jeudi 24 janvier 2013
PATIENT CENTERED PEER EDUCATION: AMONG THE KICKAPOO/KIKAPU OF TEXAS/MEXICO
PATIENT CENTERED PEER EDUCATION AND HEALTH CARE…AMONG THE KICKAPOO/KIKAPU OF TEXAS/MEXICO
The 10-seater van was fairly new, had Mexican License plates. Mena stopped at various homes in the Kickapoo Reservation in Eagle Pass, Texas, sloping down to the river, which marks the border between USA and Mexico. We were on our way to Piedras Negras, Mexico, crossing river on specified bridges under the watchful eyes of Mexican Police and Military. During this short trip, the van was full of laughter, the heart felt laughter the Indians are capable of-the conversation was not in English or Spanish, the languages of the countries we were traversing but in ancient Algonquin tongue-Kikapu/Kickapoo. I was the only one that did not understand the language, but as a Physician-anthropologist it gave me a chance to observe or continue observing the social customs of this ancient people.
Nobody would ever guess that the van was transporting a group of patients to be seen, consulted and treated by three health care professionals.
A Mexican doctor, specializing in Family Practice, Homeopathy and Complementary Medicine who had virtually grown up with the Kikapu (her father was their doctor for many years until his untimely death)
An AUS/UK/USA trained Endocrinologist-Anthropologist who is a visiting Professor at the University of Havana, in Cuba as well as a Consultant Endocrinologist to various Indian tribes.
A member of the Kikapu tribe, who is a Peer Health Educator of many years experience and a good friend to both above. She is the central person in this narrative, who organized this trip, selected the patients from the long list of Kikapu who consult her at her home, she selected a few who were not satisfied by the medical care in Eagle Pass or San Antonio by GPs or Specialists (failure to resolve their sufferings). Mena had taken the day off from work as an accountant at the Tribal Casino plus sacrificed her family life by spending the Saturday following doing the same.
In this Peer Educator oriented Health Care, not just Disease care, the emphasis is on talking and expressing of emotions. Neither of the doctors could interfere nor interrupt the conversation since they did not understand the language, and also both were culturally competent. (In America, where an average medical consultation lasts only 7-12 minutes; the MD/FNP/PA interrupts the patient narrative in less than one minute, in the name of guiding the narrative, but more likely because of lack of interest).
Every now and then Mena would turn to me and explain the conversation with the patient and translate the symbolism inherent in the conversation, and hand over the bag of medications prescribed and purchased in the USA (which they may or may not be taking).
All Primary Care Providers could take a point from here: they have to be culturally sensitive and culturally competent, if you are looking after people in a mixed cultural setting, which most of the USA is. They also have to understand the symbolism, hidden in their expressions and have to be very polite when it comes to counselling the patient. He or She cannot afford to put self-pride before these.
On the average, the three of us, the Mexican MD, the Endocrinologist-anthropologist and Peer Health Educator Mena spent one hour, at least, with each of the Kikapu patient. We didn't finish our consultation, each of us taking turns in no particular order, until the patients were satisfied and their queries answered to their satisfaction. We could order and get the Laboratory tests as one was open nearby, and the patient could go home with the prescribed medications from the pharmacy around the corner, thus alleviating extra trips for blood tests or seeking medications from pharmacy. (Also saving money for the tribe because medications are only a fraction of the price in Mexico). From the point of view of the patient: (1) the sociability of the situation contributes to their wellness, they can socialize while the consultation is taking place, before and then some afterwards.
(2) The satisfaction that their problems are attended to in the manner that culturally and emotionally satisfactory to them.
(3) No need for an extra trip to draw blood for labs, another visit to the MD for him to explain it to you, and yet another visit to the pharmacy to pick up the medication
(4) During the entire time they were at the clinic, about four hours in all, they were not forced to speak either English or Spanish but could speak their traditional language and could explain their symptoms and suffering in symbols that the Peer Educator understood and translated it to the two doctors. They know the words for their suffering in their language but not in Spanish or English.
These descendants of an ancient culture, striving hard to maintain their cultural identity, are caught between their holistic belief systems and the technology/profit/time demand of an American civilization to which the doctors and other providers in Eagle Pass and San Antonio belong.
Not only it is the satisfaction of the individual patient where time and cultural appropriateness is attended to, the tribe also saves money because of the efficiency of the care and the absence of inappropriate tests and treatments.
It was more than 5 hours when we had finished with the last of the consultations, they were patiently waiting knowing fully well that each one is being attended to, and in the end they all got into the van and returned home.
(Later that evening, I was told that some of the older ladies were bent on preparing a traditional Kikapu meal for us when we returned to the reservation)
One case presentation to demonstrate the effectiveness of
This Peer Educator!
61-year-old lady with repeated visits to Emergency Room and Clinic for Anaemia and High Blood Sugar.
She was given what appears to be a standard treatment on the other side of the bridge in Eagle Pass, Texas
70/30 Insulin twice a day, 120 units
Metformin twice a day, 1000 mg twice a day
She had received blood transfusions for her anaemia at the Emergency Room
By looking at the treatment regime, any Endocrinologist can tell you that the Primary Care Physician was treating the lab results in front of him, rather than the patient.
Using the anthropological approach, I directed the question at Mena.
Why does she think she has low blood? (Anaemia)
Then comes the revelation! She said:
I think it is because of my habit of peeling and then juicing and drinking the lemons!
How may Lemons do you peel, juice and drink?
At least 8! As if we were unconvinced, she shows us the nail bed of her right thumb, which is eaten away because of the corrosion! We could only wonder which other parts of her body were corroding!
She continued; after the last time I got a bag of blood I made the connection and stopped eating Lemons.
Did anyone ever ask you about this habit of yours?
No, you are the first one!
We will get a blood test and see how well your blood is responding after you stopped eating Lemons.
What about your sugar?
Are you taking all the medications prescribed for you?
Then why do you think your sugar is always over 200?
I think it is because I drink at least six cans of regular coca cola per day.
I mentally calculated, 149 calories per can, six cans 900 calories, 15 calories in one teaspoon of sugar, 60 teaspoons of sugar!!
I told her
She did not flinch.
Mena steps in. It would be good for you to reduce the number of cans you are drinking. She agrees.
That simple act will assist her body in more ways than all the Metformin/Glimepiride/Insulin!
The idea is not to increase medications, the MD had increased all the medications to their limits but none of which had shown any beneficial effects, these medications are probably not strong enough to ward off the dangers of High Fructose Corn Syrup or Maltodextrin or other chemical sweeteners in a can of coke.
(THE PEER EDUCATOR RECLINING WHILE CONDUCTING THE LAST OF MANY INTERVIEWS LASTING HOURS)
Thanks as always to the unselfish dedication of Dra Estela Rosales Garza of Muzquiz for her attention to the well being of the Kikapu. I consider her one of the best practitioners of the art and science of Medicine…anywhere in the world.