareness- an active awareness that has the potential to create change. I was blessed to care for many Navajo children with their bright smiles, laughter and individual styles. As physicians, we bear witness to much, which is a privilege and responsibility not to be taken lightly. It is the very thing that motivates us to improve the system and work towards equity for all. My guess is, in your profession, you also are privileged to know someone’s rather personal narrative.
As we go through our day-to-day lives, it behooves all of us – not just physicians – to foster increased mindfulness to what we bear witness to, and then take it a step further by sharing and educating others while questioning our current systems that create inequity. It is understandable to move on with your busy day and hope someone else takes on the cause, but when you are blessed as a witness, it becomes your duty to share the story, because that is where change begins.
