By Dawson S Brown

Interview

Jane Doe is a 57-year-old member of the Blackfeet Indian Nation, living in Montana. Native Americans are a significant entity in Montana, a state that otherwise lacks much in the way of ethnic diversity. Having grown up in Montana myself, I thought it might be interesting to learn about the health and health practices of the Blackfeet. Though I had never met Ms Doe before our interview, I knew of her background through some of her coworkers. As I understood it before contacting her, she is very involved in the traditional practices of her people, perhaps even acting as the keeper of the "medicine bundle." She agreed to meet with me at her office on December 21, 2004.

Upon first meeting Ms Doe, her dark features, braided black hair, jewelry, and distinctive vocal intonation gave me the impression that she embraces her Blackfeet ancestry. She spoke very softly, but eloquently and with purpose. I learned that she had been born in a small town in the northern part of Montana along the Rocky Mountain front at the heart of the Blackfeet Indian Reservation. From a working-class family, Ms Doe has four siblings: three sisters and a brother. Ms Doe's husband is from a large family in the same community. During her childhood, people were punished for speaking their native language, so she spoke English in and out of her home. When she was in middle school, her family moved to northern California as part of a program designed to relocate and assimilate Native Americans into other parts of society. She eventually attended UC Berkeley earning a degree in Social Work. She then returned home, married and raised three daughters and five sons. Two years prior to our interview, Ms Doe moved to a larger city and became employed full-time as a social worker.

Ms Doe and her husband, aged 60 years, own their own home and several of their children live nearby. They have a large extended family, and support structure, within a three-hour drive. Ms Doe and her husband are both fluent in the Blackfeet language, though their children are not; therefore they speak English at home and on the telephone. Ms Doe told me that she has had a television in her home for as long as she can remember, though she personally dislikes it. She would prefer to get her news and information from National Public Radio, and the local newspaper, which is delivered daily.

His Heart and a Root

We did not discuss the specifics of her income, housing costs, etc. However, she did indicate to me that her husband receives federal disability payments, which supplement her salary from the Housing Authority.

In keeping with the traditions of her native people, Ms Doe endorses the use of many natural medicines and herbs. Ms Doe related one story about traditional Blackfeet medicine that I found especially fascinating. A member of the tribe--known for his commitment to living by traditional customs and values--experienced the acute onset of chest pain. His wife was concerned he was having a heart attack and called an ambulance. While they were waiting for it to arrive, the man requested that she bring him a particular root. Unfortunately Ms Doe claims only to know its Blackfeet name and could not tell me what it was. Traditionally, however, the root has been used to treat anxiety. The man ate the root, and by the time he arrived at the hospital, he was symptom free. While in the hospital, he began to have more chest pain, and again he asked his wife for some of the root. In the process of working him up, the hospital staff discovered that he had, in fact, suffered a fairly serious myocardial infarction. He was subsequently transferred to a larger facility. On the way, he experienced chest pains for a third time. Again he ate some of the root. Later, in the hospital, when his blood work returned from the lab, one of the doctors asked him if he had taken or been administered any nitroglycerine. He insisted that he hadn't; yet according to Ms Doe, significant levels were detected. The group concluded that the root he had been eating might have contained a chemical analogue. One could postulate that its vasodilatory effects might also relieve the uncomfortable symptoms associated with an anxiety attack.

Traditional Medicine

Ms Doe and her family have had a lot of experience with the medical profession. When I asked her to compare her experiences of the traditional medicine of her people and those she has had with modern "western" medicine, I laughed at the obvious irony, by definition, her people and their medicine are western. She admitted though that their practices more closely resemble those of Asia. While growing up, Ms Doe says, her family viewed the Indian Health Service as a place for extreme emergencies only. She remembers having hepatitis (possibly hepatitis A) as a child, and still harbors suspicions that the Indian boarding schools were sometimes used as testing laboratories. While raising her own children, she saw the hospital only as an emergency room and a place to get immunizations. Surprised, I pressed her on the issue of immunizations. She anticipated my question and stated that she immunized her children only because the law required it.

While Ms Doe was living in northern California, she was diagnosed with thyroid cancer. It had metastasized to a nearby lymph node by the time she had a thyroidectomy. Over the next five years or so, she had regular scans with radioactive iodine to ensure the cancer wasn't coming back. Unfortunately, one of these scans came back positive for a recurring "hot nodule." The doctors in Oakland told her they would administer several bouts of intensive therapy, but a possible side effect of the radiation would be permanent sterility. Concerned about the possibility of not having any more kids, she consulted doctors in Montana for a second opinion. They agreed that she would require the aggressive therapy, but told her that the possibility of side effects was very small. She found the apparent contradiction disconcerting. She highlights it as an example of the imperfect knowledge any of us have about the human body. She is frustrated by the many assumptions that underlie decisions we make--some with monumental consequences--in western allopathic medicine. She asks, "How many people would have just accepted this [contradiction] without question?"

Before returning to California, Ms Doe visited a traditional Blackfeet healer. She recalls, "I was told--in a sweat--by the great spirits that everything was going to be okay." When she returned to Oakland to begin treatment, a preliminary scan failed to detect the nodule. She has subsequently been cancer-free for more than 20 years.

Responsibility for Health

Because my interview with Ms Doe took place at her office, I did not have the opportunity to assess any possible health hazards in or around her home. I would expect, given my impression of her, that the attention she pays to the health and safety of her family is far superior to that of the average member of her community. She shows great concern that her people "no longer feel responsible for their own health." The fault for this is shared. While Ms Doe admits that "western diseases," a lack of innate immunity, mistrust, and the Indian Health Service structure are all contributing causes, the larger responsibility rests with the Blackfeet people themselves. She believes that there is an inseparable synergy between a person's integrity/morality and their health or wellness. Ms Doe describes her people as suffering from a sort of post-traumatic and intergenerational stress. Until they take responsibility and recognize that there is no distinguishing between medicine and daily living, they cannot be truly healthy.

My Personal Reflection on this Interview

Ms Doe's tale of her battle with thyroid cancer was a fantastic story. Of course, I have a perfectly rational allopathic explanation for her outcome. Each of her "diagnostic" scans was conducted using radioactive iodine. Even though the isotope is sometimes different than that used in treatment protocols, any radioactive iodine is going to preferentially localize to the site of the tumor and confer some degree of therapeutic benefit. It is quite possible that the diagnostic scans themselves were curative in the sense that they eliminated the recurring nodule.

This explanation is the embodiment of rational, evidence-based, "modern medicine." In making it, however, I am perhaps guilty of the greatest faux pas of "culturally sensitive medicine." For whatever reason we find security in the knowledge that there is but one answer, and that it can be reached through methodical process and logical thought. We are trained to be skeptical of novel ideas, and we eagerly dismiss anecdotal evidence. Beyond all of this, though, we are supremely confident that "ours" is the correct way. It is doubtful that this egocentric viewpoint is limited to the medical profession. It is likely instead that it is an inherent quality of humankind, and that it is manifest to varying degrees in different social contexts. One's inability to transcend our own worldview is obviously a huge barrier to achieving understanding. In medicine, the unfortunate result might be a physician's inability to administer care, as well as a patient's reluctance to receiving it.

What about the health of the Blackfeet Indian Nation today? Ms Doe is the first to admit that she is the exception. She attributes her current mental and physical health to her return to the traditional practices and philosophy of the Blackfeet. Interestingly, she feels that this personal renaissance has been triggered by her experiences with modern allopathic medicine. In her words, "cancer saved my life."

Indian Health Service

Like the Veterans Administration, Medicare, and Medicaid, the Indian Health Service (IHS) is a federally funded system of universal health care. It is also arguably the biggest failure. Before meeting with Ms Doe, I honestly did not know that the IHS existed. And yet, if the health care of all Native Americans is, in essence, "covered," why are they still vastly underserved, and indeed, unhealthy?

One could argue that the responsibility lies in a failure of the system to integrate and adapt to the culture it's serving. As I discussed before, our culture of medicine has traditionally been narrow-minded, operating within the comforts of our own assumptions and social context. Superimposed on this, at least historically, there has been a culture of racism, disrespect, and mistrust of Native Americans. Indeed, Ms Doe told me that when she visited Missoula as a child, it was not uncommon to see signs on storefronts that read "no Indians or dogs allowed inside." As with other social inequalities, it would be irresponsible not to consider the underlying conditions that might be contributing to the unwanted outcome. It was only recently that the medical profession recognized the importance of practicing culturally sensitive medicine. We are realizing that we must try to understand and integrate the belief structures and traditions of our patients into the healing process. Nevertheless, I personally believe that the converse is both necessary and inevitable. The patient too must be willing to compromise. For our part, we can begin by positioning ourselves to be both aware of and amenable to our patients' needs.

Returning to the issue of the IHS, one might argue the alternate viewpoint that Native Americans themselves are responsible for their own health failures. According to Ms Doe, the Blackfeet people have a strong tradition of self-healing. Appealing to a third party was only done in extreme circumstances. The arrival of the IHS, like many social support systems, created an environment where responsibility for one's own health was diminished. The basis of western medicine still remains outside of the sphere of understanding for many Blackfeet. There is reluctance on both sides to integrate the traditional with the modern. In essence, a "barrier to trust" has been established. I think it is very difficult for any of us to imagine the sense of upheaval experienced by the Native American people. There is no way to quantify the relative impact of the loss of their land, lifestyle, identity, sovereignty, and pride. We can only presume to understand the psychological impact. On several occasions, Ms Doe addressed this issue, but only indirectly. As I said before, she thinks that the rampant alcoholism, hypertension, addiction, diabetes, obesity, etc, of her people can be traced to what she considers a type of post-traumatic stress. I think this is a compelling explanation. I am equally impressed with her reluctance to spread concentric layers of blame.

Realize Our Limitations

Ms Doe prefers instead to look forward, assigning the responsibility for the health and healing of her own people solely to them. She believes the crisis of the Indian people and the crisis of health care are one and the same. She equates their lack of innate immunity with a continuing deficiency of personal integrity. Wellness, morality, and life are indistinguishable. At the end of the interview, I asked Ms Doe what I might do in the future to improve the health of the underserved. She told me that it is important to realize our limitations. Know that western medicine is very good at treating western diseases, but that Native Americans especially need to take some responsibility for their own healing, especially psychologically. Additionally, it is important that our patients know they have the opportunity to agree, disagree, and to ask questions. The ability to communicate is important to everybody's health. I would add, as I said before, that it is important to be aware, amenable, and active in the process of providing health care to people with different cultural perspectives. Smiling, Ms Doe told me that our discussion has been a step in the right direction. Already we have begun dismantling the barrier of fear.

To Winter 2007 Contents >>