Chair's Column: Acoma
By David H. Johnson, Bannerman & Johnson, P.A., Albuquerque, NM
I have previously written about the connection with land and sky that I, and many other New Mexicans, feel for certain places in our state. In May members of the Section Council gathered for our annual spring meeting at the Tamaya resort on the Santa Ana Pueblo north of Albuquerque. My not-so-secret agenda was to expose my colleagues to a location far removed in time and place from everyday life as most experience it. The Acoma Pueblo filled that bill perfectly.
Acoma is a place apart. Situated atop a remote 360 foot mesa at an altitude of more than 6,000 feet, about sixty miles west of Albuquerque, the Pueblo was originally settled by people descended from the Anasazi between eight and nine hundred years ago, making it arguably the oldest continuously inhabited community in the United States. Until the arrival of the Spanish in the 16th century the nearly vertical walls of the mesa provided protection from raiding parties of Apache, Navajo and Comanche. In 1598 a punitive expedition captured the Pueblo resulting in the death, amputation of limbs or enslavement of almost the entire population. Eighty-two years later, Acoma participated in the Pueblo Revolt of 1680, which forced the Spanish to retreat to Mexico for 12 years before returning in force and re-taking possession of New Mexico.
Today, the village remains much as it has been for the past few centuries. It is without electricity or water. While most members of the Acoma tribe live in communities about ten miles north, several dozen people, primarily elders and religious leaders, live there year-round. The largest building is the San Esteban del Rey mission church, which is the only Native American site designated as a National Trust Historic Site. Built of traditional adobe bricks and enormous timbers logged and carried by slave labor from 40 miles away, the mission represents a sanctuary from the tumult of the modern world.
After arrival at Acoma, the Council heard two presentations at the Cultural Center before ascending to the village known as “ Sky City” atop the mesa. The first was an overview by Casey Duoma, in-house counsel for the Laguna Pueblo, of the Pueblo legal system and initiatives undertaken by tribes to take responsibility for their healthcare services, which have historically been the province of the Indian Health Service (“IHS”). Casey spoke softly, but passionately, without notes for almost an hour, emphasizing the importance of maintaining harmony within the community as a critical goal of the legal system. Following Casey was Dr. Anthony Fleg of the nearby IHS hospital, who spoke of his efforts to integrate traditional healers into western medical practice. Both speakers reflected on the criticality of engaging community into both the healthcare and legal systems. Community as a buttress against the ravaging effects of crime, obesity and diabetes — products of our modern world.
For the outsider, Acoma engenders questions more than answers. An extensive body of research in the social sciences points to social cohesion as a critical factor in developing and maintaining healthy communities. Yet healthcare in the United States, like most other facets of our society, is organized around addressing the needs of individuals, not communities, which are of course comprised of individuals. The healthcare payment system is directed almost exclusively toward paying for services provided to individuals. Spending on public health occurs mainly as an afterthought. The unsustainable rate of increase in healthcare spending in the United States is thought by many to stem from our historic reliance on fee for service as the method of paying for the delivery of healthcare. Fee for service is yet another expression of the focus of providing specific increments of care to individuals. While the fee-for-service system may work well in the context of car repair services and numerous other economic activities, few would dispute that fee for service in the healthcare context is plagued by incentives to provide more and more services as long as there is a payor willing to pay. We are thus beset by a system, which, at enormous cost, provides sometimes exemplary care to individuals, but when measured by examining population health outcomes does a rather middling job at best, particularly when measured in relation to the overall cost of care.
Returning to Acoma, I am reminded of what I heard from Casey and Anthony. Contemporary western medicine is an important part of the community’s response to the serious health problems it faces, but it may not be the major part. While obesity and diabetes, once rare among Native Americans, are now characterized in such terms as “epidemic” and “public health crisis,” the crisis is hardly limited to Indian reservations. As recently as 2000, not a single state reported more than 30 percent of its adults as being obese. CDC data from 2010 indicate that ten years later over 35 percent of U.S. adults are obese. Many of these people will ultimately develop diabetes. Limb amputations, kidney failure and dialysis are the endpoints. In the near term, western medicine may offer limited respite from the wave of obesity and resultant morbidity and mortality.
It is easy to attribute the increasing longevity experienced (but not necessarily enjoyed) by Americans to the extraordinary advances that have occurred in medicine. While there is undoubtedly some truth to this, public health experts point to improvements in sanitation and nutrition as having even greater impact. This points to the importance of focusing on improvements in the care of populations (or communities), not just improving the care of individuals. In our contemporary medical culture, care is usually directed at individual “patients” with the community in the often distant background.
Acoma forced me to think about just what is involved in creating a healthy population, in keeping people healthy. It symbolically raises the question of whether solutions are to be found in more medicine or even better medicine. Perhaps as the Pueblo people teach us, the answer lies in achieving balance. Balance between medicine and public health initiatives to be sure, but also initiatives to promote balance and harmony in everyday life. I am reminded of the remarkable film by Godfrey Reggio, Koyaanisqatsi, meaning life without balance in the Hopi language. Can we effectively promote health in the absence of promoting and achieving balance? I don’t really know, but I suspect we have much to learn from places like Acoma. Until and unless this occurs, we may pay a heavy price indeed.
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