When Culture and Poverty Trip Up Care

Photo by Graham Ramsay Ellen Rothman

Although Effie was only sixty-six, she had aged well beyond her years. She emitted a faint rumble with each exhalation, and her head bobbed slightly up and down on her chest as she dozed. Her large body slumped amorphous in her wheelchair.

I gently woke her to examine her for the umpteenth time. Effie had become a regular in our small emergency department on the Navajo Reservation. Her complaint that day, as always, was stomachache. Her family members who brought her in had already left. Even through a translator, we got only that she felt “somehow.”

Effie had many years of uncontrolled diabetes. As I paged through the chart thick with emergency department visits, I realized that it had been more than a year since she had seen a primary care physician. Her family brought her for emergencies only, insisted that her medication be refilled, and failed to make the arranged follow-up appointments. She bounced between the homes of her various children, and none of them ever seemed confident of her medical regimen.

Heart Attack in the Making
Abdominal pain in an older woman with diabetes could represent many problems, from simple acid indigestion to nonspecific symptoms of heart disease. In her chart, there were pages and pages of electrocardiograms. She had had several brief hospitalizations, and although I saw a few referrals for cardiac stress testing, I did not see that she had kept any of these appointments.

I dutifully checked her electrocardiogram and some blood tests—all were normal, just like the countless other tests in her folder. I gave her an antacid and some pain medication, which helped enough that she felt better by the time her family finally returned to pick her up. I set up another appointment with a cardiology specialty group that specialized in the care of Native Americans.

A few weeks later, I returned from a vacation to learn that Effie had been hospitalized with a massive heart attack. She had not kept her appointment with the cardiology group. She suffered a cardiac arrest and required a prolonged resuscitation. Miraculously, she survived the event and subsequently underwent a quintuple bypass. She was hospitalized for more than three months.

When I saw Effie back in our emergency department again, she was a wisp of her former self. Again, she had belly pain. This time, I rechecked her heart, and everything was normal.

Her daughter folded her arms across her chest and stood, towering over me. “Well, we went to Tucson, and come to find out, all those years with stomach pain, it could have been her heart all along.”

Systemic Ills
Recent articles in The New England Journal of Medicine have pointed to the shortcomings of the federal Indian Health Service. American Indians have worse health outcomes than the general public. The mortality rate from diabetes reported by the service in January 2005 was 213 percent higher than the general public, which is clearly unacceptable.

Critics have pointed to the financial disparities as a primary issue contributing to poor health outcomes. The Indian Health Service spends approximately half of what the average health insurance company pays per patient. Nevertheless, from my perspective, the disparities in health have less to do with health care–funding shortfalls than with the broader, and more challenging, issues of rural poverty and cultural barriers.

On the Navajo Reservation, as on other reservations, acute poverty and extreme geographic isolation combine to produce daunting obstacles to receiving adequate health care. For instance, the Navajo nation has the highest number of dialysis beds per capita of any area in the country. Yet, because the distances are so huge, many of our patients still have to travel 40 or 50 miles to reach their site. The lack of a ride is the most frequent reason patients give us for their missed primary care appointments. Instead, they come to the ER on whatever day they can find a ride.

Cultural barriers compound the complexities in providing care for our indigent, far-flung population. Many Navajos are at best wary of Western medicine after a long and troubled history with white doctors. The father of one of our patients declined heart surgery for his daughter, insisting that we planned to open her up to experiment on her without fixing the defect.

Once our patients reach the major centers, many do not speak English and have difficulty understanding the care they receive. Another of my patients, dying of terminal prostate cancer, described his palliative radiation treatment as follows: “I was in Flagstaff for five weeks. Every day they took me to a big machine that went click click click all around me, then they told me I was all better.” He did not keep any further appointments with his oncologist.

Effie’s younger sister Mary had begun frequenting our emergency department for recurrent abdominal pain. She, too, has had uncontrolled diabetes. And also like Effie, she fails to keep her primary care appointments. On a recent evening, I saw her again for belly pain. Although the initial tests for her heart in the ER were normal, I was suspicious. Further testing during her hospitalization showed that she had indeed suffered a small heart attack. She underwent bypass surgery, which was complicated by severe kidney failure. Now she sits in a Phoenix nursing home, biding her time until she recovers enough to return home to the rez.

—Ellen Rothman, HMS ’98, practices in northern Arizona
on the Navajo Reservation.

The names used in this column are pseudonyms, and the opinions expressed are not necessarily those of Harvard Medical School, its affiliated institutions, or Harvard University.

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