Beulah Allen, MD, reports a magical, all-night rain has doused her Arizona ranch, which she shares with a cousin who lives a mile away and is her nearest neighbor.
"It smells just wonderful here. This isn’t desert. I’m up 7,000 feet. My house is at the base of a mountain."
And this is precisely where she wants to be.
"I’d been trying to get back to the reservation most of my life," says the 61- year-old internist. She is the chief medical officer at the Indian Health Service’s Tsaile Medical Health Center on the Navajo reservation in Arizona’s northeastern corner. While she knows of many Navajo doctors who did not return to the reservation following their medical training, Allen felt an irresistible pull. "I’d left the reservation when I was so young, and I needed to come back to grow up as a Navajo woman. I needed to learn the language. I needed to learn the philosophy."
Born to the first certified Navajo nurse employed on the reservation, Allen remembers spending much of her childhood in hospitals while her mother worked. That experience, she says, most certainly influenced her career choice. Many of the physicians her mother worked with came from Cornell University, where she enrolled in medical school at age 21.
But two marriages, two divorces, three children, and traveling and living throughout Europe and the United States interrupted her training. Then, in the late ’70s, nearly 20 years after she first entered medical school, she learned about a fellowship through the Office of Indian Education that would fully fund her medical school training.
She re-enrolled, this time at the University of Florida in Gainesville, completed her residency in the Tucson Hospital Medical Education Program, and returned to the Navajo Reservation in 1984 to begin her practice with the Navajo Area IHS, one of 11 service areas established throughout the United States dedicated to providing health care for Native Americans under the auspices of the federal Department of Health and Human Services.
"What I really wanted to do all my life is settle here," Allen said. "There’s no way I’m going to leave again."
Her story of departure and return is also the story of her people. The Navajo Nation - 215,000 strong - is the largest Indian tribe in the United States, and it has the largest reservation. The reservation encompasses nearly 26,000 square miles of the Great Basin Desert of northeast Arizona.
Interstate 40 (formerly Route 66) is roughly the southern edge, the Grand Canyon is on its western border, and it includes a strip of northwest New Mexico and a small portion of southern Utah. It includes most of the region known as the Four Corners area, where Arizona, New Mexico, Colorado
and Utah now meet.
Home to some of the continent’s earliest inhabitants, the reservation guards the abandoned cities of the Anasazi people who built their homes into canyon walls. They appeared some 2,500 years ago but had been gone at least 200 years by the time Spanish explorers arrived in the mid-16th century.
The Hopis are widely thought to be descendants of the Anasazi. About 10,000 members of the Hopi tribe live on a 4,000-square-mile reservation within the Navajo Reservation.
Although the Navajos believe they’ve always lived in the Southwest, anthropologists think Navajos and Apaches are members of the Athabascan language group which migrated from Asia to the northwest Pacific coast of North America 1,300 to 1,600 years ago, then migrated south from Canada. There are definite signs dating their presence in Arizona from 1450 to 1550. Sketchy Spanish records indicate failure of Spanish missionaries among the Navajos and sporadic, but increasingly persistent warfare with them.
Eventually, the Navajos’ reputation as raiders pitted them against the United States government, and they became the target of an all-out campaign to relocate and re-educate them at the Bosque Redondo on the banks of the Pecos River in New Mexico.
Brigadier General James H. Carleton, who hatched the relocation experiment, wrote of the plan’s objectives in a report to the 39th Congress: "Soon they will acquire new habits, new ideas, new modes of life; the old Indians will die off, and carry with them all latent longings for murdering and robbing; the young ones will take their places without these longings; and thus, little by little, they will become a happy and contented people, and Navajo wars will be remembered only as something that belongs entirely to the past."
Mountain man Kit Carson was commissioned as field commander to bring the Indians in to the Bosque Redondo. Because only a few bands complied with orders to surrender, Carson invaded the Navajo country with a small army that, when met with resistance, destroyed the crops, rounded up the sheep, and shot the Navajo men. On March 6, 1864, 2,400 Navajos began the "Long Walk" to Bosque Redondo. By May an additional 3,500 were on the way. Although an undetermined number successfully hid in the canyons and in the mountains, some 8,500 Navajos were eventually removed from their homeland.
Dispirited and homesick, the Navajos failed to adopt the lifestyle planned for them. They reluctantly took up farming, and then had their crops attacked by drought, hail, and worms. In 1867 the Navajos refused to plant crops, and during the winter several hundred deserted. The Bosque Redondo scheme was officially abandoned in 1868 as a costly failure, and a treaty was signed permitting the Navajos to return to a new reservation in their former homeland.
Although they’ve had their homeland back for more than a century and are full citizens of both the Navajo Nation and the United States, the Navajos’ medical issues reflect an ongoing culture clash with the world beyond their reservation.
While national unemployment rates remain below five percent, for the Navajo it stays around 50 percent. Crushing poverty, in which extended families pool resources to buy gas to go to town, leaves its indelible mark on people’s lives.
Allen sees lots of infectious disease and trauma in her clinic, and hypertension and early stages of coronary disease are showing up more frequently, she says. Diabetes is a concern among the Navajo and is particularly prevalent in the southern Arizona tribes, she says.
"There is a very heavy push for health education to teach people about nutrition and exercise. There are organized walks across the reservation, 5K and 10K races, and it’s not just the kids who are participating. There are a lot of older people too," Allen says.
"One of the hardest things is for people to take responsibility for their own health, and that’s no different here than any place else. But I do think there’s more interest on the reservation in sitting still and enjoying food," she says.
Allen also sees a difference in the way appointments are kept. "In off-reservation society, you set up appointments and are expected to keep them. But here, you set a time and a place, and you work toward that, but there is no hard and fast commitment.
"That’s partly engendered by the land we live on. In the wintertime, it can be very hard to get around," Allen says. "And sometimes, activities come up that depend on the weather or having people around to help you, like planting, sheep sheering and cooking for the people who are helping you. When that happens, a lot of times people don’t come in for their appointments."
Young doctors often are frustrated by broken appointments, she says, until the public health nurses take them out to see people’s living conditions. Missed appointments also cause people to run out of necessary medications and can result in long delays for rescheduling.
"Sometimes they’ll miss an appointment with a therapist or a consultant who won’t be back for months," Allen says.
Frank Armao, MD, a psychiatrist and clinical director at the Winslow Indian Health Center, just a few miles south of the reservation, says there have been no epidemiological studies of psychiatric illnesses among the Navajo, but he believes their history affects their mental health.
"It’s true that there’s more psychiatric morbidity among lower socio-economic groups, and the poverty and unemployment here are overwhelming," Armao says. "People say ’Get over it, it’s history,’ but I can’t help but believe that the relationships of the past, the residue of long-term deprivation and the defeat of their culture contribute to depression," he says.
Alcoholism is evident, not so much by how many patients he treats for it, but by its effects. "We can tell by the number of deaths, the number of accidents, and the cases of hypothermia that it’s a problem."
Armao also treats post-traumatic stress syndrome often linked to trauma from childhood physical or sexual abuse. "I’d say that’s in proportion to the rest of the country."
Armao, originally from Springfield, Pennsylvania, compares working on the reservation to other rural practices. "This is like any rural community," he says. "We can treat most things right here, but when we need to, we send away for the sub-specialists."
The Navajo IHS has its own otolaryngologist, general and orthopedic surgeons, a cardiologist, several ophthalmologists, and an obstetrician/gynecologist in addition to a large cadre of primary-care physicians - a total of about 300 physicians.
Winslow, population 9,000, has a community hospital, Winslow Memorial Hospital, that the IHS contracts with for routine inpatient care. More complicated cases are sent from four small IHS-run IHS hospitals to the hospital in Tuba City on the western part of the reservation, or to Gallup, New Mexico, where the IHS runs a hospital off the reservation, or to Flagstaff, 55 miles away, where the IHS holds contracts with sub-specialists not available on the reservation.
The Navajo Area IHS employs a total of 3,500 people, runs six hospitals, seven outpatient facilities, and 12 part-time health stations. The service covers a million outpatient visits and 20,000 inpatient visits each year, according to Chief Medical Officer Douglas Peter, MD.
A $350 million annual budget includes not only physician, nursing, and other medical staff, but also the services and staffing for environmental health, which installs such services as sanitary waste disposal and clean water supplies. Even so, Peter says, many residents of the reservation still have sub-standard waste disposal and fresh water.
"We’re a clinical care and public health provider all put together," Peter says.
The budget also includes about $45 million for contracted transportation and tertiary care in Phoenix, Flagstaff, Albuquerque, and other off-reservation locations.
Of 300 physicians employed by the Navajo area IHS, only 10 are Native American, Peter says, despite the IHS policy to give absolute preference to qualified Indian candidates.
The IHS is always looking for qualified candidates, period, but special incentives help attract physicians to the program. The physician vacancy rate ranges from 25 to 30 percent, and up to 50 percent "on a bad year," according to Peter. "People come here for various reasons, like the IHS loan repayment program. Recently, salaries have become a little more competitive," he says.
The IHS can repay up to 100 percent of physician student loans after three years of service, according to Jim Jones, acting physician recruiter for the Navajo Area IHS. In addition, to compete with the private sector, the IHS offers a bonus program in the more remote IHS areas. Because of those incentives, Peter says, salaries on the Navajo reservation for pediatricians, internists, and family practitioners are competitive with private HMO salaries.
"It’s the surgical subspecialties where we don’t compete well," Peter says.
On the horizon for all IHS programs is the possible shift of their administration from the federal DHHS to the tribes they serve. Because of the Indian Self-Determination and Education Assistance Act of 1975, tribes have the option of receiving federal funds to staff and manage their own health systems.
IHS services in Alaska are all run by tribal consortiums, according to Peter, and services in California and the Portland Area Indian Health Service, which serves Idaho, Oregon, and Washington, are largely managed by their tribal constituents.
The Navajo are discussing the option, and Peter expects them eventually to assume control of IHS operations. There has been some speculation that in that case, the tribe would fire all the doctors to replace them with Navajo physicians, but Peter says that "is ludicrous."
"First of all, there aren’t 300 Navajo physicians available, and second, people just won’t let it happen. Current IHS staff are people’s doctors they’ve come to rely on," Peter says.
Originally from Nebraska, Peter came to the Navajo reservation in 1974 to practice family medicine. "In my training, I had two colleagues who joined the IHS. One went to Gallup (New Mexico) and one went to Barrow, Alaska. So I called the IHS and they said the Navajo needed help. Being the helping sort, I decided on Kayenta and I went sight-unseen. I figured, it was close to Grand Canyon, I could always go to the Grand Canyon every weekend."
Besides, he soon learned, if he stayed for two years, his Vietnam era military requirement would be fulfilled. Stay for three years, and 85 percent of his school loans would be paid.
"When I stayed, I realized that these people were paying me to do something I loved to do," Peter says.
Kayenta is a small town in the north-central part of the reservation that was much more remote 25 years ago than it is today. Peter found working there to be "magical," as patients and staff began to trust him. "Based on their previous experience, they expected a very shortlived stay. All the nurses and staff felt that way."
For the patients, he says, "I had to convince them that if they didn’t get better to come back. We’d be there for them."
Over the years, Peter has become part of a Navajo family that he befriended more than 20 years ago in Kayenta. With spacious government housing, Peter invited a Navajo EMT to stay with him in town rather than "commute." When the young man married, he moved out to stay with his wife’s family, as is Navajo custom. But when their first child was born and had medical complications, the young family stayed with Peter because he had running water and sewer. When Peter moved to the Navajo Nation’s governmental seat of Window Rock 12 years ago, the family soon followed, and they live with him today. Recently, their first-born son, now 20, was married.
Pediatrician Steven Holve, MD, a Los Angeles native who originally came to the reservation on a one-month rotation during his residency at the University of Denver, says he and his pediatrician wife Diana Hu, MD, can’t imagine living and working anyplace other than Tuba City, in the western portion of the reservation.
"We came here as residents and really liked it. We liked the Southwest and we liked the other physicians. They’re well-trained, friendly, and interested in providing the best care for their patients.
"Now, I’ve been here 14 years and this is my practice. I live here. These are the people and the families I know. It’s become my little niche," Holve says.
Armao, who married a Navajo woman after he came to the reservation in 1979, says he sometimes falls into a routine where he forgets that his surroundings are unique. "Sometimes, life is so mundane, but then you wake up to the fact that it’s really different here," he says. "There’s the whole exotic aspect of being in a different place that you see only in postcards."
Armao has grown to appreciate his surroundings and takes advantage of the wealth of wonders at his disposal: "I don’t think you can ever lose your love of the land, the people, and the culture," he says. "Being out West, you just get in your car on the weekends and go someplace. You put a tremendous amount of miles on the road out here. But with all these fantastic places, you’d feel like an idiot if you didn’t go see them."
The reservation and the southwest have become home to the native Pennsylvanian. "We go back East to visit, but the East is like a museum to me now. I can’t believe people still live there," Armao says.
The rewards and challenges of practice among the Navajo are something CMO Peter tries to convey to potential IHS recruits. He answers their questions about life and practice on the reservation and then he leaves them with this thought: "If you care, and if you want to make a difference, you should come because you still can make a difference here." ■
Pam Prescott is a freelance writer based in Roscoe, Illinois.