As a group, American Indian and Alaska Natives suffer the worst health in the nation. They have higher rates of chronic diseases, such as diabetes and high blood pressure, than other groups and die much younger: 25 percent of Native deaths occur before age 45, compared with 15 percent of African American deaths and 7 percent of white deaths.
When they do get sick, Native patients often aren’t seen by Native doctors, who are underrepresented in the profession. While about 2 percent of the U.S. population identify at least in part as American Indian or Alaska Native, only about 0.56 percent of practicing doctors do so. So tribal health organizations recruit doctors from outside the reservation, sometimes young physicians who spend a few years caring for an underserved community while taking advantage of loan forgiveness programs. The downside, wrote Ronald Shaw, former president of the Association of American Indian Physicians, is that Native health facilities “rely on a workforce composed of too many physicians serving out a commitment rather than being committed to the people.”
Michael Tutt, M88, who grew up on the Navajo Nation reservation and has worked there as a physician for the last 19 years, has been doing all he can to change that. As the chief medical officer for Tséhootsooí Medical Center in Fort Defiance, Arizona, he seeks out doctors who will wholeheartedly serve the center’s 30,000 user population. Piecing together a dedicated staff, along with a practice that encompasses both traditional and contemporary medicine, is the best way he knows to reduce the health disparities that have followed his people for centuries.
“One of my main jobs is to protect my community, my people, my family, my clans—protect them from harm,” Tutt said. “That is one of my main focuses in life. Medicine is just a small part of it.”
Here, Tutt talks about traditional medicine, his own road to becoming a physician, and the value of knowing where you are from.
Tufts Now: Who are you?
Michael Tutt: As Navajo, we always introduce ourselves by establishing clanship. I am Michael Tutt, born for the Kinłichíí’nii (Red House) clan on my mother’s side, and my father’s clan is Táchii’nii (Red Running into the Water People). So those are my clans. This is who I am.
Can you describe where you live?
I come from an area where there is no physical address. You will never find me on Google Maps. Running water, electricity and paved roads are luxuries on the Navajo reservation. Our closest grocery stores are usually gas stations. So within our United States there are still areas where we do live in developing-country status.
What made you want to be a doctor?
I had grandparents who were traditional practitioners. They had their own way of taking care of health on the Navajo reservation, as it had been for hundreds of years. A lot of that knowledge has gone away, because people have gone toward western medicine. But here we still use both—traditional medicine and western medicine. And I remember my grandmother, she pushed us, all of us grandkids, to go further and become physicians. I went to the University of Arizona undergrad and that led me to Tufts University School of Medicine.
Because Tufts sounded like my name [laughs]. And I’m glad I chose it. It led me to Boston, which was totally different from Arizona. A lot of the learning I did was non-medical. It was all interactions with different people. My classmate Bill Brennan [A84, M88, now an orthopedic surgeon in Rhode Island] had been a philosophy major and we would have long talks. The doctor I remember most was [Distinguished Professor of Medicine] Jerome Kassirer. He really listened to you, and his knowledge and the way he talked made you think.
Boston has a long history of discrimination. Did you feel that when you were here?
I heard it and I saw it, within the student body, too. Especially when at parties, when alcohol made lips loose, I heard it.
It must have made medical school especially hard.
It was fine. I’m cocky—I was just built that way. Maybe I’m overconfident but you have to be that way sometimes. You have to think, “I can do this.”
Did you always know you would return to the reservation?
Deep in my mind, that was my plan. As Navajo, when you are born, we bury the umbilical cord. That is where you are tied to Mother Earth. We all come back to where our belly button is buried. When you know where you are from, it gives you peace of mind. A lot of people are lost because they don’t know where they are from.
What do you do?
I was trained as an internal medicine doc and I’m also a rheumatologist. But for the last six years my main job is being the chief medical officer. I didn’t plan it. I assumed the position with no training and it was very difficult. I learned by trial and fire how to be a leader. One of things that medical schools can do is put leadership training in their curriculum: All these young doctors, they will be leaders somewhere. It will help them on the way. For me it’s become a passion to mentor people into leadership positions.
What makes a good leader in medicine?
As a leader one of the biggest things I’ve learned is to listen. My grandmother told me listening is medicine. And what you say, what comes out of your mouth, is medicine. Probably stronger than what you give as medication. When you only treat patients physically, you just throw medications at them. But the Navajo way, we treat them physically, mentally, spiritually.
Your medical center’s motto is to “provide superior and compassionate healthcare to our community by raising the level of health, Hózhó [hoe-jhoe], and quality of life.” What is Hózhó?
Hózhó is when you are balanced physically, mentally and spiritually. It’s a journey. You are always working every day to maintain that Hózhó. If you look at today’s medicine, nobody’s in Hózhó. Everybody is so focused on taking the pill and ‘this will make you better.’ It’s more than that.
How do you merge western medicine with traditional medicine?
We have four traditional practitioners here. Sometimes they say prayers, sometimes they give some traditional medicines.
I do a mobile rheumatology clinic once a month. There are really good medications to treat rheumatoid arthritis, and I have a physical therapist who does hands-on therapy. Then I bring a traditional healer. Sometimes my patients are looking forward more to the traditional healer than to me. That’s what I want. Because they feel good when they get a prayer, that things will be all right. To me it’s a pure way of praying for somebody. It’s Navajo, it’s tied to the ground, tied to our surroundings, non-denominational, non-judging. Our way of praying has been going on for 500 years. And it will still be here 500 years from now.
We have an adolescent care unit, Arizona’s first inpatient psychiatric clinic for young Native Americans, where we take care of kids from 8 to 16 for drug and alcohol addiction. A lot of these kids—I call them scrappers because somehow they’ve survived this long—have lost their parents to drugs and alcohol. We take care of them with their addiction; we give them tools to survive their daily life. But one of the things that I think makes a big difference is we instill within the program traditional teaching. We have a sweat lodge. The kids sit in the Hogan [a sacred dwelling for Navajo ceremonies]. They learn to be respectful, something they may have missed when they were growing up.
When the program ends, a lot of these kids don’t want to go home. This is a place where they are safe, where they are loved. That’s all the kids want.
What are the biggest health issues for your community?
We focus a lot of our resources on chronic care—diabetes, heart disease, cancer—and also end of life. We’ve been talking about spending more of our time on how to keep our young kids healthy, focusing on kids from birth to 5.
A lot of the issues here are outside medicine. It’s social stuff. There’s homelessness, there’s poverty, there are no jobs. Mental illness is the umbrella over all the other diseases, which makes things worse. Depression is probably the most prevalent disease on the Navajo Nation for many reasons.
To me, what I do is not just health care. It’s clean water. It’s clean air. Housing. Jobs. Police. We need a better judicial system. I could go on. There’s so much to do here. Not just from a medical standpoint, but building a community where it is safe to live.
What are your biggest challenges as chief medical officer?
Because we live in such a remote place, the big challenge is retention. You can’t establish good patient care if physicians are leaving every three or four years. We use a lot of contractors and locums [physicians who fill in when an office is short-staffed], but they are hit or miss.
One of the things I got involved with is the HEAL Initiative at the University of California San Francisco. It is a fellowship for providers who want to do international medicine. The directors of the fellowship realize that the conditions in the developing world are just like the conditions on the reservation. Why go outside the country when you have the same conditions here? This fellowship places providers six months out of the year at our medical center. And some of them have stayed on.
Why do doctors choose to stay?
I’ve asked them that myself. We have a podiatrist from Haiti who used to work in Kansas City. He has been here going on ten years. Why are you here, I asked? He goes, “The people are grateful. I’m a black man and they don’t judge me because I’m black. Here, they are grateful.”
Our hospitalist comes here once a month from Norway, for the last 12 years. I asked him the same question, and he said, “because I practice medicine here,” not the rushed appointments and red tape that you find some places.
We have an orthopedic surgeon who could work anywhere on this planet, but he works here. His family is originally from Guam and now lives in Vancouver, Washington. He flies back and forth. And I go, why do you come here? He told me that during World War II the Japanese did terrible things to the Guamanians, and it was the Navajo code talkers who helped defeat the Japanese. This is his way of paying back.
These are the ones who have been here a long time. I value these people.
Very few physicians are American Indians. How does it affect the medical center?
When I first started being a physician, patients didn’t believe I was a physician. The Indian Health Service has been providing care since the late 1950s, and most of those physicians tended to be Caucasians. The patients were so used to white doctors taking care of them they didn’t believe that a physician could be Navajo. To the point where some of the patients actually requested, “Can I see a white doctor?” Yes, it stung for a second, but then I realized, this is just the culture that they were used to.
Homegrown providers can relate to everyday Navajos. At one point, we had three Native doctors here who graduated from Tufts Medical School. Victoria Matt, M97, is an orthopedic surgeon, and Sahar (Nouri) Chavez, M04, is an obstetrician. They have moved on, but others are staying. One thing I’m proud of is we have eight Navajo physicians, and I just hired two more who will be coming in the fall. They know the environment. They know the people. Because this is home.
Julie Flaherty can be reached at firstname.lastname@example.org.