Native American Health Care Is a Challenging but Solvable Puzzle

In honor of National Native American Heritage Month, ABFM is examining health disparities facing the American Indian community. Dr. Carlos Gonzales recently spoke with ABFM to discuss the current state of family medicine for American Indians.

Dr. Gonzales is a member of the Pascua Yaqui tribe, an ABFM Board Member, and the Assistant Vice President of Indigenous Affairs at the University of Arizona Health Sciences Center- Global MD program. “It’s important for those interested in rural care to realize the reality facing indigenous populations. Understanding how they live is the first step in finding ways to address and overcome challenges,” he said.

Native Americans can be somewhat cleanly split into two groups: those who live in urban centers and those who still live on remote tribal reservations.

Those in urban centers have unique struggles. They’re facing disenfranchisement and the feeling of loss being separated from their tribal homelands. Some return to the reservation for traditional healthcare, while some struggle and remain in the urban environment.

Those on tribal reservations have the priceless benefit of living among family and friends in a culturally respectful community. However, their health care is more challenging for several reasons.

“Many tribes have members who don’t speak English, or only speak partial English. My tribe is predominately Spanish speaking,” said Dr. Gonzales, who has almost 40 years of medical experience. “You have to be willing to accept that and find other ways to communicate.”

Dr. Gonzales pointed out that reservations may be extremely limited on basic amenities we take for granted. Some don’t have potable water or electricity.

“There are really third world situations happening that the rest of the country doesn’t even know about. For example, I may want to prescribe insulin for a patient. That needs to be refrigerated,” he explained. “If you’re a physician who doesn’t know certain reservations are without electricity, then you’ll write a prescription for insulin. The patient will be polite, but they’re never going to get it filled. They have no way of taking care of the medicine.”

The problems aren’t magically solved for those Native Americans with access to water and electricity. There are a variety of cultural hurdles to overcome including, but not limited to, significant racism and generational trauma. Many Native Americans were removed from reservations as children and forced to assimilate to mainstream society in boarding schools. All these forces combined to create a people displaced within their own country.

“Hunters had to stop hunting and become farmers. Some farmers lost their water so it could be diverted to Phoenix and Tucson. Then, these people who were established farmers had to turn to subsidies from the federal government,” Dr. Gonzales said.

“Their previous diet was very healthy. It was corn, squash, beans and lean meat like rabbit and deer. Suddenly, they switch to fatty meat like beef and lamb. They start eating starchy wheat and rice. They stop exercising. They gain weight, and that leads to diabetes, hypertension, and heart disease.”

Dr. Gonzales pointed out that many tribes have life expectancies 10 years less than that Caucasian Americans. “At the age of 68, I’m one of the elders. I see myself as someone who is young, but that’s my reality. These health care issues are killing us early and killing us young.”

He mentioned that the trauma within the Native American community sometimes encourages men and women to use alcohol or drugs for self-medication. All of these challenges refract onto each other and create a culture searching for a way forward. What is a young physician entering rural practice to do?

“Listen to people. If possible, get to know your patients personally. Perfect your examination skills and don’t rely on technology,” said Dr. Gonzales.

“When discussing the care of Native Americans, there’s a concept of non-compliance, or ‘These individuals don’t want to get well.’ It’s not that. They’re simply dealing with a lot of other issues.”

Health care of Native American communities will continue to be a challenging puzzle to solve if physicians see themselves as distinctly separate from these communities. Rural physicians must embrace the lives of the communities they serve to heal individuals one by one.

Thank you to Dr. Gonzales for his insights into Native American culture, as well as nearly 40 years of family medicine care in the American Southwest. We’re lucky to have you.