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Reducing Social Determinants of Health on the Navajo Nation

jahasteen 1 / -  
May 1, 2021   #1
The following essay is for my English 102 class that indicates we must write an argumentative research essay. I would like to know what my three weakness and three strengths are. I appreciate any assistance you can provide :)

Reducing Social Determinants of Health on the Navajo Nation

Access to health care on the Navajo Nation has been a long standing issue for tribal leaders and have been actively voiced by health care professionals. The presence of health disparities against the indigenous population of North America have persisted for over 500 years since Europeans first settled (Jones, 2122). The constant neglect by the federal and tribal governments are partly to blame for the large gaps in care that ultimately place Native Americans at a disadvantage when it comes to health management. Tribal leaders have the resources available to them to close the gaps and eliminate these barriers, but little has been done to do so. The main question is why? This paper will argue that Navajo Nation tribal government has failed to close gaps in care by demonstrating that several opportunities have presented itself to improve the quality of life of its members on the Navajo Nation by reviewing past research focused on addressing and identifying social determinates to health, increasing accessibility to healthcare, and participating in community-based initiatives.

The existence of combating social determinates to health is not a new concept in fact has been reviewed over and over by various governments through the World Health Organization which developed a commission in March of 2005 to specifically address the concerns of social factors leading to ill health and health inequities (WHO). Since the United States is part of the World Health Organization, it is fair to say that the U.S. participates and structures its response to addressing health inequities through the recommendations made by the World Health Organization. Some experts may argue that the Navajo Nation is a sovereign nation and is responsible for their own planning and infrastructure related to health management and that would be true if the Navajo Nation was able to self-govern to the extent of maintaining their own economy and not rely on federal support. Furthermore, the Indian Health Services, which is an agency within the Department of Health and Human Services, is responsible for providing health care to Native Americans within the United States (IHS.gov). Operating under federal jurisdiction makes the Navajo Nation more of a state than an actual self-governing nation. Also, to prove that the Navajo Nation does rely on guidance from the World Health Organization, Executive Order No. 001-200 Declaring A State of Emergency Due to the Confirmation of the Covid-19 virus in Regional Areas Surrounding the Navajo Nation released by the Navajo Nation White House on March 13, 2020 references recommendation made by the World Health Organization and other agencies within the federal government.

Establishing that the tribal leaders do take part and listen to these external agencies it is clear that previous recommendations were neglected and that tribal leaders are aware that social determinates to health do exist but have not done anything to correct the issue. A specific example of this can be seen in the hundreds of residents on the Navajo Nation that lack the basic fundamentals to disease prevention which is running water and electricity which according to Neeta Thakur in her article "The Structural and Social Determinants of the Racial/Ethnic Disparities found in the American Journal of Respiratory and Critical Care are two basic factors of proper hygiene care and disease prevention (943-949). This makes sense as we are often told that washing our hands removes germs and that would be very difficult to do if people did not have access to running water. Thakur also indicates that the lack of electricity prevents people from utilizing more advances technology that may require the use of electrical outputs.

Those who work in the tribal government may express that they have been working on providing access to running water and that they may have been limited due to funding. This is where I would argue that funding has always been provided to provide members of federally enrolled tribes housing with running water and electricity and that his was specified in the Native American Housing Assistance and Self Determination Act of 1996. Reports released by the Department of Housing and Urban Development indicate that since 1998 over 1.66 billion dollars have been allocated to the Navajo Nation to develop homes with running water and electricity to tribal members and that less than 500 single unit homes had actually been built. The report also indicated that roughly 34,000 homes were needed (HUD.gov). It has been over 25 years since the act first passed and to this day families on the Navajo Nation have not been able to access homes with running water and electricity further adding to the negligence of the tribal government.

In addition to the lack of access to running water and electricity, the lack of access to medical treatment facilities is a major barrier that affects the care continuum of those who suffer from comorbidities and require follow-up to ensure proper disease management. Accessibility to care is one of the biggest challenges that attributes to the existence of social determinants of health as it does lead to high rates of mortality and poor disease management. Researchers have identified that preventative care and regular follow-up care is crucial to maintaining health standards and quality of life. This can be seen in chapter 12 of Nancy Lopez's book Mapping Race: Critical Approaches to Health Disparities Research where she identifies that the care continuum is vital to improved health outcomes and interestingly suggest that racialized-gendered social determinants of health are to blame because "the framework that interrogates intersecting systems of stratification at multiple levels" is what drives medical systems to operate within specified regions. This quote is a reference to the social and political systems at the state, federal, and local levels in terms prioritizing access to care. Although there is a new hospital developing on the Navajo reservation in Dilkon, AZ, the fear is that this hospital will not be properly staffed or maintain the necessary resource for emergent care but may service as a central point for primary care needs. The preventative model is also favored by insurance payers as it reduces to cost of emergency visits and overall improves the quality of life which is also expressed in Jennifer Haas et al article "Effects of Managed Care Insurance on the Use of Preventive Care for Specific Ethnic Groups" published in Medical Care which is a peer reviewed journal.

Lack of transportation is another major concern that researchers have shown to be on of the biggest drivers to poor health outcomes as many people who reside on the Navajo Nation do not have the means to travel of afford to make routine trips to the reservation as some are on fixed incomes and other have no source of income. An interview with the Director of the Navajo Nation Washington Office, Mr. Jackson Brossy, revealed that tribal government is aware of the transportation issue and have adopted a non-emergent medical care model which allows for patients to be transported to their appointments at no cost and everything was billed to the Arizona Health Cost Containment System (AHCCCS). One would say that this shows that the tribal government is indeed trying to address the barriers and is being proactive in extending care. Normally I would agree but the issue that remains is that this would only cover members that are located within the state of Arizona. The Navajo Nation stretches across four states being Arizona, Utah, New Mexico, and Colorado. A majority of the reservation is located within Northern Arizona, but this model does not address the members that live on the reservation in the surrounding states. When questioned about this, Mr. Brossy had not comment to provide for the outer states and directed me to conduct my inquire with the Navajo Nation Department of Health. I attempted to reach out to the Navajo Nation Department of Health but there was no response.

A relatively new approach that the tribal government has made is working to increase accessibility to healthcare through diverting resources in improving the tribal infrastructure to promote telemedicine models which would extend access to care for manageable and low risk members reducing the cost of transportation (Begay, Kakol, and Sood). Although there are good intentions, the issue with this move correlates back to the issue of the lack of basic fundamentals being running water and electricity. Improving the infrastructure is one thing but the ability to utilize telemedicine services is futile without access to electricity and running water to practice simple hygiene techniques. In addition, there is reason to suspect that older generations may be resistant to modern technology as well as western medicine as they are more intertwined with traditional and spiritual ceremonies. The article argues that telemedicine also includes telemedicine where I would rebuttal and further indicate that not only would the lack of electricity prevent them from engaging but that most spiritual ceremonies involve physical contact by holding and ingesting herbs provided by the healer. Thakur makes strong arguments that basic fundamentals have a large impact on health outcomes, and it is true in the sense we are very technology dependent. How does the tribal government expect its members to engage in telemedicine or improve the technology gap when the issue predominantly starts within the household. Focus should be to providing families with the homes they were to receive 25 years ago before improvements are made in other categories.

One practice that is favored by health professionals and is not largely adopted on the Navajo reservation is participating in community-based initiatives. If the tribe diverted more resources and participated in more community-based initiatives, there would be a larger impact on health outcomes that would be beneficial to communities while the government continued to improve the housing situation. Research conducted suggest that health outcomes are attributed by ethic identity which shows a positive shift in self-identification and adds to an increase in health outcomes. This is important as it addresses several concerns mentioned previously especially with older and more traditional tribal members. Specific research to support this idea includes studies relating to oral health initiatives that appear to have the ability to be replicated in other health specialties. "Association of Ethnic Identity with Oral Health Knowledge, Attitudes, Behavior, and Outcomes on the Navajo Nation" published in the Journal of Health Care for the Poor and Underserved suggest that the linkage between health outcomes and self-identification enhances connection to culture and increases positive relationships with care providers (Brega, Henderson and Harper).

Common challenges include economic hardship and the scarcity of resources; both which are important social determinants of health and Brega, Henderson, and Haper suggest that additional research needs to be conducted to clarify the role. The tribal government should be taking the advice of these professionals and allow for continued research to better plan for additional initiatives.

There are several other researchers who share a similar thought to include the research paper "A Cluster-Randomized, Community Based, Tribally Delivered Oral Health Promotion Trial in Navajo Head Start Children" that was published in the Journal of Dental Research that discuss how ethnic identification plays a role in health and this article focuses on testing how community-based initiatives focused on the promotion and intervention of health.(Braun, Quissell and Henderson).

Adopting a community-based approach would serve the tribal government well as it would keep the community engaged in disease management and also reduce the impact that current barriers have. Implementing community health representatives and programs shows positive results in disease management and can be seen through different programs such as the Navajo Nation Special Diabetes Project. The Special Diabetes Project seeks to manage diabetes in the community by increasing physical activity and providing nutritional counseling services (NN.gov). The Navajo Nation President, Jonathan Nez, said himself in a special press release from the Office of the Navajo Nation President that "Nez-Lizer applaud three-year reauthorization of the Special Diabetes Program for Indians to help address health issues on the Navajo Nation". The same press release also indicated that the President Nez approved of the program because it "empowers tribal nations to make decisions at the local level, to choose best practices, and adapt the program to be culturally appropriate".

If the Navajo Nation President sees the value in these types of initiatives, then why are more resources not being diverted into these initiatives? Research has shown that these initiatives have positive results. More importantly, community-based initiatives that relate and address cultural and ethnic concerns have the most positive results. Letizia Trevisi et al. supports this by suggesting the integration of community health representatives with health care systems playing a role in culture increases participation in health and health outcomes through clinical and cultural intervention. Trevisi's research revolved around management of diabetes which produced results indicating reduced rates of diabetes on the reservation (7-8).

Overall, the existence of these social determinates of health to include accessibility to care, disease management, transportation, and quality of care could be eliminated through aggressive intervention by both the federal and tribal governments. The willful negligence from both sides is apparent through the review of past research and current issues such as the COVID-19 pandemic. Simple factors such as the ability of wash one hands would play a pivotal role in disease management. The lack of running water and electricity are the major culprits to this issues and it appears that little to nothing has been done to address the issue. The federal government must intervene and implement strict requirements on the tribal government of the Navajo Nation of its members are ever to achieve health equality. By simply taking advantage of the opportunities that present itself the tribal government of the Navajo Nation could improve the quality of life of its members through acceptance and review of past and current research aimed at addressing social determinates to health, increasing accessibility to healthcare, and participating in community-based initiatives.

Works Cited
Holt  Educational Consultant - / 13,886 4564  
May 2, 2021   #2
Consider providing a historical perspective of how the Navajo healthcare system came to be at the start of the presentation. The arguement that you present lacks historical data to explain why the national government cannot interfere with their healthcare system . These information will help the reader understand the root of the problem and provide a clearer understanding of the Navajo healthcare system works independently, while still being a part of the U. S . health department.

For those not familiar with the reasons why the Navajos are considered a nation rather than a state, a basic explanation will be needed . It appears to me that your paper has too broad a coverage to be discussed in arguement form . You still need to narrow down your topic focus to come up with an effective arguement. That is because the problem runs too deep in terms of history and errors in judgement on both sides.Maybe choose a more specific topic in relation to the Navajos that doesn't require too deep a backstory when it comes to arguements ?

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