Last Wednesday, I had the opportunity to go on reservation home visits with a Navajo Community Health Representative for the Teesto Chapter House of the Winslow Service Unit. In 1967, the US Office of Economic Opportunity initially funded the old “Community Health Aide Program”, which was eventually transferred to the Indian Health Service as the Community Health Representative Program, as the first tribally contracted program. There are over 1,400 CHRs representing over 250 tribes within the United States. In the Navajo Nation, there are 8 different Service Units, each made up of dozens of Chapters. Unfortunately, there is too little funding to support the need of CHRs in the communities. On average, there are about 9 CHRs per service unit and each month one CHR will see over 35 patients on average.
Leaving at 6:00am, I left Gallup to arrive at the Teesto Chapter House 10 minutes before 8:30am to meet the CHR I would be shadowing for today. She arrived promptly on time, and we would spend the next 6 and a half hours driving over 50 miles to check on 10 of her clients. The purpose of my visit was to gain an understanding of the CHR’s work and to learn more about their home interactions for the design and development of a training module I am making for them on common brain disorders, such as Parkinsons and Alzheimers. In that one day alone, we visited patients who had gall stones, a developmental disorder, dementia, a hip fracture, a tumor, cancer, a blood clotting problem, knee pain, parkinsons, depression, and tons of diabetes! It was a heavy day, even for a CHR. Each house, and by house I mean a reservation home, which city-dwellers might be apt to call a “shack”, the CHR would walk to the door, knock, be welcomed in, and greet the client with a good “Ya-ah-te” or hello. Being bilingual the CHRs are about 35-55 and have the cross-generational experience to be able to relate to both elder and their “americanizing” grandchildren. While she talked, she took the temperature, blood pressure, heart rate, oxygen saturation, respiratory rate, and blood sugar for each patient. Since diabetes is so prevalent on the reservation, the blood sugar test became another component of her normal vitals check up. Unfortunately, I was seeing sugars which were almost all very high, even if some just ate, or didn’t take their medications yet. Patient’s health literacy varied widely, but was universally low for the “elders” and better for their children. Often elders with worse conditions would be cared for by their children, grandchildren or contacted home care provider. Most elders refused to leave their home to go to available nursing homes. Wanting to stay with their sheep was a common concern for many. And even for the patient’s family members who struggled to rotate their 24 hour shifts, I’ve heard some families prefer their grandparent to stay in their reservation homes so that money saved from nursing home care can be distributed through the family. With both pros and cons of all health care systems and community dynamics, I found myself shocked by the disease burden among just 8 patients that we visited that day! During one visit, my CHR became very silent and let me talk with the family member because her client’s struggle reminder her of personal experiences. At the end of the visit, I wasn’t sure if it was appropriate to hug in Navajo culture, as I know it isn’t in conservative Japanese cultures, but I gave my CHR a good-bye hug because I was so honored and blessed to have followed her that day. Without her, many of her clients, who do have access to clinics and hospitals, would be lost due to the lack of their own health literacy as well as culturally and linguistically insufficiencies of their providers. Even beyond their health care services, the CHRs help connect the broken infrastructure and communication systems that their patients often get trapped in. Just finding a car to get a ride in to buy the “insure” drink for a patient, fill their water tank, or get firewood for winter can be an impossible mission for some. Although CHRs are not allowed to transport patients, they find themselves being put in “emergency” or “ethical” situations that call for them to get approval for exceptions to these policies. My CHR even has had to walk around and pick up firewood for clients on several occasions. So if I haven’t overwhelmed you enough I should add, that these CHRs attend regular program, case management, and training meetings as well as regular health fairs. Because of all this, CHRs are at increased risk of burnout and therefore take care of themselves, while having an inner strength that shows itself in the field. These truly are an amazing group of individuals who are committed to the health and well-being of their communities.
*Authors Satterfied et al (2002) referenced a study that showed that identification with patients showed greater influence on improving patient behavior than any other factors such as cultural competence, positive relationship, etc. With my one day anecdotal experience and statistical evidence, I will forever be an advocate of these patient advocates.