TUBA CITY, Ariz. — The hospital stands in the midst of a world of traditions: of Hopi clowns dancing around centuries-old villages, of Navajo elders tending their sheep, of customs as ancient as the winds that buffet the mesas and desert lands that stretch to the horizon.
And so, even at this center of modern medicine on the 27,000-square-mile Navajo Nation, it's not unusual to see Native medicine men attending the sick.
They might perform ceremonies to rid patients of bad spirits, or offer song and prayer in blessing a room where someone has died.
Moving between the two worlds is Joachim Chino, M.D. A Navajo-Acoma, he grew up on the reservation where the practices of medicine men often came first. He is well aware of how the cultural beliefs of his patients can affect what he does.
Chino, 37, modest and soft spoken, makes rounds wearing a white lab coat, a stethoscope stuffed in one pocket. He carries the authority of chief of surgery at the Tuba City Regional Health Care Corp., a major medical facility on America's largest Indian reservation.
Yet he often avoids eye contact as he consults with his patients. He speaks in the third person when delivering a difficult diagnosis. And unless he is asked directly about the chances for survival, he doesn't say.
Strongly held Navajo cultural tenets do not allow directly linking a person to an illness and its consequences. To do so could be interpreted as wishing harm.
"It just delays their fear — not mentioning death and dying specifically in their situation," Chino said. "I think it's helpful."
But cultural deference goes only so far, he said. Ultimately, "it's just like going to see any other surgeon."
And that's as it should be, said Navajo medicine man David Begay. Patients seek medicine men for encouragement and to restore their spirituality, yet they also must put faith in modern doctors.
"Any way to get healed, any way to get help, I think that's the ultimate thinking here," Begay said.
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Bridging the cultural chasm between physicians like Chino and traditional healers is seen as essential for improving care on tribal lands, where hospitals and clinics struggle to keep doctors. It is the oft-expressed hope of Native elders that their talented students will leave the reservation to get an education, then return to help the people.
Health reform comes to the tribes
Tucked into the larger health care reform passed by Congress was reauthorization of the Indian Health Care Improvement Act. The bill addresses recruiting and retaining physicians and other care providers, including mentoring programs, workplace support systems for Natives in the medical field, and increased attention to scholarship and loan programs.
The return of even one medical graduate to a tribal community can make a huge difference in the quality of care, said David Bear, assistant dean of admissions at the University of New Mexico's School of Medicine.
"It doesn't take a whole lot," Bear said. "We're sometimes just focusing on going from zero to one."
Chino was among just a handful of Indian students studying medicine at UNM a decade ago. Last fall, a record nine Native students were admitted to the four-year program in Albuquerque. The gains in recruitment are small, given the program's 300 students, but meaningful with the university's proximity to Native populations and its vigorous outreach.
The universities of Minnesota, North Dakota, Washington and Oklahoma produce about 25 percent of all American Indian physicians, said Dr. Gerald Hill, a board member and past president of Association of American Indian Physicians.
University officials say the biggest barrier to getting more tribal members to pursue careers as physicians is showing them that goal is within reach and persuading them to leave the reservation.
Native physician role models can help.
Missy Begay, a self-assured young Navajo woman and second-year medical student at UNM (not related to David Begay), was in high school in northwestern New Mexico when Chino visited to encourage students to follow his lead.
She was drawn immediately to the young doctor's demeanor.
"He came in in scrubs and he was talking about some sort of surgery and the brain, something just really far out, just beyond what I could even imagine," she said. "He seemed just really passionate about what he was doing."
With her unique family heritage, Begay was ready to be convinced. She is the daughter of another UNM medical school graduate and the granddaughter of a medicine man.
Some of her earliest memories focus on the people who came to her grandfather, seeking diagnoses for their ailments. Her role was to serve coffee before her grandfather's private consultations.
"Afterward, they would do this ceremony for the person," she said. "As a child, I remember being really curious about that."
Arriving at UNM medical school, the Stanford graduate was already prepared for the potential clash between cultural tradition and Western medicine. The first-year anatomy class, which calls for dissecting a cadaver, can be particularly challenging.
Navajos are told to stay away from dead bodies and from burials. Begay said her community back home conducted ceremonies to prepare her for the class.
Her elders understood that the bad parts of taking the class would be outweighed by the good of her becoming a doctor, she said, and so they were willing to help her, even though it pushed her farther away from tradition.
"You're going to be seeing the human body inside and out," she said. "If you're curious, that's like the height of all curiosities that you can do. But as a Navajo person, you sort of had to compromise some of your identity and some of your beliefs and put that aside."
Gayle Dine'Chacon, a Navajo and director of UNM's Center for Native American Health, described the double doors leading into UNM's anatomy lab as a physical and spiritual barrier that she had to cross when she was a medical student there 20 years ago.
"Physically having to open those doors and walk through from this side to that side for me was a transformation, to go from this side of the doors to entering almost another world," she said. "It can be very soul searching when you think about what you are doing."
Twenty years later, Dine'Chacon said she still prays and has ceremonies to protect herself from the effects of that class.
A personal mission
In the Tuba City hospital, Chino walks past people adorned in silver and turquoise jewelry, their hair wrapped in buns. Women in traditional floor-length velvet skirts and men in cowboy hats talk among themselves in their native language as they wait to be seen.
Although Chino has fulfilled his commitment to the hospital under an Indian Health Service scholarship, he chooses to remain in Tuba City, a wind-swept community on the western side of the reservation that borders the Hopi reservation.
The equipment at the hospital is by no means state of the art. There are no private rooms — patients instead are separated in larger rooms by curtains with little space for visitors.
American Indians and Alaska Natives are three times more likely to die from diabetes, have a life expectancy of nearly five years less than other Americans and suicide rates twice that of the general population, according to the IHS.
Diabetes is the No. 1 medical condition treated at Tuba City along with its complications, including renal failure, vascular and heart disease and strokes, said chief medical officer Alan Spacone. Alcoholism, diseases related to uranium mining and contamination, and crash injuries along the reservation's poor roads also are prevalent here.
The dismal statistics are motivating to Native doctors and medical students alike.
"It's a very personal, emotional link that we have to our community, where we see people are really in a crisis," Missy Begay said. "It's horrible. And we don't even know if we can alleviate some of that because there's so few of us."
The hospital treats an average of 320 patients daily. Many travel hours to get here. Sixty physicians are associated with the hospital, including five who are American Indian.
Hospital staff members participate in the community and the culture, many of them helping out with youth sports or other activities.
"I think it takes a special group of people to live here, stay here," Chino said of his colleagues.
The Native healers and M.D.s are hardly ever in the same hospital room at the same time, and do not typically consult.
One exception is birth. A medicine man might be performing a ceremony to ease any complications and establish a foundation of beauty, harmony and strength for the baby. Meanwhile, a medically trained midwife is checking on the mother and may deliver the baby before the ceremony ends.
Family members might then request the placenta and umbilical cord so that it can be buried on the reservation, establishing the baby's residency and reaffirming a tie to the land.
"They really do try to complement one another," Tanya Riggs, the hospital's performance improvement director, said of the doctors and medicine men.
When cultures clash
Even so, minor conflicts arise. The most traditional of patients, for example, might not immediately schedule follow-up appointments as instructed by their physician if they've had a ceremony with a Native healer who has instructed them, for example, not to cross water.
But, said Riggs, they then return with a sense of confidence that they will heal.
Missy Begay has already learned that treating Navajo patients can require more time. The two-minute introduction to patient visits she was taught at UNM can stretch into 10 minutes as she is asked about her parents, her grandparents, her traditional clans, and hears in return stories about people who might know her. Only then do some patients become comfortable enough with her to discuss their medical issues.
Being treated by a Navajo gynecologist made a big difference for patient Lorraine Benally. The soft-spoken 47-year-old from the Navajo community of Kayenta was about to give up on health care after being bounced around from doctor to doctor, who left her fearful that she couldn't overcome uterine fibroids.
Dr. Jennifer Whitehair changed that.
"She understood what I was going through," as a Navajo and a woman, Benally said. "Just knowing that she cares enough to come back to the reservation and help us, that means a lot. It's heartwarming."
In a hospital room with nurses moving in and out, Chino prepares Kelsey Begaye for surgery, detailing how many of the procedures have been done and the time it will take.
Begaye, 59, says little, sitting with his hands folded in front of him and never looking at Chino. He later acknowledged that avoiding eye contact is an indelible link to the culture, even though he grew up far from the reservation, in Los Angeles.
But as the former president of the Navajo Nation whose vice president was the first Navajo surgeon here and served in the same role as Chino, Begaye knows how inspiring the work of American Indian doctors can be for patients and students across the reservation.
"Even back then we were encouraging our Natives to go to school, learn what they can and come back to the reservation," he said. "Me going through this procedure just confirms that's happening. It's a good feeling to be in somebody's care who you know is Native."
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