At 10 a.m. on May 14, in a small Navajo town called Shonto that sits at the bottom of a narrow red-rock canyon, Betty J. John is preparing to set off on her daily rounds.
The 58-year-old tosses a shoulder bag in an off-road pickup, climbs into the cab, and steers her rig for the canyon rim. She splashes across a stream formed by the town’s eponymous spring, past a couple leafy cottonwoods that her grandfather planted, and powers up Indian Route 221, a gravel road cut into the face of a cliff. As she ascends toward 6,600 feet, the clear blue sky unfurls overhead with all its epic, Western promise.
“I was raised down there,” she says. “I didn’t want to be stuck in a canyon.”
She chose the right job. As a community health representative for Navajo Nation, John’s “office” is roughly 1,000 square miles of crinkled brown land just south of the Arizona-Utah border and east of the Grand Canyon. It’s a swath of geologic wonders, thirsty brush, and scattered homes where many people suffer health problems and few have an easy time getting to clinics, never mind hospitals in faraway places like Tucson.
John, who is a certified nursing assistant, plays a crucial role. Like her 98 colleagues in the Navajo Community Health Representative Program, she visits well over 30 patients a month, many of them fellow members of the Bitterwater clan. In their homes, she takes blood pressures, monitors medications, and talks nutrition.
But these tasks add up to much more. By checking in with her patients once every couple weeks, often over years, she develops a deep understanding of their lives and some of the challenges they face. And she plays a key role in maintaining their attenuated link to the standard health care found on paved roads.
“Clinics are always advertising, but I like working in the field,” John says.
Today her plan is to meet with three patients—Linda, Ned, and Marie*—before lunch.
She rattles along, the shiny truck winding through sage and piñon pine, up muscular buttes, down unnamed, unmarked dirt tracks. Ominous, dark clouds walk across the horizon. Not a half-hour after departing Shonto, the fickle high-desert weather is already changing.
John couldn’t be less worried.
“The roads are terrible, but the views are amazing.”
-Betty J. John
John grew up in Shonto, which translates loosely to “sunshine springs” or “water shining on a cliff.” When she was young, her parents’ relationship ended and her maternal grandparents took care of her, raising her in Shonto. John still lives nearby, but on the mesa. When not working, she tends to her fruit and vegetable garden and spends a lot of time with her daughter, two sons, and grandkids. While driving between patients, she opts not to listen to the radio, preferring to sing gospel songs to herself. Her tidy hair bun and pastel-colored nurse’s scrubs belie her ability to break a wild horse.
John became interested in health care at a young age. When she was 6 years old, her grandfather suffered a stroke, and a pastor’s wife made regular visits to look after him.
“After she left, I would pretend that I was taking his blood pressure,” says John.
She worked in several different fields for a couple decades—chef, building maintenance, construction—until angling from senior care into community health in 2003.
“I really, really like it,” she says.
Her patients, ranging from 40 to 98 years old, suffer a variety of ailments that aren’t hard to imagine. Alcoholism is widespread, with some experts estimating that 40 percent of men drink too much. Cancer looms, in part due to late diagnosis. (Smoking rates among Navajo are lower than among virtually all other ethnic groups in America.) Diabetes is also widespread, which reflects the difficulty many have in accessing healthy foods. With a third of Navajo living below the poverty line, many people rely on the affordable, calorie-dense, nutrient-free foods that heighten blood-sugar levels and spur diabetes. Average life expectancy notches just 74 years, which is lower than in any U.S. state.
What caused this horrible situation? That’s a big, messy question. Suffice it to say that the U.S. federal government has not always acted in the tribe’s best interest—beginning in 1864, when the U.S. Army imprisoned or killed all the Navajo it could find, and continuing up to the present, when, for example, the Environmental Protection Agency’s Superfund Program makes slow progress on detoxifying the hundreds of uranium mines it is responsible for on Navajo Nation.
In the last couple decades, however, the Navajo people have begun making increasingly strong pushes for self-determination. John can be counted among them. Though she would never say it herself, she and her CHR colleagues are fierce, frontline defenders of tribal health.
Six bumpy miles and 40 minutes after departing Shonto, John descends from a plateau and turns onto a road no wider than her truck, juniper branches scraping the side panels. A cluster of three houses and a horse paddock appear. It’s the home of Linda, the first patient of the morning.
John raps on the door. A woman’s head appears and says Linda had an appointment that she forgot about until this morning.
John returns to the truck. She knows it can be difficult to find clients at home, especially because the community doesn’t have good cellphone service.
“You never know when they’re just going to be gone,” she says. “They don’t tell you.”
John drives for another 20 minutes, rounding a point above a green meadow and passing an oversized puddle called Little Lamb Pond, where she and her 3-year-old granddaughter water their horses when they ride together. Easing onto a slick rock bulge, heading toward the scalloped edge of a dark mesa, John notes the wind picking up, blowing dust off the trees.
“It snowed here two weeks ago,” she says.
She sometimes doesn’t head out when the weather threatens to turn nasty like today. A place such as Piute Mesa, near Glen Canyon, can cause problems. Two hours from the nearest paved road, with no cellphone service, it’s just sand—a fine, chalky sand the color of rust. After a rain, it becomes peanut butter. When her truck sunk up to the axles two years ago, she slipped out, grabbed the shovel she keeps stashed in the truck bed, and began digging, mud splattering her scrubs.
“Eventually I got out,” she says, a wry twinkle in her eye.
Ten minutes later, Ned is also not home, it turns out. But a half-hour later John arrives at house three, which is occupied.
Inside the one-bedroom, Marie, 81, and her husband, who appears to be about her age, are lying on twin beds in the living room, adjacent to a soot-blackened coal stove. Marie is one of John’s “high risk” patients—she has diabetes, high blood pressure, arthritis, asthma, migraines, and low platelet count.
“Yá’át’ééh,” says Marie, greeting her in Navajo.
“Yá’át’ééh,” says John.
John has been visiting Marie for five years. Before 2010, Marie was a frequent visitor to the emergency room of the Kayenta Health Center, a small clinic about an hour east. Then a provider recommended she meet with a community health representative, knowing Marie could benefit from working closely with someone in her community. John served Marie’s area, so she asked Marie if it was OK to come by and visit. Marie said yes, and they’ve met roughly twice a month ever since. These days, Marie occasionally receives health care in the ER, but less often than before.
Thanks to improvements like that, the Navajo Community Health Representative Program, which the Navajo Department of Health has run for 47 years, has lately become something of a showpiece. Studies such as this suggest that community health representatives improve patients’ health, lessen the burden on busy hospitals, and keep overall health care costs down.
The Affordable Care Act has bought into them in a big way. The Act allows Medicaid to reimburse for services provided by a community health worker that are referred by a licensed physician, and it sets aside money for so-called State Innovation Models, which are any new initiatives that improve health and drive down costs. Community health representatives—or community health workers, as they are more commonly called—neatly fit the bill. In just the two years since the Act became fully operational, some half a dozen states have launched programs like the Navajo’s, including Texas. Other states, such as New Mexico, have passed legislation to formally certify CHWs. With the Supreme Court’s recent defense of the Act, their popularity seems poised to grow.
PIH sister organization Community Outreach Patient Empowerment (COPE) works closely with Navajo Nation to ensure that the CHR program is as good as it can be. Though the Obama administration has increased federal funding for Indian Health Services for the first time in decades, the funding allocated for CHR programs remains far from flush. (Indian Health Services spends roughly $3,000 dollars per user per year, which is “significantly short of what is required to bring health parity to Native Americans” and roughly one-quarter of what Medicare spends per beneficiary, finds The National Tribal Budget Formulation Workgroup’s “Recommendations on the Indian Health Service Fiscal Year 2015 Budget.”) COPE, based in Gallup, New Mexico, operates on a shoestring budget but shares ample expertise.
COPE staff members, the majority of whom are Navajo, have years of experience working in community health. In Navajo Nation, they collaborate with local partners to create training materials, work with CHRs to teach health promotion skills, help with professional development through leadership and quality improvement workshops, and partner with health facilities to integrate CHRs into care teams.
Currently, they’re experimenting with how iPads might allow CHRs to update patient records in real time, further tightening the link between doctors and patients. Staff also work with a food coalition to spearhead initiatives to improve access to healthy foods in the community.
John and Marie have a good rapport. When someone jokes that Marie has an appointment at a hair salon, Marie doesn’t miss a beat. “Well, if I’m going to be done up, then we better find me a husband,” she says, of the man who has slept right through their chat.
John removes her stethoscope from her shoulder bag. She takes Marie’s temperature, measures her blood oxygen level, and inspects her feet—which have good blood flow and nerve sensitivity for a diabetic but could be elevated more. They decipher the labels on the new generic versions of her longtime medications. And John reminds Marie that she could stand to lose a few pounds. John notes all of this on a clipboard, to be transcribed later into an electronic health record system.
But the most important conversation, health-wise, turns out to be about challenges Marie is having in her home.
Marie moved from her hogan—a traditional Navajo home made of stacked sandstone blocks, the chinks packed with insulating mud—into her current house in the ’70s. At that time, the local Navajo government helped community members attain more modern housing. They dug a well so it had running water, but they weren’t able to connect running water to the house. Years later, they plumbed the mudroom as a bathroom, but the cramped space isn’t handicap friendly—nor was it up to code, as Marie recently discovered when an officer from Arizona’s social services paid a visit.
Since there is no electricity in this area, Marie relies on solar power. However, the solar panel array out front stopped working. A nonprofit had installed it but failed to set up a system for maintenance. It broke recently and now no longer powers the refrigerator or hot water heater.
The coal-burning stove also appears to be leaking. Marie and her husband had family members move their beds into the living room to be nearer the warm stove, but they worried that the fumes might exacerbate her asthma. So the couple stopped using the stove altogether, which finally tipped the scales, causing her recent visit to the hospital where she was diagnosed with pneumonia.
Although the provider likely prescribed the best antibiotic for the pneumonia, it is John’s attentiveness that shines. In the days following the visit, she will see about coordinating other help, and will contact a solar panel repairman in Page, Arizona, who will agree to come out and take a look at the inverter.
“I’m there. I’ll clean house, chop wood, haul coal, if I have to,” she says.
After leaving, John turns back to Shonto. She has a busy day, not to mention week, ahead of her. First off, she needs to catch up on some patient paperwork, in addition to logging every mile she has driven and minute she has worked. Then, of course, there are her visits to many other community members, including Linda and Ned.
A half-hour and seven miles from Marie’s house, the puffy, black-bottomed clouds that have been casting shadows on the ground finally open up. Hail pelts the windshield.
But getting stuck won’t be a problem today. John timed it right. She is already descending into Shonto, on Indian Route 221, right beside the water-slicked canyon wall, which shines like a mirror.
*Patient names have been changed for privacy.