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

Lisinopril

Atorvastatin

Glimipride

Fenofibrate

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?

Yes

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.

OUR HAIR DRESSER IN LONDON

OUR HAIRDRESSER IN KING’S CROSS

LONDON

One advantage of Loyalty programmes for travellers is that one gets an occasional free flight or a hotel room. Expert Frequent Fliers of course have ways of maximizing these benefits. There is even a very active website FLYERTALK in which the ways of accumulate these benefits are discussed in minute detail.

This is the third night that has been accorded to me at a rather nice hotel near King’s Cross station within a few months. Walking out of the hotel, towards the station, one comes across the paraphernalia of city living: mobile phone shops, take out and eat in restaurants and noodle stores, convenient stores with higher prices, to give some examples.

On this morning I went past a hair salon, peeped in, a solitary hairdresser looking after the coiffure of one, and an empty table in the back where the customary oriental lady is waiting for Nail/Pedi/Mani customers.

I decided to go in, to ask whether I could get a trim and shaping of my unruly hair.

How are you, sir, the vivacious hairdresser, greeted me, with a strong Mediterranean accent. Please sit down, when she was finished with the other client, she came over and said, what can I do for you, sir?

I would like a trim, but not shortening the length and a bit of a shape to it, I blurted. Wet or Dry? What do you recommend? Always better to cut it wet, she added with a theatrical flourish. She shampooed my hair and gave me a scalp massage, and then seated me in front of the mirror. She continued to chat in her chirpy voice. It was obvious she loved her work, her life in London. She is from Sicily, and regaled me stories of pasta of her grandmother, and pointing to her midriff. I was enjoying listening to her accent that one would hear in Godfather!

She had no time for foreigners who commented badly on the life in London or England. She was particularly harsh about the French, who come and beg her to speak in French, when she would say, we live in England, and I speak Good English, why you don't speak English? She had opened this salon eight months ago, feels that people are working so hard and long hours, that they could come and relax a bit in her salon while she looks after their hair, on their way home from work or at lunch time. This attention to beauty makes them feel better, she claims, with the expertise of a Psychologist, which in a manner she is. She keeps the salon open until 8 pm so that the hard working young executives have a place to go for a hair cut after long hours of work. In this day of inflationary prices for haircuts, her basis price is 10 pounds! And a little bit more for a wet cut. She attended to my hair efficiently, gave it a bit of a shape and attended to the beauty aspects of my face such as eyebrows, unwanted hairs etc. Viola!

I was expecting to pay 20 pounds or something close for such a holistic treatment, but she said that would be 10 pounds, that is all.

This hair cut for me was a pleasure, walked out of the place feeling good. I had made a new friend, Veronica, in London and she will see me again when I am in London!

INVISIBLE HELP FROM AMERICAN INDIANS

INVISIBLE HELP FROM THE AMERICAN INDIANS

Once you have been working with American Indians you begin to notice and understand symbolism of human behaviour and also understand that not all which occurs is amenable to explanations, faith is important and that being a good person is what is rewarded over and over again.

Something happened this past week during my visit to the Indians in Nebraska confirmed my already ground belief in the holistic interpretation of life of the Indians.

I arrived at the United Airlines Check in counter, I had already checked in on line, but had a bag to check in. An experienced agent, whom I recognized, was manning the desk and motioned me over. I gave her my printed boarding passes: Omaha to New York to London, arriving at London Heathrow Airport at 7 55 AM in the morning.

She asked may I see your ID please?

I was in a happy mood, so I said to her, I recognize your face, and don’t you recognize mine?

I do, but I still must ask you for your ID. I showed my passport to her.

She was tugging at the computer key and my mind was elsewhere, when she suddenly interrupted my reverie and asked me:

Would you like to get to London a little early?

Normally this kind of favours are not easily given but when asked is accorded to certain level of frequent fliers, of which I am one, but I did not request any favours today.

At what time would the flight you suggest get to London?

It arrives there at 545 AM and you might be able to avoid the rush at the Immigration and Customs, she said in a soft voice.

I would take the flight as you suggested if you could give me a nice seat. She checked and said I will give you a seat and at this moment no one is sitting next to you.

Thank you very much and I took the boarding passes and left.

I was now routed through Omaha to Chicago to London.

The flight to London was almost empty and I was surprised that there were no one sitting anywhere near me and I could easily spread out. Even more pleasant was that the flight was only a 6 h 40 minutes, one full hour shorter than the usual flight time.

I had checked the weather in London and the Continent few days before and they had predicted snow. After all it is winter, one expects snow, I thought.

The flight arrives at London, frigid cold, quickly through immigration and no one at the customs, walked over to the central bus station and by 6 am I was able to leave the airport and by 6 45 am I was at my destination.

It was cold, even though the temperature was only 0 C, but I had just left the reservation in Nebraska where the temperature was a minus 10 C! But it felt colder in London, the damp cold.

Soon after I settled down for a cup of coffee, the first flakes of snow began falling, and the pace accelerated and soon there was a full-fledged storm! The worst they had for the past few years…

300 flights at Heathrow was cancelled during the day, some flights had to circle around before they were allowed to land and some even after landing had to delay their entry into the gates for hours, up to six hours on the ground!

I have no doubt in my mind that had I taken the flight as planned from New York to London, my travel day would have been very different.

When you are with Indians for a while, you would realize the significance of such happenings. They and neither do I, believe that the intervention of the lady who had never smiled at me before did this without a reason! I am grateful.

More than 400 flights were cancelled on Friday and passengers complained about being keep on board aircraft for several hours awaiting take-off and then being unable to collect their luggage

A WEEK IN THE LIFE OF AN ENDOCRINOLOGIST

A WEEK IN THE LIFE OF AN ENDOCRINOLOGIST

TRIP REPORT: ONE-WEEK IN AMERICA

I was still a student in Australia when I read somewhere; I think it was WCFields an American comedian of his era who said:

First Prize is one week in Philadelphia

Second Prize is two weeks in Philadelphia!

I thought of it while writing down the title of this blog, without any disrespect to USA or its friendly inhabitants.

Day 1 UA 777 staffed by grandfatherly type Flight Attendants, looking tired life. Meal was not enjoyable; the wine I wanted was not available even though the brochure said it was, settled for a Russian River Chardonnay after two glasses of Heidsick Metropole. 

(Skyteam Lounge at Terminal 4 at LHR, food and drinks on the flight to Houston from London)

10-hour flight into Houston. Quickly through Immigration and Customs (Global Entry). A short connecting flight to San Antonio (40 minutes). The driver of the shuttle bus that took me to AVIS rent a car recollected our last conversation, about his lost chances of visiting Australia, when I was here in December! Incredible! Quickly to Comfort Inn where an attractive Mexican American girl assigned me to a very large room.

Day 2

(Traditional soup of the Kickapoo)

An uneventful two and half hour drive to the Kickapoo Reservation where my sister Mena was waiting with a traditional Kikapu soup. vegetables and chicken. Within a few minutes, we were off to Mexico in a van full of patients she had organized to be seen and treated there by our team of 3.

(A van full of Kickapoo patients to Mexico)

 By the time we finished at 8 pm, I was tired and yawning with jet lag stepping in but it was time to get back to Eagle Pass, USA for a pleasant dinner at Don Miguel Parrillada. The effervescent manager recognized our Mexican colleague and treated us to some heavy cheesecake! I chose Pollo Azteca with a tantalizing Margarita and that made me my own somnambulistic shadow even before I fell asleep at the Reservation.

(Dinner with Mena, Doctora, Sr Davila at Don Miguel Parrillada in Eagle Pass, Texas)

Day 3

The morning fog was very thick and it was an unusually cold morning for this part of the world. Once again across the international border into Mexico. Already patients were waiting, Kikapu as well as Mexican. When there was a lull in the clinic, I sneaked upstairs, where the husband of the doctor, a gentleman rancher, had prepared a very nice Mexican breakfast-beef machacada, eggs, avocado, and coffee…

(Caballero Don Polo Davila preparing breakfast for us)

More patients but so many courageous stories. An elderly lady who threw away her cane, after beginning her rehabilitative therapy in Cuba under the watchful eyes of la Doctora and then continuing it here, including Ozone therapy and now is mobile without any assistance.

At least a couple of people in their sixties, given up six to eight years ago for chronic kidney disease and urged to go into dialysis, still doing well without dialysis on Ozone therapy!!

Once again the clinic was not one of your usual clinics-innovation and psychology makes this clinic unusual and patients are happy.

The last ones were a couple, the lady elegantly dressed with her doting husband in tow. I was impressed with the tenderness they showed each other.

How is my wife, Doctor, he asked in polite Spanish, in all earnestness

I replied and explained, and it was my turn to ask,

How long you two have been married?

53 years he said, more than half a century, she added, with a gleam in her eyes..

 (Peer Educator Mena, resting while conducting her interviews)

(Moscogo dish of brown rice, chili and beef)

Back across the border, to the reservation where a Mascogo lady from Mexico had prepared a very nice spicy dish with brown rice. Mascogos are an interesting group of people who had lived alongside the Kikapu for a very long time in Mexico. It was 5 pm and I knew that the sun will soon set and I better leave to avoid any encounters along the lonely road to San Antonio. 2 hours and 45 minutes later, a very chilly evening, drove into the Econolodge, next to the very hotel I had stayed just two nights earlier.

A north Indian lady was at the reception, we briefly exchanged words about Indians in the hotel business in USA. I thought to myself, these immigrants reflect the general mood of the state they migrate to; when they are in Texas they are as friendly as the Texans and certainly friendlier than others in less warmer states. She wanted me to give her some pointers about a visit she and her family were planning to the city of Lights, Paris!

Day 4

The airport was only 5 miles away and on this Sunday morning the road to the airport and the airport itself were empty.

A short flight and a quick connection at IAH, at the appointed time I was in OMA, rented a car from AVIS and got on to the road north. I wanted to get to the reservation of the Indians where the Blue House was, before 5 pm, as I expected the sun to go down by then, before our four legged brothers begin their foraging and to avoid unnecessary encounters with them.

The sun was dipping at the horizon, when I reached the boundary of the reservation. Remembering my negligence for not saying a prayer of gratitude on entering the reservation (as I was taught), I called out to the open space in front of me, I am thankful that all of you have brought me here safely. Looked at the trees with affection and drove into the reservation towards the Blue House. Sure enough, within minutes, two deers, one of them a fawn, appeared. I interpreted it was a symbol of welcome; I thanked them and drove, just ahead of the falling night.

Days 5, 6, and 7

(Tonia Keller, PA a Hocank with whom I have worked for many years)

I am privileged to work at this clinic of Hocank Tribe of Nebraska, their Whirling Thunder Wellness Programme. Two excellent co-workers and a very obliging helper and also the best nutritionist in the Indian country, who is a HoCank herself.

One patient after another, with long, content, in depth interviews and counselling, along with medical care for their chronic conditions, much coated with the cultural nature of their way of thinking about sickness, we made sure that all of us did what we best could, for all of them. Most of patients needed one hour of our time each.

My personal motto is: They must leave happier than when they entered.

I had packed the night before, after the last patient, I was on the road again, 90 minutes later I was pulling into the parking lot of a stucco home in the suburbs of Omaha, where a Indian family awaited me with their welcome.

(a typical UmonHon welcome greeting for Oncle S)

Day 8

The day began with conversations and a Nespresso.. A nice sense of belonging to these ancient people.

It is time to leave the USA, thankful for a full, satisfying time for a Physician-Anthropologist…

 (AVIS should be proud to have such a good employee like Brandy)

Continuing the incredible hospitality of the Midwestern Americans, Brandy at AVIS and the lady behind the counter at United, did immense favours… what is amazing is that, they continue to do so, not just one, but time after time… that is why I like coming to the USA!