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Caring for – And Learning from – Indigenous Communities

Jennifer Michener and Robin Canada
Robin Canada (right) and Jennifer Michener (left), who was one of Canada's residents and joined the IHS at Whiteriver after graduating.

Situated in the middle of a pine forest covering more than a million acres of land sits 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 roughly 17,000 indigenous people and tribal members. It’s here that Robin Canada, MD, a professor of Internal Medicine in the Perelman School of Medicine at the University of Pennsylvania, worked for years after her residency at Penn.

“It was amazing,” said Canada of the experience. “When you work there and live there, I think it’s fair to say you are truly welcomed as part of the community.”

She quickly made friends with tribal members, some she worked with and some she treated. She would explore the beautiful Arizona terrain, spend time with locals, and was even invited to sacred tribal events, like a coming of age ceremony for one of her patients.

“You’re able to build relationships personally with people and a place that is difficult to do when you live and work in a big city,” said Canada.   

Canada served as a physician of internal medicine at Whiteriver for two years and treated individuals from an ethnic population often forgotten.

“There is becoming an increased focus on marginalized groups of people, and rightly so,” said Ryan Close, MD, a graduate of the Perelman School of Medicine, a medical officer and physician with the Indian Health Service (IHS) at the Whiteriver Indian Hospital, and a Penn Center for Global Health scholar. “The unfortunate and ironic thing is that among the marginalized, indigenous people can be even more marginalized. If you just refer to ‘marginalized people’ in the United States, most people are likely not thinking of those who are tribal members. They are marginalized within the marginalized.”

Close points to a lack of research using participants from indigenous populations. For example, a 2021 study in Ethics & Human Research, looked at internal research from the National Institutes of Health, finding that those of native American and native Alaskan populations accounted for 1 percent of the study population in clinical research from 2013 to 2017.

Canada mentions another striking figure: life expectancy. According to the Indian Health Service, Native Americans and Alaska Natives born today have a life expectancy that’s five and a half years shorter than the average American life expectancy consisting of all ethnicities and races.

When Canada moved back to Philadelphia to work at Penn and be close family, she missed Whiteriver. With support of Penn’s Center for Global Health, she decided to start a clinical rotation program for Penn residents who wanted a taste of the experience she had. In 2015, Canada placed the first four Penn residents at 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 participate in rotations, too, and financial support for these experience comes from philanthropy like the McCracken/MacCracken Student Travel Award for Indian Health.

“Penn residents are experienced, professional, and valuable additions to IHS teams,” said Canada. “But there is a lot that our they can learn from these clinics, clinicians, and their patients. “They learn about specific health conditions that disproportionately affect people of indigenous backgrounds. They learn how to understand and deliver health across cultures. And they learn about some of the really impressive efforts and innovations made by IHS clinicians to successfully deliver medicine to people in remote locations but often with limited resources.”

A Marriage of Spiritual and Modern Medicine

Travel restrictions from the COVID-19 pandemic meant a drastic decrease in the many regular global health experiences and rotations normally on the table of offerings for Penn medical students and residents.

“Those who may look abroad for clinical experience had to look closer to home this year,” said Canada. “IHS placements could largely carry on since travel to the various centers is all domestic.”

With no passport needed, last August, Cindy Zhao, a student in Penn’s joint MD/MBA track, hopped on a plane to the Alaska Native Medical Center in Anchorage, Alaska. As someone interested in ophthalmology, she signed up and completed a four-week rotation with the ophthalmology practice at the center — a clinic that handles everything from regular care to complex eye surgeries. Her travel was supported by the McCracken/MacCracken fund. She was able to observe and assist as much as her expertise allowed.

“Indigenous people around Alaska were flying in sometimes hundreds of miles for special surgery,” said Zhao. “That occurs back in Philly, but patients traveling to the Penn campus generally aren’t carefully checking weather reports and scheduling trips via bush planes. There are many more considerations both clinicians and patients are making before the appointments themselves even start.”

Living in remote locations is not the only thing impacting the health of native peoples. Many people with indigenous backgrounds and living on reservations face higher rates of poverty, addiction, and poor mental health. Zhao noted that systematic barriers which propagate such health disparities deserve far more attention.

In her experience in Alaska, Zhao found most patients to be physically active and also generally receptive to modern medicine and vaccines — sometimes in combination with traditional cultural practices.“There are a lot of beautiful aspects of their culture that we have to learn from, too,” said Zhao. “Relative to what I’ve seen here at a major U.S. academic center, I got the sense that ANMC has a more holistic approach to health that more fully embraces patients’ cultural and spiritual values, too.”

“At Whiteriver, there are traditional healers available to patients who work alongside traditional providers,” said Canada. “It’s not a one or the other approach.”

The Effect of the Pandemic

Reservations and Native Americans were not isolated from the effects of COVID-19. Readers may assume indigenous populations would be justifiably fearful of modern medicine and treatments like vaccines as marginalized populations have historically been mistreated by those who were supposed to be looking out for them.

“Patients we worked with were very accepting of ophthalmological treatments and interventions from our clinicians,” said Zhao. And “during a few of the conversations that we had about vaccines,” access to care seemed to be more of an issue than resistance to the vaccine.

The IHS put contact tracers and vaccinators on the go to visit patients at their homes, miles and miles from the medical centers.

“Providers drove to those who thought they had COVID in order to provide testing and help contain the virus,” said Close. “It’s not uncommon to see clinicians on four-wheelers to get to patients who need care, and this ‘meet patients where they are’ approach has played a big part in indigenous care over the last couple years. I think that’s a method that other hospitals, clinics, and public health experts should use for COVID and non-COVID-related care.”

A “Life-Changing” Experience

Canada calls the experiences she had with the IHS at the start of her career “life-changing.” Many Penn students who complete rotations at the IHS likely would say the same thing; nine of the 45 students who participated in IHS rotations since 2015 went on to work for the IHS after graduation from medical school.

“My experience in Alaska went by quickly and really reframed my perspective on life and medicine,” said Zhao. “I wasn’t ready to come home. I have stayed in touch with several people I worked with and became friends with, and I would not be surprised if at some point, after I graduate, the IHS becomes part of my professional career.”

To support the McCracken/MacCracken Student Travel Award for Indian Health, click here.


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