AAP Voices Blog

I hold on tightly to the dash of our four-wheel-drive vehicle, which bumps along the narrow clay dirt road and often drives up onto the side to avoid the bottomless potholes. “None of these roads have a name,” the public health nurse in the driver's seat explains to me. “We only know where these patients live based on their descriptions - it’s taken me years to really get to know this community, and even then, sometimes I have a hard time finding our patients.” 
 
I’m on my month-long pediatric rotation at Gallup Indian Medical Center (GIMC) with the Indian Health Service (IHS) in Gallup, New Mexico, where my work in the pediatric clinic and in the community have shown me the stark healthcare disparities present in the Navajo community, especially in early childhood development. As pediatricians, we can make a difference by advocating for greater access to care for American Indian and Alaska Native children, who experience higher levels of Adverse Childhood Experiences (ACEs), special healthcare needs, abuse, poverty, and foster care.

“Home visits have significantly increased access to health care for many families. A Navajo nurse not only provides home care but understands the community and language and helps build trust among families in the government-run healthcare system.”

Today I am joining one of the Navajo public health nurses on her home visitations. After feeding her cattle on the reservation, she commutes an hour and a half into work every day. Home visits have significantly increased access to health care for many families. A Navajo nurse not only provides home care but understands the community and language and helps build trust among families in the government-run healthcare system.
 
We pull up to a hogan, an octagonal-shaped, traditional Navajo home that has a single room with a wood stove for heat. An elderly woman emerges, and the nurse begins to speak to her in fluent Navajo. We are here to check on her newborn granddaughter to see how feeding is going, check if she’s gotten her vaccines, and help her find a primary care pediatrician.
 
I look around at the expansive New Mexican landscape with its red rock formations and no city buildings in sight. Near the hogan are two trailers where other family members live. There are at least six cars parked around, evidence of multiple families squeezed into one tiny home. Three stray dogs pick through small piles of trash outside the hogan. People here often are unable to afford trash removal. Many people still live without electricity due to the expense and difficulty of wiring electricity to such a remote location. This lifestyle is commonplace on the reservation, just two hours from Albuquerque and four hours from Phoenix. 
 
One day at the pediatric clinic, I see Kai*, a 2-year-old Navajo boy, for his well check. I imagine him living in one of these homes - it must have been challenging for his family to make it to our small town of Gallup for his well child appointments. He says only a few words and doesn’t make much eye contact. After discussing his development, I mention to his mother that he would benefit from a developmental evaluation in Albuquerque to check for autism. She looks down, explaining that she doesn’t have the gas money or means to go that far away. 
 
I hear similar stories multiple times during my short rotation at the Gallup Indian Medical Center. I later realized that even if Kai’s mom were able to make the two-hour drive to Albuquerque, she would find no Applied Behavioral Analysis (ABA) therapists near Gallup and limited access to other therapy services. Access to medical care in these remote communities is even more difficult because the roads are often impassable with any adverse weather. The lack of electricity makes telehealth, a strategy often used in rural communities, more challenging for Navajo families. 
 
While data is limited on the prevalence of autism spectrum disorder and developmental delay in Navajo children, several       factors put them at increased risk, including poverty, heavy metal exposure, food insecurity, and alcohol exposure in pregnancy. Navajo Nation offers an early intervention program called “Growing in Beauty,” or “Hozhóógo Jinóóseeł,” that provides home visits, if the roads are passable. I encourage Kai’s mom to sign up     .
 
“Hozhóógo Jinóóseeł” comes from the Navajo belief of “hózhó,” which is often translated to mean “beauty and balance” or “walking in beauty” to describe how they strive to maintain a balanced life in harmony with nature and their people. The program, much like my visits with the Navajo public health nurses, aims to provide culturally sensitive developmental care by people within their own communities.
 
However, once children turn 3, they no longer have access to early intervention. With the limited resources and transportation difficulties, children with developmental disabilities often do not receive services until around age 5 or 6 when they start school.            

Indigenous populations experience some of the highest rates of poverty and healthcare disparities compared to other racial groups in the United States. One of the greatest barriers to improving health is the remote nature of their reservations. I now understand how hard it is for children like Kai to make appointments on time when they travel many miles on rough dirt roads, making home visits vital to ensure children are up to date on vaccines and receiving proper health care. Home visits like the Public Health Nurse program and Growing in Beauty early intervention help promote access, but more must be done to help increase access to care in the communities where patients live. 
 
As pediatricians, we can advocate to increase access to routine healthcare and services for American Indian and Alaskan Native children with developmental delays. 
 
Through the AAP, the Council on Native American Child Health organizes advocacy and educational efforts to help reduce healthcare disparities in Native Populations, including increasing access in remote communities. I urge pediatricians to help advocate for patients like Kai to get the healthcare that they need and increase access to home-based services. Please see the following AAP resources to read more and find was you can help increase healthcare access for Native American families: 
https://www.aap.org/en/patient-care/native-american-child-health/

*Name changed for confidentiality