Alice Mae LaForge is going to die when she is 89. She'll be 86 this September.
Her smile turns into a rolling, vivacious laugh as she sets her own expiration date from the comfort of the chair where she spends most of her time. She jokes about how she doesn’t get around much anymore, and that sitting between the arms of the black, office-style chair near her kitchen table is what she does most often. But as she says it she starts to laugh again and the afternoon sunlight coming through the window turns her tan face golden, showing liveliness in her dark eyes more befitting a woman half her age.
Myra Lefthand sits next to LaForge at a small oak table in her home in Crow Agency. Both women are members of the Crow Tribe, also called the Apsáalooke Nation, and each finds levity in LaForge’s mock self-prophecy. The basis for LaForge’s prediction is that her mother and her sister (who was Lefthand’s grandmother) both died at 89. There is nothing morbid or escapist in the jest; she just gets a kick out of telling it to her doctors, and sometimes, to her family. In truth and in tone, it is more of a promise to have at least three years left with them. But for an outsider, the tone could be overshadowed by the bluntness of the words if they don’t understand that, in Crow culture, finding humor in all aspects of life is part of how they live it.
A lifetime of waggishness has manifested itself in long laugh lines reaching from LaForge’s eyes back to her shoulder-length hair, which still holds enough black to show it was once pure raven. “I don’t know when I’m going to go; might go down like that,” she says and makes a falling-tree motion with her hands, followed by more laughter.
Their sense of humor is just a small part of a unique and lasting culture of subtleties and quiet respect that can take non-Crows years of interaction and question-asking to understand. The fine-drawn mores are sometimes lost on non-Indian physicians and other medical professionals who provide care for the tribe through the government-run Indian Health Service facilities on the reservation. Stepping on these customs extends unintentional insults to tribal members and creates barriers of distrust and miscommunication between doctor and patient, adding an extra burden to a system that has historically been underfunded and understaffed.
Lefthand is the community health educator for the Crow/Northern Cheyenne Hospital (the only IHS hospital for the two abutting reservations) and has worked for IHS for 30 years. Sometimes when she’s in her office one of LaForge’s doctors will stop by and ask Lefthand to go and talk to her because LaForge is talking about dying again. LaForge has high blood pressure and cholesterol problems, as well as diabetes and issues with her thyroid, so check ups are frequent. Of course Lefthand will go visit LaForge, but not so much out of concern as out of respect for an elder. But the failure of a non-Indian to tell when a Crow person is joking is a small symptom that leads to a more serious complication for those treating the Apsáalooke.
The tribe is a matrilineal society structured in a complex clan system that is still in use today. Modesty and humbleness are mainstays of the culture and the system has built-in societal safeguards to preserve those qualities in its members, such as the teasing clan.
Children are born into their mother’s clan, but the members of their father’s clan become the children’s “teasing clan.” The role of the teasing clan is, just as the name implies, to tease clan members about anything in their life to prevent them from taking themselves too seriously or becoming arrogant. At first blush, the teasing may seem ruthless; no problem or area of a person’s life—no matter how personal—is safe from sarcastic critique, even if the clan member didn’t bring it on himself.
Recently, one of Lefthand’s clan brothers was hospitalized for a gallbladder problem. She and other members of his teasing clan frequented his room to check up on him and spread the joke that he was in the throes of giving birth to twins, and he was dilated to 10 centimeters and the babies would be there any minute. Her clan brother yelled at his clan members to get out, Lefthand says, not because he was offended, but because it pained him too much to laugh.
Health care providers often mistake scenes like this for visitors seemingly torturing or ridiculing patients, Lefthand says. The doctors and nurses, thinking they are looking out for the patients’ interests, get upset with the clan members, but in reality they are meddling with culture and customs. The patients, in turn, can get frustrated with the medical providers, and get upset with having to explain the situation. Communication suffers and the doctor-patient trust is compromised over a misunderstanding rooted in the best of intentions. Given the intricate and pervasive nature of the clan system, as well as the other aspects of culture that hold a great importance to Crow people—such as kinship ties, personal modesty, and placing the respect of others ahead of one’s self—shadows can fall between the doctors and their patients.
This, tribal members say, has led to Crows feeling hesitant to question doctors for clarifications about their treatments and to sometimes ignore directions altogether because they don’t understand their importance or don’t trust the doctor’s expertise. Many leave the exam room confused about what they actually need to do to get better, what pills to take, what to eat, let alone why they are sick or how sick they really are. In the worst cases, patients have had experiences that make them refuse to seek the health care they were promised by the U.S. government through treaties in the mid-1800s.
It was chest pains that made LaForge go to the emergency room at the Crow hospital the last time.
She was put in an exam room and monitored for a few hours by a doctor who, she says, gave her the impression he thought she was too old to be treated and there was nothing he could do for her. Once her blood pressure returned to normal and her heart rate stabilized, he prescribed painkillers and released her. Hurt by this experience, she will no longer go to the ER and instead waits for an appointment with a physician she knows and trusts. Now when she gets chest pains she places a nitroglycerin tablet under her tongue, waits for it to dissolve and hopes her prediction of 89 holds true.
In the IHS system, Crows don’t get a primary physician. They simply make a medical appointment and are examined and treated by the IHS professional on duty that day. LaForge has been able to build relationships with a few of the doctors at the Crow hospital, but even though she says she trusts them, her actions show the disconnect between her and her providers.
Currently, she takes seven different medications each day, but it should be more. She almost never takes the prescribed painkillers, and has one prescription she has no clue as to why she was prescribed it, so she just doesn’t take the drug. She feels OK, she says, so why take it? Likewise, she was diagnosed as a borderline diabetic 10 years ago. The doctor told her she could control the disease if she changed her diet and got more exercise, but she decided not to. The condition has worsened and now she controls the disease with twice-daily insulin injections, but she still eats how and when she wants. In her book, she’s OK, so why change it?
The heart of this issue is not a perceived lack of respect for Apsáalooke beliefs and practices by IHS physicians, and nor are Crow patients placing the blame for the problems solely on the doctors’ shoulders. The tribe and medical community are promoting programs to help physicians learn more about the customs and culture of the their patients, and likewise, to educate patients so as to foster better understanding, communication and trust between the two groups.
In 2001, the Messengers for Health on the Apsáalooke Reservation was started, using grant money from the American Cancer Society. The messengers are respected women from the Crow community, like Lefthand, who have been educated about cervical cancer to teach other Apsáalooke women about the disease and the necessity of testing. Women have always held a respected place in Crow culture and the goal was to bridge the gap between the physician and the patient with an educated member of the patient’s own community. Alma McCormick, the coordinator for the messengers, is also working with Lefthand and other messengers on the burgeoning Apsáalooke Health Advocate Program, which is aimed at directly addressing the different issues that cultural misunderstandings cause between the Crow people and their providers. The advocates act as a direct link between IHS professionals and the Crow community, answering questions the professionals may have about culture and also explaining the practices of IHS to the people it serves.
Dr. Tom White is one of two OB-GYNs at the Crow hospital. He lives in Hardin, just off the reservation, and in the three years he’s served at the hospital has also involved himself in the messenger program. He spent the first 27 years of his post-residency career working in a private practice in his hometown of Kalamazoo, Mich., serving patients who were primarily white and upper-middle-class. The doctor he replaced at IHS had been working at the Crow hospital for 20 years and stayed on for White’s first month. Even with the guided transition, White has still run up against cultural misunderstandings, which McCormick and the two programs have helped him to resolve.
The clan system establishes a broad network of relationships across families so that a teenage girl may have several women she calls mother. The strength of these relationships means the girl may want one or more of her non-biological mothers to be in the room during an exam, but intricate enough that she won’t feel comfortable answering certain questions about her sex life, or her body in front of them, nor will she want certain information shared with them. Walking this line, White says, was hard to master, and he can see how running afoul of these boundaries could mean damaged trust between patients and providers.
The Crow concept of modesty, White says, has also been an issue that took some getting used to. Women who have already given birth to two or more children still feel the need to remain covered during an examination and are at sometimes hesitant to even be examined, he says.
For White though, the most important medical concern that the programs have helped with is a custom of pregnant women eating clay. White says clay consumption has been linked to anemia, and causes problems with bowel function. Whether the craving for the clay is caused by the anemia or the ingestion of the clay causes the anemia hasn’t yet been determined, White says. Regardless, it still puts doctors in an untenable situation. On one hand, his patients and their unborn children would be better off medically without the clay, but on the other, “It’s a tradition that has gone on for hundreds and hundreds of years and you can’t just stomp all over that,” White says.
Working with the messengers, White says, the medical staff has found a way to remain sensitive to Crow culture while helping patients understand the medical reasoning behind his request that women stop eating clay. And that, McCormick says, is the type of interaction it will take to bring the two groups to mutual understanding.
Closing the divide between the worlds of the providers and the Apsáalooke people they serve just takes time and sincerity. For 10 years, Kristine Judd worked as a clinical laboratory scientist at the Pryor Health Station, the only other IHS facility on the Crow reservation. Located in the hamlet of Pryor, the small clinic is about an hour and half drive from the Crow hospital. It’s open five days a week and physicians work there on a set rotation, so if the scheduled doctor is out sick, there will be no doctor in Pryor that day.
Judd had worked in a clinic in Billings for about 20 years before making the switch to IHS. In Billings she had done mostly lab work with little patient contact, but in Pryor she had to draw and test blood from people with conditions like diabetes or high cholesterol and monitor their treatment. It meant almost constant contact with a people she knew nothing about.
“Thirty miles down the road it’s a whole different culture,” Judd says. “It’s a whole different world.”
Her patients were scheduled to come in from as often as twice a week to as infrequently as four-times a year, but Judd saw them all almost every day just by living in the small town. Even though she became a regular sight in Pryor, Judd says it took at least a full two years before her patients began to trust that she was there to stay, and was there to give them the best treatment possible. Simple things like eye contact from a patient were nonexistent at first. But as she kept showing up, and kept trying to learn about the people she was treating, her patients started to let her into their lives.
They began to share frustrations about the ever-changing cast of doctors at the clinic and how they felt like a forgotten community, a stepchild of Crow Agency. Her patients saw how she fought with the layers of bureaucracy that separate IHS administration from the people on the ground to get better equipment for the clinic and more services for her patients. Soon, she says, they became more than just patients. She was welcomed into their homes. She became godmother to a colleague’s baby.
“I loved my people,” Judd says. “I loved what I was doing.”
In the decade in which she served at the Pryor clinic, she repeatedly told her IHS supervisors that consistency was what her patients needed most. Too often, she says, a crisis would occur at the Crow hospital and staff and resources would be lost from the Pryor clinic to make up for shortages at Crow Agency. Then last July she got the orders that led to the end of her career on the reservation.
Report each morning to the Pryor clinic, she was told, but then get into a government car and drive 70 miles to Crow Agency and work a shift at the hospital.
One way or another, she would be forced to leave her patients behind. With a heavy heart, she quit.
Eight months later, Judd’s patients still ask about her. They had a bond. She cared for them, and they trusted her, medical receptionists left behind at the Pryor clinic say. She was as much of a part of the community as anyone could be.
On a recent spring morning, Judd sits at the dining room table in her house in Billings. Her face is smooth and she has the lean build of a lifelong runner. Her eyes spark when she talks with amusement about her failed attempts to learn the Crow language, then soon well up when talk turns to her Crow goddaughter. As the conversation focuses on her decision to leave Pryor, her eyes become lifeless and dull, much like the overcast skies that hide the sun just outside the nearby window. She still says “we” and “our” when she refers to the small clinic.
And she still talks about “her” patients, though they are no longer hers.