What We Can All Learn from the Navajo

by Ketan Sharma, MD, MPH


If you ask Americans if they’ve ever experienced healthcare in a third world country, most might answer “no”. But many more might admit to having traveled to Arizona, New Mexico, Utah, Wyoming, and North and South Dakota.

Consider the Navajo nation, a semi-autonomous territory spanning the size of West Virginia, encompassing 170,000 people in the southwestern US. The average income is not much more than half of the rest of the US, while life expectancy is four years shorter. Diabetes, obesity, and alcoholism are all three-to-four times as common. In 2011, Debra Free, who was raising a nine-year old daughter at the time, died on a hospital floor after falling off her bed and remaining unsupervised because the inpatient floor did not have enough nursing staff. Senator John Barrasso, chair of the Committee on Indian Affairs, summarized the state of health care services as “horrifying and unacceptable.”

As a resident at a premier academic program, I feel tremendously lucky to witness advancements in the field of plastic surgery. And sometimes I might even participate in expanding the frontier myself; for instance, when I’m presenting my mentor’s work at a national meeting. But at the same time, I need to fight that tendency a little and remind myself that it’s just as important – perhaps more important – to first make sure everyone can receive the same care we already have. Health care disparities exist, and as the plight of the Native American reservations show, they don’t just exist in Africa or India. The problem is a lot closer to home, and unfortunately for some, the problem is home.

Addressing the sequela of centuries of discrimination can seem quite daunting, but maybe we can all start from somewhere: awareness. To that end, the Plastic and Reconstructive Surgery journal has published some recent great articles addressing breast reconstruction, a health care disparity unique to our field. As you might expect, race matters: African-Americans are less likely to undergo implant-based breast reconstruction.1 Insurance all matters: hospitals with a higher proportion of private insured patients are more likely to perform immediate breast reconstruction2, and the gap between patients with Medicaid and private insurance is growing.3 Geography matters too: patients who live more than 20 miles from a plastic surgeon are less likely to receive breast reconstruction.4

These articles highlight the vastness and complexity of inequity of care, and represent just a modicum of many vital studies bringing attention to this issue. I wouldn’t know where to start to list the many ways we as providers can contribute, from donations to volunteering to political action. But I would like to ask plastic surgery residents – myself included – that when we’re excited about scrubbing a free functional muscle transfer, or reading up on a new fancy microsurgery flap, or refining our rhinoplasty skills in a state-of-the-art course, to remember that a lot of people are starving for the care we take for granted, and they are closer than we might realize. And I’d like to thank our journal for reminding us of that.


References

  1. Sharma K, Grant D, Parikh R, Myckatyn T. “Race and Breast Cancer Reconstruction: Is There a Health Care Disparity?Plastic and Reconstructive Surgery. 2016 Aug; 138(2):354-61.
  2. Ballard TNS, Zhong L, Momoh AO, Chung KC, Waljee LF. “Improved Rates of Breast Reconstruction at Safety Net Hospitals.” Plastic and Reconstructive Surgery. 2017 July; 140(1):1-10.
  3. Mahmoudi E, Giladi AM, Wu L, Chung KC. “Effect of federal and state policy changes on racial/ethnic variation in immediate postmastectomy breast reconstruction.Plastic and Reconstructive Surgery. 2015 May; 135(5):1285-94.
  4. Roughton MC, DiEgidio P, Zhou L, Stitzenberg K, Meyer AM. “Distance To a Plastic Surgeon and Type of Insurance Plan Are Independently Predictive of Postmastectomy Breast Reconstruction.Plastic and Reconstructive Surgery. 2016 Aug; 138(2):203e-11e.

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