Rural medicine

I worked many years in rural medicine in the USA, both in small towns and in the IHS (Indian Health Service).

Dr. John Campbell mentions the AmerIndian covid crisis in this video and there are a lot of invisible things I commented on and needs to be noticed when people discuss medical care in that community.



One: the obvious: Poverty.

Two: not so obvious: People often live in extended families, and a home for grandmom might include her grandchildren whom she is raising: the extended family and friends usually care for each other, so a house might have a lot of family and visitors there. 
If we needed to get information to a patient, often it meant notifying a relative to tell her to contact us. We also had local Tribal health workers who did home visits to check our elders for problem and do wound care on our many diabetics.

it also means that, unlike upper middle class "white" culture, no one dies alone: the entire family will stay in the room or waiting room while the patient is critically ill (hmm...sounds like us in the Philippines...)

Three: Tribes differ: and you have to know the value system of the tribe. Navajo people don't think the same as a Hopi or Objibwe for example... This is one reason that there is "Indian preference" for hiring, because you might miss the cultural cues when you treat the patient.

which brings us to: genetic differences.

Three: a very high rate of diabetes, with it's complications of high blood pressure, renal failure, heart disease, and limb care. 

Prevention of amputations is the reason most clinics have podiatrists visiting weekly to cut toenails and do foot care, and in Minnesota, we had a visiting surgeon who evaluated wounds and did vascular bypasses as part of our outreach to lower the rate of amputations. And there are clusters of immune diseases in some families: Rheumatoid arthritis, Lupus, etc. so most clinics have a visiting Rheumatology clinic.

There is also tuberculosis, albeit not really a problem now, but sometimes missed on X ray (I saw a lot in Africa, so diagnosed one on an x ray before it was sent out, so sent the patient for a bronchoscopy to culture her lungs: The nurses got very upset at me that I diagnosed her, since it meant x ray and follow up for them and six months of biweekly visiting nurse visits to supervise that the patient took her medicines correctly). 

this brings us to: 

Four: The hospitals are often understaffed and slow to get up to date equipment, but the public health outreach and preventive medicine is good.

finally you have 

Five: the side effect of cultural clashes, unemployment, etc. that leads to alcohol and substance abuse. And yes, AA and other groups are there to work with these patients. But they also lead to families falling apart (and a lot of kids brought up by Grandmom or a relative). Which is why it helps to have a nurse who knows the family to let you know the background of the case you are treating.

In summary, the covid virus is dangerous to the rural AmerIndian population because of poverty, genetics, household crowding and co morbidity.

But the IHS and tribal organizations are already there to be able to track the contacts.
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In contrast, when I worked in rural medicine, one of the struggles is to get many of these social/public health resources: social work, psychiatry, lab tests that don't take a week to come back, and you spend a lot of time doing transfers to larger facilities that do have these resources. You also ran into the problem of uninsured patients (I left practice before Obama care). In the past, we just treated them and threw away the bill, but when HMO's took over, a lot of these patients ended up going to the ER for care, often later than they would if they could just see their local doc as they did in the past.

You also have to know the ethnicity and value system of your patients; American Hispanics, Mexican Hispanics, Central American Hispanics, Eastern European Ethnics, Italians, LDS/Mormon patients, etc.

a lot of what I have written is probably out of date: Medicine has become more cookie cutter and computerized since I retired, and Obama care probably has helped with the uninsured. On the other hand, the paperwork takes time from patient care, and the "efficiency" stresses mean you can't sit down and discuss the grandkids with grandmom because the business office sees this as wasting time, even though you get critical information about her and the family by such "gossiping".