Nurses are accustomed to assisting each other in order to get the job done. But for many of us, however, working without electricity, running water, or educational materials is far from reality for most US nurses. While in Boston for the 2011 Oncology Nursing Society (ONS) Congress, we had dinner with some fellow home care cancer specialists. Our dinner conversation revealed that such hardships actually exist! They occur on a daily basis and in a variety of settings. The reservation of the Navajo Indian Nation of Arizona, Utah, and New Mexico is one example.
Among our dinner group was Linda Cothron, MS, ARNP, OCN, Nurse Practitioner of Kayenta Public Health Nursing (now retired), and Ellen Choyou, CNA, a senior community health worker and certified nursing assistant for the Navajo Nation Division of Health. Both nurses are also ONS members. The problems and hardships the Navajo nurses described were nothing most of us might ever experience. Their account regarding a US health care system may be an eye opener for many readers. This is their story.
The poverty level here is amazing. I have heard it referred to as the “third world in the first world.” The area we cover is called a service unit; the Navajo Nation is divided into eight service units. We serve about 20,000 clients. The difference between the Navajo Nation Division of Health and other public health programs is that the other programs are either federal programs or part of private corporate health care organizations, having just become independent of the federal system. We are actually employees of the executive branch of the Navajo Tribal Government, which depends on the federal system for funding, and therefore, we have fewer resources than if we practiced elsewhere.
We are able to get most medical supplies, but newer items such as the samples we get at conferences do not come our way. Federal government programs cannot accept donations, including samples from drug companies, so we do not get visits from drug representatives or information about new products. In addition, we cannot provide cancer care such as chemotherapy or radiation on the reservation. Our clients have to travel to Flagstaff, Arizona (3 hours away), Farmington, New Mexico (3 hours away), or Phoenix, Arizona (6 hours away), for such care.
Because we are not federal employees, both Ellen and I can accept samples of products for mucositis, vaginal dryness, and metallic taste from product representatives we meet at conferences. We pass them on to a doctor who we know will distribute the products to patients who need them.
We have health fairs to educate our Navajo clients on screening, resources, commercial tobacco risk, sun screen, etc. We distribute anything we receive among the Navajo people. It may be clothes; toys; school supplies; and home-care goods such as detergent or dish soap. Whatever is given to us. The only restriction is that all products must be alcohol-free. Alcoholism is a serious health care issue here, and some clients have been treated for drinking alcohol-based hand cleaner.
The group of oncology nurses from the Philadelphia area were astounded by the Navajo nurses’ story. They wanted to learn more about the Navajo Indian Nation so they could implement a plan to assist the nurses’ efforts to provide health care for the Navajo people. After much discussion and banding together with several local ONS chapters and contact persons from the Navajo Nation, including Ruth White, RN, community health nurse and supervisor with Kayenta Public Health Nursing, the group compiled a list of items people on the reservation needed to provide care. Health care education materials specific to the needs of the Navajo people, medical supplies, and many other items not readily available on the reservation were collected, including gas cards to help patients and families who needed to travel for their routine oncologic care.
WHO ARE THE NAVAJO NATION?
The Navajo Indian Nation of Arizona, Utah, and New Mexico is the largest US Indian reservation. It covers an area of more than 27,000 square miles—roughly the size of the state of West Virginia—in Arizona, New Mexico, and Utah. The reservation population fluctuates but is estimated to be approximately 200,000 people. Due to the remoteness of their homes, the Navajo people have been able to maintain much of their native culture, producing a significant non-English speaking population that lives in a traditional lifestyle. Generally speaking, Navajo people do not live in villages, which is common in some other Native American societies. Their traditions did not dictate this practice; however, Navajo people have always banded together in small groups, often near a source of water. Their wide dispersion across the reservation is due in part to the limited amount of grazing land, and the limited availability of water.
Health care for Native Americans in general has never been funded at a level comparable to that of the general population.1 In fact, in 2009, American Indians in the Indian Health System (IHS) system received just 55% of required per capita funding.2
The 2010 National Healthcare Disparities Report states that health care quality and access is suboptimal, especially for minority and low-income groups; and although quality is improving somewhat, disparities in preventive services and access to care are not. Native Americans younger than 65 years have a 1.7 times higher risk of not having health care insurance and a 1.6 times higher risk of not receiving the standard colorectal screenings.3
A CALL TO ACTION
A plan was formulated within weeks of our brainstorming a strategy to help the Navajo nurses. A request was sent to all local chapter members for donations of books, up-to-date medical journals, teaching models, and other supplies. The response was overwhelming. Boxes and boxes of supplies were received for the Navajo people. The coordination was seamless. Phone calls were made to our contacts to check for any additional needs, and updates on the project were indicated as the needs arose. Two ONS chapters sold tee shirts with a Navajo tapestry made by the reservation residents printed on them to raise money to support the health care program’s activities.
Our efforts to help the people of the Navajo Nation has made just a small difference in their lives, but with their guidance on their ongoing health care system needs, we hope to continue this support, thereby supporting more than just the cancer patients we see daily in our own communities.
SO MUCH MORE CAN BE DONE
The prevalence of health care disparities exists, along with a newly developed focus on minimizing them. Access to a high-quality system of health care may reduce these disparities, but this may be a long time coming. The overriding point of this service project, and others like it, is to know that most people are unaware of the many groups in need of assistance throughout this country. Helping others only takes someone speaking up on an issue and a few others willing to assist to find solutions. Whether the care is provided on an Indian reservation, in a rural farming area, Appalachia, or an urban center, there are issues that need to be raised and addressed in order to resolve health care disparities. Clearly, much more work will need to be done.
The challenge for us all is to look around; ask questions such as, “Is there something or someone I can help?”; and to work together. It can start with one person or one idea, but if local chapters take on the service mission, no one person works alone. Nurses can make a difference while the public health system confronts issues of equity. ONA
Rosemarie Tucci is an oncology program manager at Lankenau Medical Center in Wynnewood, Pennsylvania. Patricia Frank is a retired home care nurse from the University of Pennsylvania in Philadelphia.
1. Dixon M, Roubideux Y. Promises to Keep: Public Health Policy for American Indians and Alaska Natives in the 21st Century. Washington DC: American Public Health Association; 2001.
2. Indian Health Service. FY 2009 IHCIF allocations—Navajo. http://www.ihs.gov/NonMedicalPrograms/lnf/2008/IHCIFAllAreaAllSites5-8-08.pdf. Accessed August 31, 2012.
3. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010 National Healthcare Disparities Report. Rockville, MD: Agency for Healthcare Research and Quality; 2011. AHRQ publication 11-0005. http://www.ahrq.gov/qual/nhdr10/nhdr10.pdf. Accessed August 31, 2012.