Poverty and complications from diabetes are closely connected and poor communities suffer. Some Native American communities are gravely affected. But with the right focus on information, healthcare availability and interdisciplinary collaboration within communities, complications can be addressed and both limbs and lives can be saved.
Some of the places that are most affected by diabetic complications are the poorest communities in the United States. One such place is the Choctaw community in Mississippi, home of the Mississippi Band of Choctaw Indians. Health complications are abundant here, and limb amputations are far too common.
“We see small vessel disease like I’ve never seen before in my life. We have patients that are 29 years old that are calcified all the way into their toes. You can see every artery. We see patients that are 23 years old and already on dialysis. Their health is absolutely abysmal,” says Dr. Nathan Randall, a podiatrist currently working with the Choctaw community in Mississippi.
Originally from Oregon, having Native American ancestry himself, he wanted to serve in the Native American community. In North Dakota and South Dakota, he has helped establish new diabetic, wound, and limb salvage programs that would address the needs of the affiliated tribes. Now he is continuing that work in Mississippi.
Access to healthcare is crucial
Geography plays a critical role in the access to quality healthcare in the US, but even more so in Native American communities. There is not a one model fits all when addressing the general health issues in communities across the country. Though some issues are the same and have similar causes, each community also has its own unique challenges and resources to draw upon. This presents different challenges within the infrastructure of the healthcare services.
Part of that infrastructure is also communication and collaboration between different subspecialities to ensure that the patients are directed to the proper medical specialist. To educate the patients and make information available for them is crucial to ensure quality treatment and optimal outcomes. It is also necessary to educate medical practitioners on how to best serve the community, to ensure they understand the needs of the patients and how best to inform and guide them.
This is the task Nathan Randall is assigned to.
“Talk, smile and ask questions”
Part of the challenge for Nathan Randall is to engage in the culture as a newcomer. To understand and address the needs of his patients, he has to understand them. So how does he go about that?
“Talk, smile and ask questions,” he says and continues:
“Just like if you were going into any other place in the world: Don’t go there to teach everyone. Go there to learn first. Learn what you can and make a friend. Let that friend help you become part of the community. And then once you’re part of that community, you’ll understand more and more. And when you do make that wonderful faux pas, someone puts their arm around you and say, ‘That was a mistake’ and explain what the mistake was.”
“And thankfully, I’ve had very good mentors. My nurses are very good, very adept about keeping me out of most trouble. But, you know, it does happen. But when it happens, I apologize and move on. And I try to understand what the problem was first.”
A generational depression
The Mississippi Band of Choctaw Indians is a tribe of the Choctaw Native Americans. Originating in areas in and around Mississippi, like all Native American nations they have a long history in the land, but recent centuries has largely been a history of suppression, harassment and racism, which has had devastating consequences for the communities all the way up to the present day.
The Choctaw of Mississippi now live in some of the poorest areas in the poorest state in the Union. This poverty is extreme and brings enormous challenges to the communities, where some live without running water and electricity. They have, in many ways, not been treated favorably by authorities throughout their history.
“All of these nations are very proud of who they are and what they are. But they’re also tribes that have been forced onto reservations. And they’ve all had to deal with that portion of their history in different ways,” Nathan Randall explains.
This is also the case for the Choctaw in Mississippi.
“They are, for the most part, a very positive people, but also a people that have learned that they’re going to get the wrong end of the stick,” he says.
“They’re going to be denigrated whenever they possibly can. So many of them have gotten what I would call almost a generational depression. And so, you not only have to work through changes in culture, you have to work through how they feel about themselves and what generationally has gone on.”
Because of this Nathan Randall experiences a lot of skepticism towards authorities, including healthcare officials and practitioners. So trust and a sense of liability also has to be built.
“One of our goals is to make ourselves available enough to get the people in and make sure that they understand that we’re not here to take their legs. We’re not here to take anything from them. We’re here to keep them attached to them. And that’s part of our mission statement,” Nathan Randall says.
It is not an easy task in communities that historically have not had much reason to trust authorities to serve their best interests.
“But being honest with them and straightforward, eventually that respect comes. It takes time. There’s no easy way about it,” he says.
Health is extremely poor
One very clear aspect of the poverty in the community is the general health, which is extremely poor, Nathan Randall explains.
There are several factors contributing to the poor health of the community, and access to proper nutritious food is one of them. Public health researchers sometimes use the term food deserts; areas where access to healthy food options is limited for residents, who also have less access to transportation. These places are often in very low-income areas.
Supermarkets and food stores are often far apart, and he ones that are present seldom has fresh produce.
This means that even when there is a focus on diet and a wish to eat healthier food, circumstances make it difficult to come by these products, and the less healthy, often highly processed food options, is all people have access to.
And then there is an aspect of societal heritage, where complications from diabetes and other health related issues are so abundant, that it becomes a normal and even expected part of life.
“I also think that part of it is the thought that ‘this happened to my mom and my dad, so it’s okay if it happens to me’,” says Nathan Randall and continues:
“Many of these people here, their parents have lost both legs and have died as a consequence of diabetes or other diseases. So consequently, they don’t see it as anything abnormal. And then that leads into that wonderful generational depression. And it’s always hard to convince them that this is a choice, and you can make your own choices as you go along and then helping them find that,” Nathan Randall says.
The poor general health also meant that the community was struck extremely hard by the COVID-19 pandemic, with very high death rates.
There is always a reason to fight
When diabetes is allowed to go untreated, the consequences are dire.
“It’s something that takes you piece by piece. It takes your eyesight, it takes your limbs, it takes everything from you. But it’s slow. It’s not like a gunshot in the in the chest. It’s being cut to pieces little bit, by a little bit, by a little bit,” Nathan Randall explains and adds:
“We’re all going to die, but you don’t want to die one piece at a time.”
Getting people to understand the seriousness of the situation is one part of the work. Another is convincing them, that they can do something about it.
“I think once people have an idea of how salacious it is and how it can move in different people, it wakes some of them up. And again, if we can get somewhat of an awakening and then to throw off all those chains of ‘oh, I can’t do anything’. You can always do something, so go do it!”
“So, you have a wound, you have a small piece of gangrene. This is not a reason to amputate. This is a reason to fight harder. And I try to draw back on their cultural identity as fighters, you know, show me that spirit, show me that need to survive,” Nathan Randall says.
Although it is a struggle for the community, the attention and effort does bring progress, and fewer amputations and deaths from diabetes complications occur. So while it sometimes seem like an uphill battle, the results very much encourages Nathan Randall to continue his work.
With access to healthcare practitioners, the right information available for patients, practitioners with knowledge of the community and with good interdisciplinary communication, health in the Native American communities can and will improve.