Doctors find a way to bridge cultural gap
By Judy Nichols
The Arizona Republic
July 21, 2002
TUCSON - Albert Bighorse is lying on the operating table, his eyes taped shut, a machine breathing for him, another circulating his blood. His chest has been cut open. Inside, his heart lies gray and motionless. Dr. Jack Copeland's gloved hands are in the chest cavity, gently positioning a vein from Bighorse's leg. The vein, speckled with black where tiny offshoots have been cauterized, will serve as a new route for blood, bypassing blocked veins. The remarkable meeting of these two men, one a traditional Navajo rancher and medicine man from one of the most isolated parts of the United States, the other an internationally renowned heart surgeon, is the result of the Native American Cardiology Program, a partnership of government, university and private sources. The program is the lifework of Dr. James Galloway, who saw the explosion of heart disease in Native Americans and found a creative way to help. Galloway joined the Indian Health Service in the early 1980s as an internist working with the Hopi and White Mountain Apache tribes. For decades, he and others had been told that Native Americans were immune from heart disease, and even into the 1970s the incidence was low. But in the '80s, Galloway saw the beginnings of an epidemic fueled by diabetes, obesity and high blood pressure. Although heart disease was declining in other populations through diet, exercise and aggressive treatment of high cholesterol and high blood pressure, it was on the rise in Native American populations, only recently exposed to fast foods, high-sugar sodas and sedentary lifestyles. Some heart disease was hard to detect because diabetes, another epidemic among Native Americans, affects the nervous system, masking the pain normally caused by heart problems. The Indian Health Service wasn't ready for the onslaught. "When they started seeing heart disease, they referred it to the private sector," Galloway said. "But there were deficiencies." It was expensive. Sometimes unnecessary tests and treatments were ordered. There was no continuity of care. If a patient was sent to Phoenix for care, the doctor back home often didn't know what had been done. "Sometimes we didn't even know if someone had a pacemaker put in," Galloway said. "There would be no discharge summaries, and if the patient spoke only Navajo, they often didn't know exactly what had been done because there was no interpreter. There was no long-term vision, no cultural sensitivity, no prevention activities." So Galloway decided to change things. Solution in partnership Galloway went back to school, to the University of Arizona, to specialize in cardiology. As he was finishing his studies, he proposed a partnership among the Indian Health Service and the University of Arizona Medical Center, a teaching hospital, and its non-profit Sarver Heart Center. The result is the Native American Cardiology Program, housed at the Medical Center since 1992. Today, it has four cardiologists, two nurse practitioners, two nurses, two translators and one traditional healer. It has a budget of about $1.5 million, about half of which comes through the Indian Health Service. The rest is paid by the other partners. The program serves nearly 500,000 Native Americans at the center in Tucson and through "house calls" to 38 hospitals and clinics in Arizona, Nevada, Utah, New Mexico and California. Galloway is setting up a second site for the program at the Flagstaff Medical Center to better serve patients in the northern part of the state. The team in Tucson performs more than 200 bypasses a year and thousands of cardiac catheterizations, echocardiograms and stress tests. Doctors have done eight heart transplants. The program charges private insurance or Medicare or Medicaid, when applicable.
Long journey For Bighorse, the journey began in Cameron, about 40 miles north of Flagstaff on the Navajo Reservation, where he has cattle and horses. Bighorse, who has been a dancer in Navajo healing ceremonies, began suffering shortness of breath, coughing and fatigue. Traditional ways no longer were helping him, he said. Doctors in Tuba City referred him to the cardiology program in Tucson, where he underwent a cardiac catheterization, in which dye is injected into the veins of the heart. It revealed blockages. Bighorse speaks only Navajo, and Phyllis Sanderson, the program's translator, helped him understand what was going on. "Navajos have hand tremblers and crystal gazers," Sanderson said. "I tell them the White doctors use different things for diagnosis. The EKG is like a hand trembler, the large crystal is a catheterization and the small crystal is the echocardiogram. Then they understand that nothing will be done until the doctors decide what's wrong." She tells them the treatments are like the ceremonies and prayers, actions taken to heal. The translations are crucial, said Dr. Eric Brody, a cardiologist with the program. "In other places, sometimes patients don't get procedures because they don't understand what's going on and don't give their consent," Brody said. "When they have someone like Phyllis explain things to them, there is no resistance to care or recommendations." Bighorse said he wants to get better to teach his sons and grandsons and other boys from his community how to handle livestock. "I'd like to take care of my sheep," he said. "My wife has been doing that. There are horses and cattle that need to be rounded up, branded and castrated. I want to be useful around the house. Right now, I can't walk far or carry a bucket of water or chop wood." Carol Locust, the traditional healer, walks with Bighorse to the first floor, where nurses wait to prepare him for surgery. Locust says prayers in her native Cherokee language, and uses items recognized by many tribes like eagle feathers, cedar and tobacco to give a blessing before surgery. Earlier, Copeland, known for using the first artificial heart to keep a patient alive until transplant, reviewed films of Bighorse's heart. In a small notebook, Copeland draws the heart and its spidery vessels, marking blockages with tiny Xs to help him remember which portions to bypass. Soon, Bighorse is on the table, his heart slowed by cold, saline water, then stopped altogether, the blood routed to the machine. Heart failure Edward Setalla, 60, a Hopi from Keams Canyon on the Hopi Reservation in the northeastern corner of Arizona, had the same surgery in 2000. He'd had a cardiac arrest two decades earlier while working as a painter. Earlier this month he was back with a potassium overdose and fatigue. Setalla said he didn't know how serious his heart problem was when he went to see Galloway in Flagstaff two years ago. "He had me walk on the treadmill for five minutes," Setalla said. "Then he said, 'You flunked.' He had me lie down on the bed. My wife came in and asked if we could go get breakfast. Dr. Galloway said, 'That's as far as he's going.' " Setalla's grandfather was a Hopi medicine man, and Setalla said he learned the Hopi religious ways and dances, but gave it up seven years ago when he became a Christian. "I put my faith in God," he said. Tsosie Bedoni, 73, of Chinle near Canyon de Chelly on the Navajo Reservation, had a valve replacement and a pacemaker installed. "I was digging postholes with a pitchfork, and I couldn't finish," Bedoni said. "They cut a big incision in my chest and put a device on my left shoulder." Despite being told to take it easy, he was back on his horse in two days, said his niece, Ella Singer. Bedoni sheepishly admits the transgression, but said he "misunderstood."
A mother, daughter Sanderson said she sometimes has influence because of her relationship to patients through the Navajo clan system. Bedoni's father is Bitter Water Clan, the same as Sanderson's mother. So others from that clan are parents to him. "To him I am like a mother," Sanderson says. "He listens to what I say." Bighorse also is related to Sanderson through the Towering House Clan, the same as Sanderson's father. So, to him she is like a daughter. The night before his surgery, he didn't want to sleep in a hotel. "It was overwhelming to him," Sanderson said. "He couldn't register. He didn't know how to order meals, or request the shuttle in the morning. He said, 'Why don't you let me sleep in your sheepskin, daughter. I'm sure you have a corner you're not using.' " Sanderson took him home, fed him. He told her he slept better than he had in weeks. Strong, steady beat In the operating room, at 6:05 p.m., Copeland has finished attaching the vein and has taken off the last clamp. Blood begins to flow through Bighorse's heart again. Bathed in warm saline, it begins to beat, slowly and somewhat erratically at first, then a strong, steady beat. Soon Bighorse will return home. Galloway and Brody both say that, as tribes stress nutrition and exercise, and as doctors aggressively treat high cholesterol and high blood pressure, they expect to see great improvements and lower death rates. Earlier this month, Galloway was on the Navajo Reservation, at the hospital in Chinle, where he examined Thomas Tsosie, 56, an electrician having trouble breathing, and swelling in his legs. Sometimes Tsosie's heart races and he wakes up sweating. An echocardiogram shows Tsosie's heart is pumping out only about 10 percent of the blood it collects, compared with about 60 percent in a healthy person. Galloway is worried about blockages in the veins, which can make the muscle weak, and tells Tsosie he should come to Tucson for a cardiac catheterization. But Tsosie has used up all his sick leave and wonders if he can wait until he gets more in January. "If you were my brother, I would have you go next week, not January" Galloway tells Tsosie. "How bad is my heart?" Tsosie asks quietly, his head bowed. "It is serious," Galloway says, his hand on Tsosie's back. "But there are things we can do."
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