Situated in the middle of a pine forest covering more than a million acres of land is the Whiteriver Indian Hospital, part of the Indian Health Service. The hospital is located on the Fort Apache Indian Reservation and serves as a medical center for approximately 17,000 Native people and tribal members. It’s here that Robin Canada, MDprofessor of internal medicine at the Perelman School of Medicine at the University of Pennsylvania, worked for years after his residency at Penn.
“It was amazing,” Canada said of the experience. “When you work and live there, I think it’s fair to say you’re really welcomed into the community.
She quickly became friends with members of the tribe, some she worked with and others she cared for. She explored the beautiful Arizona territory, spent time with locals, and was even invited to sacred tribal events, like a coming-of-age ceremony for one of her patients.
“You are able to form personal relationships with people and a place, which is difficult to establish when you live and work in a big city,” Canada said.
Canada served as an internal medicine physician in Whiteriver for two years and treated individuals from an often forgotten ethnic population.
“There is an increasing focus on marginalized groups of people, and rightly so,” said Ryan Close, MD, a graduate of the Perelman School of Medicine, an Indian Health Service (IHS) physician and physician at Whiteriver Indian Hospital, and a researcher at the Penn Center for Global Health. “The unfortunate and ironic thing is that among the marginalized, indigenous people can be even more marginalized. If you simply refer to “marginalized people” in the United States, most people probably don’t think of those who are members of a tribe. They are marginalized among the marginalized.
Close highlights a lack of research using participants from indigenous populations. For example, a 2021 study in Ethics and human researchreviewed internal research from the National Institutes of Health, concluding that Native American and Alaskan populations made up 1 percent of the population studied in clinical research from 2013 to 2017.
Canada mentions another striking figure: life expectancy. According to the Indian Health ServiceAmerican Indians and Alaska Natives born today have a life expectancy five and a half years shorter than the average life expectancy for Americans of all ethnicities and races.
When Canada returned to Philadelphia to work at Penn and be close family, she missed Whiteriver. With support from Penn’s Center for Global Health, she decided to launch a clinical internship program for Penn residents who wanted a taste of her experience. In 2015, Canada placed Penn’s first four residents in Whiteriver. Since 2015, 45 Penn residents have completed clinical rotations at various Indian Health Service medical centers. The program has expanded to include four other reservations in the Southwest and other IHS medical centers in more urban areas like Anchorage, Alaska. Additionally, Perelman School of Medicine students also participate in internships, and financial support for these experiences comes from philanthropies like the McCracken/MacCracken Student Travel Award for Indian Health.
“Penn residents are experienced, professional and valuable additions to the IHS teams,” Canada said. “But they have a lot to learn from these clinics, these clinicians and their patients. “They uncover specific health issues that disproportionately affect people of Indigenous descent. They learn to understand and ensure health in all cultures. And they learn about some of the truly impressive efforts and innovations made by IHS clinicians to successfully deliver medicines to people living in remote areas, but often with limited resources.
A marriage of spiritual and modern medicine
Travel restrictions due to the COVID-19 pandemic have led to a drastic decrease in the many regular global health experiences and rotations normally available to Penn medical students and residents.
“Those who might seek clinical experience abroad have had to move closer to home this year,” Canada said. “The IHS internships could largely continue since travel to the different centers is only within the country.”
Without a passport, last August, Cindy Zhao, a student in Penn’s joint MD/MBA degree, hopped on a plane to go to the Alaska Native Medical Center in Anchorage, Alaska. As someone interested in ophthalmology, she signed up and completed a four-week rotation at the center’s ophthalmology practice, a clinic that handles everything from regular eye care to complex eye surgeries. His trip was financed by the McCracken/MacCracken fund. She was able to observe and help as much as her expertise allowed.
“Alaska Natives sometimes flew hundreds of miles to have special surgery,” Zhao said. “This is happening in Philadelphia, but patients who travel to Penn’s campus generally don’t check weather reports carefully or plan their bush plane trips. There are many other considerations that clinicians and patients need to make before the appointments themselves even begin.
Living in remote areas isn’t the only thing that impacts the health of Indigenous people. Many people of Indigenous descent living on reserves face higher rates of poverty, addiction and poor mental health. Zhao noted that the systematic barriers that propagate such health disparities deserve far more attention.
During his experience in Alaska, Zhao found that most patients were physically active and generally receptive to modern medicine and vaccines – sometimes in combination with traditional cultural practices. “There are many beautiful aspects of their culture that we need to learn from, too,” Zhao said. “Compared to what I have seen here at a large American academic center, I feel like ANMC has a more holistic approach to health that also more fully embraces the cultural and spiritual values of patients.
“In Whiteriver, traditional healers are available to patients who work alongside traditional providers,” Canada said. “It’s not about one approach or the other.”
The effect of the pandemic
Reservations and Native Americans have not been isolated from the effects of COVID-19. Readers may assume that indigenous populations would be rightly fearful of modern medicine and treatments such as vaccines, because marginalized populations have historically been mistreated by those who were supposed to look out for them.
“The patients we worked with were very accepting of our clinicians’ ophthalmic treatments and interventions,” Zhao said. And “in some of the conversations we had about vaccines,” access to care seemed to be more of an issue than vaccine resistance.
The IHS has set up contact tracers and vaccinators to visit patients in their homes, miles and miles from medical centers.
“Providers went to the homes of those who thought they had COVID to offer testing and help contain the virus,” Close said. “It is not uncommon to see clinicians on four wheels traveling to patients in need of care, and this approach of ‘meeting patients where they are’ has played a large role in Indigenous care in the over the last two years. I think this is a method that other hospitals, clinics, and public health experts should use for COVID and non-COVID care.
A life-changing experience
Canada calls her experiences with IHS early in her career “life-changing.” Many Penn students who intern at IHS would probably say the same thing; nine of the 45 students who have participated in IHS internships since 2015 have continued to work for IHS after earning their medical degree.
“My experience in Alaska happened quickly and really reframed my outlook on life and medicine,” Zhao said. “I wasn’t ready to go home. I have stayed in touch with several people I have worked with and become friends with, and I would not be surprised if, at some point after graduation, IHS becomes part of my professional career .
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