A groundbreaking textbook explains how old practices and modern medicine can work together for indigenous patients’ spiritual, mental, emotional, and physical health.
Working as a nurse at Santa Fe Indian Hospital in New Mexico, Margaret Moss thought she had seen it all in her career. Then one day, prepping a woman for surgery, Moss peeled back the blanket and saw something unexpected: An ear of corn had been laid next to her patient. The corn, Moss would learn, had a special spiritual significance to the Pueblo Indian tribe to which her patient belonged. It was a physical representation of the woman’s inner self.
“The corn is the person, and the silk is the hair,” Moss explains.
Moss’ impressive academic background — she has a PhD in nursing as well as degrees in law and biology — and tribal affiliation as a member of the Mandan, Hidatsa, and Arikara Nation make her uniquely qualified to work with tribal communities. Nevertheless, Moss says, years of education and an urban upbringing near Washington, D.C., didn’t fully prepare her for the regional variations in beliefs and customs among the 567 federally recognized Indian tribes. This knowledge can be crucial to understanding the distinctive health issues and challenges that affect Native Americans throughout the country.
“When did I ever learn this?” she says, lamenting the lack of Native-specific training in her nursing programs. “And I’m somebody that took great interest in American Indian things from the dominant culture world.
“If I didn’t know this, how would anyone else?”
It was the realization that knowledge of Native American culture was limited or nonexistent among many working outside tribal boundaries that led Moss to edit and write American Indian Health and Nursing (Springer Publishing Company, 2015), the first-ever nursing textbook specifically about Native Americans written for Natives and non-Natives alike. The book is the culmination of years of research in tribal communities, outlining health disparities and the history and culture of 10 tribal regions within the United States. More important, it’s an opportunity for healthcare workers to better understand their patients and, in doing so, help ensure that their treatments are effective.
These differences can be hard to discern for outsiders. As Moss explains, there are times when tradition can seem incongruous with the realities of tribal life and chronic illnesses like diabetes that affect Natives disproportionately.
“In the Southwest, people do these really large dances in traditional regalia while barefoot. There are high diabetes rates in the Pueblo area, and you have people dancing in the hot sun on dirt plazas,” she says.
Off the reservation, doctors may not be aware that some of their Native American patients lack running water in their homes, reliable transportation, or nearby drugstores, restricting their access to available treatments.
“You don’t know that they have to go back 150 miles, that they have no refrigerator. You can’t assume they have the ability to get to a pharmacy,” Moss says.
Moss, while a member of the Minnesota Board on Aging, interviewed a wheelchair-bound tribal elder with diabetes and arthritis on the flat, frigid North Dakota plains six miles from the Canadian border. During the harsh winters, the man was dependent on other tribe members to deliver supplies and clear the 10-foot-high snow drifts accumulated in front of his outhouse.
“The man lived in a teeny little wooden structure home, probably as big as most people’s two-car garage. There was a potbelly stove in the middle of his home with wooden slats for the floor,” she says.
To the outside world, the man’s living circumstances could be considered inadequate for someone whose frailties made him susceptible to the elements.
“From the tribe’s perspective, he needed to be there,” she says. The elder was a cultural expert whose knowledge was highly respected. “If you didn’t know that, you would say, ‘He’s got diabetes and arthritis. He can’t be up here.’ He was happy living there. They don’t want to leave because the spiritual aspect is more important than the physical.”
The story illustrates a tenet of Native belief about health: All four components — spiritual, mental, emotional, and physical — must be in balance, much like the holistic paradigm that nurses are taught in their curricula.
“One elder recently told me at a conference, ‘You have to think of the four domains of a person like a car with four wheels. If one is flat, you’re going to have a very bumpy ride,’” Moss says.
This expression proved to be applicable to Moss, who witnessed family members struggle with alcoholism and self-medication while growing up in a suburb of Washington, D.C., suffering from what she describes as “the vestiges of historical trauma.”
“There was a lot of prejudice in the mid-’60s. We were probably the only Indians in our town,” she says.
Witnessing the early deaths of several of her family members from liver failure, HIV/AIDS, and complications from diabetes made Moss want to study a healthcare system whose failures disproportionately affect Native Americans. According to the National Congress of American Indians, Native Americans live an average of six years less than other ethnic groups and have higher rates of diabetes, heart disease, and substance abuse than any other group.
“All these factors intertwine,” Moss says. “There’s more to the person than the physical. My siblings had every physical thing taken care of, but they had three ‘deflated tires.’ The emotional and mental weren’t working.”
Part of the difficulty in assessing cultural needs, she says, is that healthcare providers may not know that someone is Native American and are afraid to ask for fear of offending them.
“In the East, everyone thinks I’m white; west of the Mississippi, everyone knows I’m Indian. In the Southwest, people think I’m Spanish,” she says. “I’ve had four kids, and no one’s ever asked me what I was. How do you propose to give culturally competent care?”
Moss’ hope for the book is to raise awareness of the needs of the Native community, for whom federal healthcare funds are often lacking.
“Before there was nothing; it did something. I have no idea if people will use it but at least it’s out there,” she says.
From the August/September 2018 issue.