Weaving a Workforce: Strengthening Anesthesia Care on Navajo Nation

Navajo Nation covers a land area of approximately 27,000 square miles, making it the largest indigenous reservation in the United States (Prev Chronic Dis 2022;19:E78). The current official enrollment figures put the number of people identifying as Navajo or Diné, the name the group uses to refer to themselves, at just under 400,000, with about 170,000 currently residing on the reservation (asamonitor.pub/3RsLh1p). Diné living on the reservation face many structural barriers, with more than 75% reporting food insecurity, approximately 30% lacking access to electricity and running water, and more than 50% lacking broadband internet access (Public Health Nutr 2014;17:58-65; asamonitor.pub/3R1oYOU; asamonitor.pub/3uNwGFa). These structural barriers, in addition to the long-lasting impact of colonization and forced assimilation, contribute to higher rates of obesity, diabetes, cancer, and heart disease than the U.S. population as a whole (Prev Chronic Dis 2022;19:E78). Potentially surgically treatable conditions such as unintentional injury and malignant neoplasm are the first- and third-leading causes of mortality among the Diné (asamonitor.pub/485wmQy).

The Indian Health Service (IHS) was established in 1955 to fulfill the U.S. trust responsibility to provide health care to indigenous people who are enrolled as members of one of the 574 federally recognized tribes (Annu Rev Public Health 2022;43:559-76). The relationship between the U.S. government and indigenous peoples has been characterized by cruel policies of sanctioned massacres, forced removal, and forced assimilation over several centuries (Annu Rev Public Health 2022;43:559-76). In the face of famine, disease, and military conflict, many tribes signed treaties with the U.S., agreeing to give up parts of their territory and, in many cases, be relocated to reservations in exchange for the U.S. providing health care, education, and other resources (Annu Rev Public Health 2022;43:559-76). The IHS represents the current federal approach to provision of health care to indigenous peoples to fulfill these treaty obligations. The IHS faces significant funding and workforce challenges. In 2021, federal expenditure per capita for the IHS was half of other federally funded health programs, with the IHS receiving approximately $4,140 per user compared to $15,763 per beneficiary for Medicare and $8,908 per enrollee for Medicaid (Figure 1) (asamonitor.pub/46JHUYu). A 2018 report found a 30% vacancy rate for provider positions in the Navajo Area IHS (asamonitor.pub/3Nbzimk). Since the 1990s, some tribes have sought more autonomy, control, and flexibility in the provision of health care services and have started pursuing tribal compacts with IHS, where they receive a block grant for a total budget amount and can use that budget to meet their specific, local needs rather than have direct health care services administered by the federal IHS (Annu Rev Public Health 2022;43:559-76).

The IHS is divided administratively into 12 different geographic areas, of which Navajo Area is one (Figure 2). Health care in Navajo Area is subsequently organized and administered across eight service units, including Shiprock, Crownpoint, Gallup, Ft. Defiance, Chinle, Kayenta, Tuba City, and Winslow. Of these, Ft. Defiance, Winslow, and Tuba City are administered through tribal compacting, known as 638 compacts, and the others have health care provided directly by the federal IHS. Surgical services are provided by IHS or tribal facilities in Shiprock, Gallup, Ft. Defiance, Chinle, and Tuba City. The surgical services delivered at these facilities vary, with all facilities providing general surgery and obstetrics and gynecology services, and some providing more subspecialized care, including orthopedic and podiatry surgical care. Anesthesia staffing varies across the facilities with staffing shortages sometimes impacting availability and scope of surgical and analgesic services.

Currently, there are 21 ORs and one endoscopy suite across Navajo Nation facilities that provide surgical and anesthetic services (Table). Of the ORs, four are dedicated to obstetrics cases while the rest are utilized for all cases. There are currently six physician anesthesiologists and 22 CRNAs practicing in Navajo Nation facilities. CRNAs are permitted to practice independently in both Arizona and New Mexico, the states where all Navajo Nation facilities providing anesthesia services are located. Of the anesthesiologists, five of the six (83%) are locums or contract providers, while only one is a permanent employee. Epidurals are currently available for labor and delivery at two facilities, with plans for addition of this service at another in the near future. At facilities without labor epidurals, pain in parturients is managed with single-shot intrathecal opiates and intravenous opiates. Additionally, some facilities lack access to OR-dedicated ultrasounds and videolaryngoscopes as well as around-the-clock intensive care support.

Clearly, there is a need to improve the permanent anesthesiologist workforce and expand access to labor epidurals in Navajo Nation. In primary care specialties, resident rotations at IHS facilities have been an effective recruiting tool for permanent providers. A 2006 survey found that 45% of providers currently working at IHS sites in Arizona and New Mexico had completed a rotation with the IHS prior to employment, and 87% reported this experience as a substantial motivator in their decision to return after they completed training (Fam Med 2005;37:701-5). There are no formal anesthesiology resident rotations at any Navajo Nation facilities.

Anesthesiology residency programs should collaborate with Navajo Nation facilities to establish formal, longitudinal rotations to improve resident exposure to rural and indigenous perioperative care and increase the likelihood that the number of permanent anesthesiologists working on Navajo Nation improves in the future. In addition, every parturient at all Navajo Nation facilities deserves the right to choose whether or not they would like to receive epidural analgesia during labor. Access to epidural analgesia is not universal across Navajo Nation facilities despite competence with epidural placement and management being required pieces of both anesthesiology and CRNA training. Barriers, including increased nursing and anesthesia provider workload, equipment procurement cost, and pharmacy workflows, have prevented labor epidurals from being adopted across all facilities.

Despite historical injustices and continued structural barriers faced by the Diné, one of the most gratifying aspects of providing perioperative care on Navajo Nation is being immersed in the resilience and deep community that exist in abundance. There are undoubtably challenges to providing anesthetic care in rural, resource-denied settings like Navajo Nation, many of which are detailed in the preceding text. The solutions to these challenges will not come from the pages of an academic journal. They will come from committed providers interested in the adventure of living and working in a mesmerizingly beautiful place and leveraging the entirety of their physician skill set to care for an immensely deserving and resilient population.

Providers interested in working on Navajo Nation or at other IHS facilities across the country should consider applying to open positions at usajobs.com.