By. Drs. Aaron Price and Kevin Duan
Originally published in STATnews. HEAL Fellow Aaron Price and his colleague Kevin Duan write about the impact of Medicaid expansion on Native populations.
“…the Indian Health Service spent just $3,107 per person, whereas Medicaid spent $5,563, the Veterans Health Administration spent $7,036, and Medicare spent $11,910.”
Given the current political debate about healthcare coverage in the United States, the topic has been on the minds of many patients and providers, including mine.
I was one of the many providers who enthusiastically welcomed the Affordable Care Act‘s expansion of insurance coverage to millions of patients in the US. Despite the ACA bringing the uninsured rate to a historically low, about 9% of Americans remain uninsured, most of whom are members of low-income families.1 While we are still struggling to insure all Americans and at the same time are considering policy changes that would take insurance away from many, Mexico has achieved universal health insurance coverage with the implementation of Seguro Popular, a public insurance option.
However, in places like rural Chiapas, one of the poorest states in the nation, many barriers to care make the promise of true universal healthcare access difficult to achieve. Compañeros En Salud (CES), the organization I have worked with for the past six months, is committed to filling in these gaps between coverage and care.
One patient that highlighted the barriers to care in rural Chiapas was a 49-year-old woman pregnant with her ninth child. She received prenatal care at the CES clinic in Plan de la Libertad where I was working as a supervisor to the pasante (a physician completing the mandatory year of social service) in that community. This patient was severely anemic and, given her many prior births, had a high risk of complications including hemorrhage, which is the highest cause of maternal mortality worldwide.2 While lay midwives work with women in several communities, their experience and capacity is variable; in the case of an emergency in this rural setting, they often lack the materials and training needed to save the lives of a mother and her baby.
Under Seguro Popular, this patient should be able to deliver her baby in a hospital, which would greatly reduce her risk of complications. However, the reality is that for our patients, the journey to a hospital is blocked by often insurmountable barriers: lack of food for the patient and her family during their stay, few transportation options to a hospital many hours away, lack of funds to pay for lodging near the hospital prior to delivery, and mistrust of healthcare facilities due to historic mistreatment of women.
CES has worked hard to understand and overcome the many gaps that exist between health care coverage and true access to care. The Salud Materna (Maternal Health) program specifically addresses the barriers that exist for expectant mothers trying to reach maternity care through multiple interventions. The Salud Materna program provides vouchers for food and transportation for a patient and a support person, as well as free lodging in a maternal house attached to the hospital. They provide training in patient-centered, dignified health care to pasantes in an obstetric and perinatal nursing program to make patients’ birthing experiences positive. Finally, they support improved communication between providers in the community with those in the hospital.
CES is continually working to overcome barriers to care in the communities they serve in rural Chiapas, and have seen great success in terms of the number of women choosing to deliver in a hospital and being able to successfully travel there for delivery. While the barriers faced by patients in the communities CES serves highlight the fact that health insurance coverage does not equal healthcare access, universal health insurance is an important starting point that opens doors for patients. I hope that as our country continues to debate healthcare policy, we think critically about ways to increase health care insurance coverage as well as overcome barriers to improve access to care.
He was about 11 years old on his way home from school. I imagine what his day was like. He was maybe late for class. Perhaps, like most boys his age he might have been disruptive. Or maybe he was the studious type and he sat quietly in the corner trying to get every sum right. The end of the school day would have arrived and he would have eagerly grabbed his school things to head home as he had done every other day. He would get home, hopefully have a meal, do housework, then play until bedtime.
Today was different for him though. He never made it home. Instead his body laid on display on the side of the highway. His head in a pool of blood, the rest of his body still positioned on the motorbike he was riding on. Today, instead of making it home he became another statistic; another road fatality. There will likely be no news headlines of his death, instead only the tears of his family and the empty seat in class the next day.
Less than one month earlier a family was devastated. On their way home from burying their daughter who had died suddenly, the unimaginable occurred. The truck carrying countless mourning relatives overturned around a corner sending the almost 50 occupants spilling out of the open back. The deceased woman’s husband and several relatives died. Her 3 children were now orphans.
Unfortunately, stories like these are not as uncommon as they should be. In fact, over one million people die from road traffic injuries annually and 90% of these are in low- and middle- income countries. But why are all these accidents occurring? Why are the poor most vulnerable? It is not difficult to see. There is no need for scientists and analyses. One simply should spend a day in any low or middle income country and one will notice that poor road infrastructure, high speeds, poor vehicle standards and regulation of public transportation, lack of use of seatbelts and helmets all contribute to an environment which is ripe for disasters and fatalities. This is further complicated by lack of both public education and safer alternatives for the poor.
So, while the WHO 2015 Global status report on road safety showed through the use of complicated mathematical formulas that the number of road traffic deaths have plateaued, is enough being done? On the ground it sure does not seem that way. Perhaps there needs to be greater attention brought to the problem. Perhaps there needs to be further activation of all sectors including, health, government, law enforcement and education and they should be held accountable to ensure the risk factors that contribute to road fatalities be lowered. If not, then school boys dying on the side of the road will remain so commonplace that one merely slows down to look then continue on their way.
Brown, the color of your skin,
Still wearing your uniform,
White and green.
Red, the color of your blood,
Which should have been within,
But instead was spread thin,
On the black surface,
Which your head impacted with.
The rest of your body still in place.
White, the color of innocence,
That, you must have been,
While the white sheet hid the last of your suffering.
T.S.Augustine, MD. 16th January 2017. Dedicated to a young school boy that I saw die on the highway in Haiti from a motorcycle accident. R.I.P.
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.
I don’t drive on a real road to work – it’s a dirt one, that fills with potholes whenever it rains. My address can’t be found on maps, so getting services to where I am takes a bit more effort. Many of my patients don’t have running water or electricity and cannot get to the doctor, as transportation and gas money are not always readily available. I went into medicine to do global health, to serve the underserved and where I currently work is in the United States. I live in the Navajo Nation, in Tuba City, Arizona.
Growing up on the East Coast, we learned about Native Americans briefly, to cover the time of Columbus and the founding of the United States. This was a time we recognize as holidays in the US but are gross injustices to the Native American people. However, what we didn’t learn was how those injustices have continued for centuries. From the long walks they were forced to undergo to boarding schools riddled with abuse to the current situation at Standing Rock. The US government has taken from the tribes again and again with no repercussions and no administration that puts a stop to it.
I just got back from Standing Rock early this morning and it was quite a moving experience that I will remember for the rest of my life.
The solidarity that was felt amongst the Water Protectors was shared amongst many of us as we provided comfort and protection to each other. As a social worker, I helped with what I could at the Emotional Wellness tent which was located in the medic area. Two volunteers were manning this particular teepee and the availability was 24 hours / day. Certainly, more can be done. The presence of the US Veterans was quite moving; however, there were many cases of symptoms related to PTSD being triggered.
The experience reminded me in detail about historical trauma that indigenous people feel everywhere. The wounds from recent altercation with the military were felt by many people, including myself. Although I am not of Lakota origin, I felt strongly the history of the area in general and the presence of past traumas. Particularly resonant were the forced removal of the Lakota from the Black Hills and the government’s refusal to honor past treaties, the Wounded Knee Massacre (that occurred twice), the killing of Sitting Bull by “Indian” military police, and the attempts to eradicate the language and spiritual practices of our people. Although I felt safe in the camp, I also felt a sense of uneasiness and heightened anxiety due to the constant presence of the media, helicopters flying overhead, and the presence of a sheriff whose purpose was to remove us from the area. I am no stranger to forced removal and forced relocation as many of our indigenous peoples have felt this from various sources.
The pipeline is described by indigenous people as “the black snake” and this prophecy was foretold by our ancestors. I was painfully reminded again of the ongoing history of treaty violations and the need to stand together and continue to voice our concerns in a peaceful manner.
Although the Dakota Access Pipeline was denied by the Army Corps of Engineers, I feel this is short-lived. I cannot put faith in the government to honor their word due to past atrocities against indigenous peoples. This is shared by many close friends, colleagues, and volunteers. With the imminent administration taking over in one month’s time, I continue to feel uneasy about the entire situation. All I can do is strive to help, to support my fellow people through donations and healing with comforting words, and to pray that our shared goal of diverting the pipeline and maintaining the dignity of indigenous peoples everywhere will be realized.
“I am a servant of Achhami people.” Uday Kshatriya replies to my question: how do you define yourself as a person? Uday is a senior Health Assistant in his homeland of Achham, a remote district in Far-Western Nepal. He has worked for almost a decade with Possible, a nonprofit healthcare organization delivering high-quality services free of charge in rural Nepal. I sat down with Uday to learn about his life, his motivations, and his experience as a healthcare provider in Achham.