Volunteer Opportunities Available with Indian Health Service

Despite looking out for cases of Hanta Pulmonary Syndrome, Bubonic Plague and rattlesnake bites, Christian Arbelaez, MD, MPH, was most startled by the number of injuries related to alcohol that Navajo patients presented with at an Indian Health Service hospital in New Mexico.

“So many of these traumas could have been prevented,” said Arbelaez, a BWH Emergency Medicine attending physician who volunteered one week last month to treat patients and educate staff at Gallup Indian Medical Center, one of the largest Indian Health Service (IHS) hospitals in the U.S.

This spring, the Physicians’ Council chose to support a volunteer outreach project with IHS as part of the Brigham and Women’s Physician Outreach Program (BWOP). Phyllis Jen, MD, of the Department of Medicine, and Amy Judd and Howard Hiatt, MD, of the Division of Global Health Equity, submitted the project proposal, citing IHS’ clinical, administrative and educational needs at its hospitals in Gallup and Shiprock, New Mexico.

Jen, Judd and Hiatt gauged the health care needs in Gallup and Shiprock with an April 2007 trip. “The trip confirmed the urgency of the situation there,” Jen said. “The resource needs of these Americans are similar to the needs of people in many developing countries.”

Jessica Dudley, MD, chief medical officer for the BWPO and co-chair of the Physicians’ Council, said the Indian Health Service hospitals are a place where many physicians can make a difference. “For BWOP, we wanted a place where all interested physicians, no matter their specialty, could contribute for a week or two and make an impact,” she said. Physicians from Dermatology, Gynecology, Dental, Radiology, Pathology, Primary Care and Emergency Medicine already have expressed interest in volunteering through this program.”

According to the U.S. Department of Health and Human Services, American Indians and Alaska natives die at higher rates than all other Americans from alcoholism, as well as tuberculosis, diabetes, accidents, homicide and suicide. Native Americans have limited access to preventive services including cancer screening and immunizations, as well as chronic disease management, and their life expectancy is six years shorter than for the general U.S. population.

Both the 55-bed facility at Shiprock on the Navajo reservation and the 99-bed hospital at Gallup have adequate equipment, medication and supplies, but they are challenged by a shortage of staffing. The Indian Health Service reports a nearly 15 percent vacancy rate in essential clinical positions.

Arbelaez, the first physician to volunteer through BWOP, worked nine-hour shifts in the Gallup ED, which enabled other physicians to spend time completing paperwork and other responsibilities that they simply cannot get to because there is no coverage. In addition, Arbelaez lead on-the-job teaching and training for clinicians in Gallup, showing them newer technologies and techniques in use at BWH.

“We can help them simply by covering shifts, but we want to also help them through teaching to build their infrastructure,” Jen said. “Physicians who go will spend part of their time doing a grand rounds presentation or educating staff one-on-one, like Christian did in the ED.”

For example, physicians there seek training to perform echocardiograms. “If one of our doctors could train them, it would greatly enhance their ability to care for patients,” Jen said.

Navajo patients who receive care at these hospitals face many socioeconomic obstacles, including the great distances they must travel across vast New Mexico to receive care. About 37 percent of Navajos live below the poverty line, according to the U.S. Census Bureau. One third live in homes without plumbing, and two thirds do not have telephones. In New Mexico, nearby uranium mining leads to severe lung disease among many residents.

Navajo cultural preferences also may create barriers to care, as Arbelaez quickly learned. “They are a very stoic people, so they typically hold on to pain and wait longer to be treated for it than people here,” he said. “I had one woman with abdominal pain who was very reluctant to receive morphine. I had to build trust with her before she allowed it, but she was much more comfortable because of it.”

During a trip last August, Jen treated many patients with painful diabetic ulcers. “Many of them have been living with these ulcers for months,” she said. “One was so severe that the patient needed to be admitted.”

Physicians who go should be aware of cultural sensitivities. “Many Navajos believe that if you talk about a bad outcome, it will happen. It’s almost like a curse you put on them,” Arbelaez said. He urges physicians to use caution when describing potential health outcomes.

Arbelaez learned to talk about potential outcomes in the third person when treating patients and using interpreters as much as possible. “You have to be really thoughtful about wording,” he said. “Talking about death is another cultural taboo, although one that varies throughout the population.”

Arbelaez noted the ease with which he was able to begin contributing almost immediately upon his arrival in Gallup. “You complete and send some paperwork before you get there, and then you finalize the credentialing process and have an orientation on the first day,” he said. “After that, it’s very easy to begin caring for patients and working alongside staff right away.”

The Physicians Council aims to make it easy for physicians by streamlining the logistics of planning a trip like this, such as the flight and lodging. “New Mexico is easy to get to and safe, and there isn’t a significant language barrier,” said Brian Bilchik, MD, chair of the Physicians’ Council. “The opportunities for physicians to create a lasting difference here are boundless.”

The program is further strengthened by pre-existing relationships between the Indian Health Service and BWH and HMS groups. The BWOP is coordinating with these groups, including the Internal Medicine residency program, which sponsors residents to complete rotations at Indian Health Service facilities each year. Jonathan Iralu, MD, a former BWH chief resident in Medicine, now works full time at Gallup and has a research appointment in the Division of Global Health Equity at BWH. The Harvard University Native American Program (HUNAP) offers resources and educational experiences to students and Native American communities. Thomas Sequist, MD, of the Department of Medicine, hosts Native American college students at BWH each summer, too.

“We are greatly indebted to the Native American community,” said Hiatt. “Here is an opportunity for a small expression of our feelings.”

Already, about ten physicians have signed up to volunteer through BWOP. “We hope some will go time and again to build a long-term relationship with the facilities,” Jen said.

Arbelaez certainly will.

“This outreach program is truly in line with BWH’s mission,” he said. “I urge all physicians to go to New Mexico and help by teaching and caring for patients. I definitely plan on going back.”

Those interested in volunteering or learning more about this opportunity should contact Phyllis Jen.