There is growing recognition today of the importance of cross-cultural issues in medicine. No matter how well-intentioned a caregiver is, it's not possible to truly serve the needs of patients without understanding their cultural assumptions and tenets. This point is illustrated by a medical student's perspective on two clinical rotations in very different settings.
Gallup, New Mexico
As I get off the airplane in Albuquerque, N.M., the first thing I notice is the sky - a deep-blue dome that cuts into the desert at a right angle all the way around the horizon. On the drive west to Gallup, the shimmering highway never wavers from its straight path through the waterless scrub, flanked on both sides by low, red cliff faces.
Gallup is close to the Arizona border, its billboards rising up suddenly out of the sparse growth. The town - a cluster of muted brown buildings - squats to the south of the highway and stretches its arc of neon lights north into the Navajo reservation. This is high desert - its elevation more than a mile - and the rays of the sun, having a less atmosphere to penetrate, are brilliant and unwavering on this warm spring afternoon.
I step out of the car and into an arid westerly wind (which never stopped blowing the entire time I was there). The wind blurs the sharp boundary between desert and sky, scraping meager, dusty soil from the red earth and forming a roiling, ocean-like wave that moves ever-eastward. This wave breaks in dusty grit against the west-facing walls at the high points of the town. The town of Gallup is where I will spend the next month, caring for pediatric hospital inpatients as a third-year medical student.
Navajo children come to the hospital with a parent or relative after having traveled most of a morning to this, the largest and nearest town. Both the town and the hospital look tired and dusty. Even the ubiquitous, familiar fast-food signs seem somehow to have been muted over time by the scratchy desert wind and unrelenting sun. The predominant noise in this town is the hum and vibration of truck tires on Interstate 40 - bearing loads headed westward to Arizona and beyond. For the few trucks that pause here, historic route 666 curves through the north end of town, connecting a row of pawnshops and truck-stop motels.
The Gallup Indian Health Service Hospital perches on the highest point of Gallup and leans its crumbling stone facade into the persistent wind. A dusty smudge follows each car or pickup truck that drives in on the dirt reservation roads leading to this largest of Indian Health Service hospitals. Patients wait to be seen in cracked red fiberglass chairs. Long, parallel, colored lines of tape bunch and diverge on the hallway floors, directing patients to the various clinics. The hospital fans out in all directions over four floors of skinny hallways and 1960s decor. Faded blue doors open into rooms with thin orange curtains that try, in vain, to keep out the harsh glare of the desert.
The hospital is dated, and the town of Gallup is financially undernourished, but both are thriving compared to the reservation that lies to their north. The Indian Health Service cares for a Navajo population that is, by some estimates, almost 75 percent unemployed. Most homes on the reservation have dirt floors, and only rarely is there a phone, electricity, or running water. And, yet, when I interact with these people - some of whom have ridden for hours with a neighbor to bring in a screaming child - I am always left with a deep sense of their quiet dignity.
In Gallup, I am able to witness in actual patients what I have previously only read about in medical textbooks. I see gall bladder disease in young teenagers, and signs of insulin resistance in a slim and active 13-year-old. In non-Native American populations, these are both largely adult diseases. Behind the health problems in this town of pawn shops and laundromats lurk signs of bleak poverty and little hope for future change. This is an area of little water, no new industry, and few jobs. A Navajo teenager can either search for a new life in the foreign culture outside the reservation or stay in this arid desert, where alcohol competes with the beleaguered public schools for the attention of students. The quiet courtesy of the Navajo people belies the extreme stress of their situation today.
The nights in Gallup are cold and star-filled, and the constant wind chatters against my apartment windows. The piercing beeps of my pager often bring me out of a deep sleep, echoing in rooms empty except for a bed and a few rented pieces of furniture. I then trudge up the hill to the hospital - often winded by the short walk, due to the altitude - and ride the elevator up to the quiet, half-light of the nighttime pediatric ward. Most of the nurses in the hospital are Navajo, and when I answer a night call I usually find the pediatric nurses clustered and chatting easily at one end of the long desk that holds all of the inpatient medical records. I sit at the other end, with one of the physicians who is just out of residency, and quietly write orders for admission. The physicians at the hospital, unlike the nurses and staff, are largely Caucasian and relatively new to Navajo customs. Throughout my stay in Gallup, I wonder how the Navajo staff see me - a medical student, a white outsider.
I never glimpse any of my apartment neighbors during that lonely month, and not one pair of shoes save my own crosses the threshold. I have weekends off and use them to flee in my car, craving conversation and contact with a more familiar world. But those conversations - as I visit friends in Phoenix, as I hike down the trails of the Grand Canyon, as I tour Santa Fe with my father - are always about Gallup. I try in vain to explain the contradictions of the place: its crumbling infrastructure in the midst of such natural beauty, the traditional Navajo trapped in modern clothes and cars. As the month wears on, I anticipate with increasing longing my return to my wife and my young daughter back in New Hampshire. But even as I ache to leave the place, something compels me to consider the possibility of returning there someday as a physician.
I spend a month talking to the Navajo and treating their children, and yet never do I get a glimpse beyond their polite, stoic exteriors into their ineluctable desperation.
When the month is over, I leave in the middle of the night for an early flight home from Albuquerque, silent in my tiny rental car. As the constant wind and the wakes of huge trucks buffet me back towards my world, my family, I wonder about the future of theirs.
White River, Vermont
He comes in on one of two intersecting highways, driving in the far right-hand lane, his vintage windowless van tracing a thin line of gray smoke around one of the many interstate cloverleaves encircling this hillside setting. He has traveled from a small town in northern Vermont, leaving behind the quiet safety of his trailer in the woods to make the hours-long drive to the VA.
The "VA" is the Veterans Affairs Medical Center in White River Junction, Vt. It looks like a small, disorganized city from its front entrance at the bottom of the hill. The hospital rises up in a jumble of red-brick additions, between a row of gas stations and truck stops on the road down below and the Vermont woods that stretch northward behind the water tower out back.
I follow the green and gray van up the curved driveway. Now, I turn into the main parking area, while the van continues slowly into the crowded handicapped lot right in front of the main building, with its heavy white columns and too-small windows. Glittering red, white, and blue Disabled American Veterans' vans shuttle infirm patients to the different entrances. As I walk in from the parking lot, it is immediately apparent that this is a culture of bumper stickers. One bears a small, black profile and the words "You are not forgotten" while another shows only the green, gold, and red of the Vietnam Service Medal. Many of the rusting vans or pickups have spraycan-mottled amateur paint jobs and license plates emblazoned with a Purple Heart. I also pass a group of symmetrical, polished gray granite blocks that stand at attention and list the names of local veterans who served in Vietnam. As I near the building, I see a group of stooped and watchful fair-weather smokers chatting just outside an entrance.
The doors to the emergency department open automatically, noisily. Inside, the clinics are clustered, seemingly randomly, by numbered desks. The place is a labyrinth. There are outpatient adult clinics, a drop-in clinic (where some patients wait all day), specialized referral clinics, and inpatient wards; there's radiology, pharmacy, and the financially-threatened surgical service. In fact, this VA hospital has been at a fiscal crossroads for the past few years, expanding and shrinking, wondering if its hallways will get a new coat of paint to cover the lime-green of the 1970s, or if the veneer of dust over closed clinics will ever be lifted.
White men in their forties, fifties, sixties, and seventies - the majority of the VA's patient population - wait socially with wives or friends, sitting for hours on slippery brown-vinyl chairs. Many of the men are overweight and move with a shuffling gait or in a wheelchair from waiting area, to reception desk, to smoking area, and back again. The veterans suffer from a myriad of ailments, ranging from anxiety, post-traumatic stress disorder, and substance abuse to diabetes, congestive heart failure, and lung cancer. The VA brims with socioeconomically challenged patients who present with multiple diagnoses and even more prescription medications.
As a fourth-year medical student, and as a veteran myself, I am in a position both to see these veterans as they are and to imagine them as they were - fighting for us so many years ago. And I can learn from them, both in the halting way of the medical student and as a fellow former service member, hearing echoes of my own story as I listen to theirs. Being at the VA brings our emotions to the surface as we meet, connect, and try not to remember.
And, yet, they are relieved to be at Desk 40, which happens to be under construction, on this brilliant late-summer afternoon. They chat and smoke and trade their stories of isolation. A nurse stands at a microphone and calls out a name. A quad-cane hoists its owner, and he limps toward her. The place is full of stoic patients, braving the clumsiness of the medical student and the junior resident with cheery resignation. Mostly, they just want to talk.
The VA is a supportive environment for these veterans, a moment away from their isolation. The facility even boasts a store and a cafeteria and its own police force. The police officers are posted just down the hall from a dusty room with a worn "foosball" table, a velour couch, and the 12 points of Alcoholics Anonymous written on a chalkboard. This hospital - this community - is a place where everyone jumps at the same loud noises, where happy memories of a shared duty-station are mingled with flashbacks of violent death to which nightmares cannot compare.
The VA communes with those who, all too often, have no other community. While many veterans move on to prosperity, others here are beyond the concerns of health maintenance and the flexible sigmoidoscope. These are men, mostly, who hang on to the edge of society, who sit with their backs to the wall and face the door. Sadly, because we did not allow them tears when they came home, we will care for them here for the rest of their high-risk lives.
The author is currently a fourth-year student at Dartmouth Medical School. After earning his undergraduate degree, in earth sciences, from Dartmouth College in 1987, he entered the Navy and spent the next 10 years as a pilot. He flew F-14s as a fleet naval aviator from an aircraft carrier in the Mediterranean and Red Seas, enforcing the no-fly zones over Bosnia and Iraq, and F-18As as a fleet adversary pilot in Key West, Fla. He has also taught in the Naval ROTC unit at Texas A&M University. After his graduation from DMS in June, he plans to do a transitional internship at the Naval Hospital in San Diego, Calif.