Orientation to HEALTH on the Nawajo Indian Reserwation OF HEALTH, EDUCATION, AND WELFARE oT = & ''wal oo 2 oS Se ee 16 ibe Navajo ceremeny 25 sooo eS oe ~hegeene se 16 (ee Megmine Mam 2.2) 5. ee eee 17 Psychotherapeutic Aspects of Ceremonies- -------------------- Lt Adapting White Medicine to Indian Culture- ------------------ 18 Navajo Perception of Symptoms- ---------------------------- 18 The Navajo Language and Problems in Communications Importance of Learning the Language- ----------------------- 20 iii 851 ''Probiemeain internusting. 2 Le ie Se ee Wee. Olalmenmpneloie =e oe Se ee Qualities of a Good dmterpreter2 5 ee ee Role of the Interpreter in Diagnosis... -~. 2. -.-s.-..-22_--_---- Navajo Concept of Pimes = 952 3S ee Life on the Reservation- Scenery----- Ameotent Indian Wuins: oo 2 ee ee Recreational Sports and Hobbies. = 2.5. 2222 be Atta otis a Se eee SHOPPING Areas =o 35 a eee H OUsiip-and Venoole==- =. 5i<85u. 0522s ee ee Social Orgenizatione.. == 2c = fo el ees New Reservation Map Available)... .- --- 22 ce Bibliography viv 21 21 22 23 24 26 27 27 27 28 28 28 28 28 29 ''FOREWORD The purpose of this guide is to provide public health and medical workers new to the Navajo Reservation with some background informa- tion that will be useful in their new work on the Reservation. References listed at the end of the text have been used freely in the preparation of this guide. These sources are recommended to those who wish to increase their understanding of the Navajo people. In addition, many other ex- cellent source materials may be found in the Window Rock Field Office Library and in the Navajo Health Education Library at the Tuba City Service Unit. The contents of this guide have been discussed and pretested with members of the Navajo Tribe, with personnel of the Public Health Serv- ice and the Bureau of Indian Affairs who have been on the Reservation for long periods, with anthropologists who have studied the culture and the health practices of the Navajo people, and with others familiar with the culture. In reading this guide, the physician in the hospital setting may be looking for answers to such questions as: “How can I get Navajo patients to follow instructions?”’; ““What sort of approaches should I use in ex- amining and treating Navajo patients?”; “What are the Navajo beliefs and practices relating to pregnancy and childbirth?”; “Why is it difficult for Navajo patients to describe the symptoms of their illnesses accurately enough to help me make a diagnosis?” The physician in charge of the field health program may be more interested in answers to such questions as: “How can the field health staff work most effectively with the Navajo people?”; “How can we get the Navajos to participate in planning for health services in their communi- ties?”’; “How can we use education to reduce infant diarrhea?’’; “How can we get better attendance at field clinics?”; “How can we help the Navajos to gain a better understanding of preventive health measures?” The nurse in the hospital setting and the public health nurse in the field may have similar questions. Others they may have are: “How can we communicate more effectively with non-English speaking Navajos?”’; “How can we interpret our services to the Navajos?”; ‘““How can we ac- complish educational work best in the clinic setting?”; ‘““How can we get the Navajo patient to cooperate more effectively in the treatment of his disease?” ; The sanitation personnel may raise such questions as: “How can we get the Navajos involved in developing individual or community water Vv ''supplies, and in building and using privies?’’; “How can we teach them to improve their individual and family sanitation practices?” Many of these same questions will occur to the health education worker or community worker, who may also be concerned about: “What groups or channels of communication are most effective for getting across - health information?”’; ‘‘How are decisions on health matters made?” All staff members, whether new to the Reservation or there a long time, will be concerned about how to work together most effectively in dealing with the many problems that inevitably arise. It is not the purpose of the guide to specifically answer the questions as raised. The answers to these questions, and to all the others with which health and medical personnel are always confronted, are to be found in -the understanding of the health attitudes, motivations and behavior of the Navajo. The health worker who is to be both successful and satisfied in his work is the one who has learned how to bridge the gap between his own professional knowledge and that of the culture-bound Navajo. It is hoped, also, that the information in this guide will enable a new health worker to become an effective member of the Indian Health team more quickly than he could otherwise. This, together with other reading, should better fit him to do his part in bringing health services to the Navajo people. He will be better able to help them make maximum use of these health services, to adopt preventive health practices, and to avail themselves of preventive health measures. The approach to health among the Indians, which this guide attempts to implement, is best described by an excerpt from an explana- tion given by Dr. James R. Shaw, Chief of the USPHS Division of Indian Health, to a recent Congressional Appropriations Committee: “The objectives are to bring the health status of the Indians up to par with the non-Indian population in a way that en- courages self-reliance, independence, strengthens their com- petency, capacity and desire to manage their own affairs, and gives full recognition to their rights as citizens and to the obligations of the Federal Government to them as a result of numerous treaties and Congressional enactments. Funda- mentally, it means working with rather than doing things to or for the Indians, and adapting the program to the customs, traditions, temperament, and the acculturation of each tribe. In every instance, it means introducing changes gradually rather than abruptly as has characterized so much of the past to the detriment of the Indian’s sense of responsibility.” In the final analysis, one point should be emphasized: the Navajo are people; the principles of human relationships which apply to working with people anywhere apply also to working with the Navajo. vi x '' Public Health and Medical Work With the Navajos STEP NO. 1. IT is natural that, as professional health workers, we tend to see the world revolv- ing around health. We have been re- warded for doing so. Public health work- ers are like other specialists; we have unique points of view and develop | a sharp focus in a restricted area of interest. The price we pay for this is seen in the difficulty we find in recapturing the unspecialized way of seeing things. It is often difficult for us to see health as other people cus- tomarily see it. This problem of professional bias in perception is further complicated when cultural lines are crossed, as on the Navajo Reservation. IN the many contacts that health workers have with the Navajo, differ- ences in values, attitudes, and ways of doing things will become apparent. This will be confusing sometimes, and perhaps annoying. As public health workers we carry with us an enormous amount of “cultural baggage” of our own. In nutrition, for example, we will often insist on three meals a day, animal milk for babies, and a balance of diet every twenty-four hours. This insistence is the result of our non-Indian culture, rather than a con- sideration of the basic principles of nutrition, or an examination of the local Navajo dietary pattern for the actual nutritive and caloric value of their food in relation to their growth and work patterns. Understand your own _ professional biases. Personal frustrations and program failures can be avoided by examin- ing the basic scientific health idea or practice involved, and by deter- mining the absolute essentials needed in order to make it possible for the Navajo to learn to use the idea or to practice it in a living, participating way. STEP NO. 2. THIS orientation guide is written to pro- vide only a beginning at understanding the Navajo people. There are additional sources of information in the library of the Field Office at Window Rock, the Navajo Health Education Library at Tuba City, and elsewhere on the Reservation. People who live in Understand the Navajo People. 1 ''Navajo communities have a wealth of knowledge to share with the work- er who will take time to talk with them. Personal contact with the Nav- ajo people in their hogans, chapter meetings, the clinics and hospitals is by far the best way to learn to understand Navajo ways, to gain an ap- preciation of their culture, and to get to know and appreciate them as people. STEP NO. 3. STUDIES in psychology and anthropology indicate that, for the most part, an indi- vidual’s behavior, beliefs and attitudes grow and change only to the minimal ex- tent that is called for by the demands of his immediate situation. For example, a Navajo patient in the hospital cannot be expected to change his feelings suddenly about the hospital as a place of possible contact with ghosts of those who have died there. Navajo patients are going to hold on to many of the traditional beliefs and practices that have made sense to them in the past. We need to find appropriate ways of communicat- ing with the Navajo and helping him to utilize as many of his familiar ways of dealing with problems effectively as is possible. Understand how to adapt services to the Navajo. t STEP NO. 4. EACH local unit of operations in the Di- vision of Indian Health is known as a Service Unit. In the effort to enable it- self to raise the health status of the In- dians and Alaska Natives to a level which will compare favorably with that of the Nation,.the Division of Indian Health has established eight minimum requirements for elementary medical care, emergency service and health protection. These minimums are not standards, but repre- sent only a first step in a planned approach toward meeting acceptable levels of operation necessary to attain the Division’s goal. Each Service Unit is expected to work toward meeting these minimums within the resources available, before providing additional services. Each Unit was directed to study its problems, resources, and needs, in the light of the minimums, and to establish its “Most Pressing Health Needs or Problems” and how it planned to meet these. On the basis of this study, which was carried out during the latter part of 1959 and early part of 1960, each Service Unit prepared a “Service Unit Program Plan” to di- rect its operations during the period of July 1, 1960 to June 30, 1963. Understand your Service Unit Objectives. 2 ''The “Most Pressing Needs or Problems” are listed in order of priority. An example of this are those listed by the Tuba City Service Unit: 1. Infant and Childhood disease and mortality, from age 0 to 4. 2. Excessive Oral pathology causing a majority of patients by age 20 to become partially edentulous. 3. Excessive respiratory illnesses. 4, High incidence of complicated simple illnesses. Copies of these Program Plans are on hand at Service Unit offices, and should be studied by all incoming workers as both a further step in orien- tation and for a better understanding of the local health problems. The Program Plan covers considerable detail on the local environment and life of the Navajo, and discusses in detail the ways in which the hospital and field health staffs will approach the “most pressing needs or problems.” Morbidity and Mortality THE two tables which follow are pre- Statistics sented to give the incoming worker a glimpse of the morbidity and mortality incidence and rates among the Navajo as compared to the total United States rates: Family Group, Outside of Hogan 575291 O-61 -2 3 ''TaBLE I.—Reported Incidence of Specified Communicable Diseases Navajo and U.S., All Races 1957 ek Navajo U.S., All Races Disease Rates per Rates per ae Number | 100,000 | 100,000 eee tere population | population CHiEKGnpax ON es, 160 213.3 184.4 ' Diarrhea of newborn................. 23 30.7 - DiphiWerie.: 2400 Oo ee 2 a 0.7 Dyseniery, di tormme: 25 88 fs 648 864.0 . a ANIMNNGSIS 265 Se Fe 4 . 3.0 Beenie os 27 36.0 5.8 Other and unspecified.............. 617 822.7 : Gastritis, enteritis, etc................ 1,684 2,245.3 2 OnOMNOt 6 fe iss ce ee 166 2213 130.4 Hepatitis, infectious & serum........... 178 237.3 8.8 ipnueed a ee ee ee 4,862 6,482.7 2,320.9 TOR Ss ie ee ee ce 1,043 1,390.7 289.4 3 Meningococcal infections.............. 16 21.3 1.6 PAUINE os ee a a 86 114.7 153.6 Rneunmonidw.4 Se as 1,047 1,396.0 50.0 “ POlONI AHS oe oan ee 4 : Jaa Streptococcal sore throat & scarlet fever. . . 491 654.7 133.3 Syphilis and its sequelae.............. 106 141.3 79.9 4 Tren oe St 1,119 1,492.0 4 Tuberculosis; all tonne... 2 220 293.3 51.0 Wyohoid. fevers 292i. Se Zz : 0.7 s Whecping coughs 403 4. oie 2 27 36.0 16.6 * Estimated population used as base for computing 1957 rates is approximately 75,000. : 2 Not reported. 5 Rates not computed whenever fewer than 10 cases were reported. Sources: Navajo—Derived from monthly reports from PHS facilities serving the Navajo Reservation. All Races—Derived from National Office of Vital Statistics, Morbidity and Mortality, Volume 6, No. 53 (Annual Supplement) October 29, 1958. 4 '' TaBLe Il.—Ten Leading Causes of Death Among Navajos Death Rates and Percent of Total Deaths, Navajo Average for 1955- 1957, U.S. All Races, 1956 Cause of death Rates per 100,000 population Percent of total deaths Navajo All Races Navajo All Races 1955-1957 1956 1955-1957 1956 All causes 730.6 935.4 100.0 100.0 MOCMONNS 3 isa es oa es 129.7 56.7 15.1 6.1 Influenza and pneumonia... . 103.7 28.2 13.9 3.0 Certain diseases of early InfeneV co see es es EF2 38.6 10.5 4.1 Gastritis, duodenitis, enteritis end -colilis 5.0. 2: cen 57:9 4.5 8.0 0.5 Tuberculosis, all forms....... 525 8.4 73 0.9 Diseases of heart.......... 33.6 360.5 4.4 38.5 Malignant neoplasms....... 27.3 147.9 3.7 15.8 Vascular lesions of central nerv- GUS 4YSOM. a. ess 15:9 106.3 21 11.4 Non-meningococcal meningitis . 15.5 1.2 2.2 0.1 Congenital malformations... . 13.4 12.6 1.8 13 NGMENEE ees ass 13.0 0.3 1.8 0.0 All other causes........... 190.9 170.2 29.2: 18.3 Sources: Navajo rates calculated on 3-year average with rates centered at midpoint year. Cause of death available from death certificates on file with Navajo Agency Census Office; figures for 1957 are provisional. All Races, 1956: National Office of Vital Statistics, Special Reports Vol. 48, No. 7, August 14, 1958. '' Family Discussion, Inside Hogan 6 ''The Navajo Reservation Population FROM a population estimated at 10,000 in 1868, the Navajos have increased in number to more than 80,000 at present. The annual population increase is estimated as slightly over two percent. Although this is the largest Indian reservation in the country, it cannot support its present popula- tion. Many Navajos are forced to seek permanent or seasonal employ- ment elsewhere, With assistance from the Bureau of Indian Affairs, many are being relocated in Los Angeles, the San Francisco Bay Area, Denver, Chicago, and in other urban centers, where factory and skilled labor job opportunities are available to the Navajo. Navajo life is changing today, more so in some regions of the Reserva- tion than in others. On the periphery of the Reservation, where con- tacts with the outside are more frequent, the family patterns and ways of living have become different from those of the Reservation interior. The husband, wife, and children are living increasingly as a single fam» ily unit, rather than the more traditional “extended family” units of grandparents, children, and relatives. The husband often leaves his family for seasonal work on the railroad or in the mines. Part of the family group—men, women, and children— may spend several months of the year in the cotton fields and truck gar- dens of southern Arizona, or the sugarbeet fields of Utah and Idaho, while other members of the group remain on the Reservation to care for the crops and sheep. Causes of IT is readily apparent that health prob- Health Problems lems would be prevalent in an area where : the following conditions exist: crowded and seinen hhogans; an individual per 2 which often make difficult cae access to “hospitals and chindes, ‘lp addi- Pare tion, there is a time-honored custom of seeking a medicine man before considering medical care; a language barrier between the Navajos and 7 ''public health and medical personnel; and a rather low level of general education. A significant proportion of all illness on the Navajo Reservation is caused by lack of adequate water in quality and quantity. Also involved are improper waste disposal, flies and other insect vectors of disease, and accidents. Priorities have been given to sanitation and health educa- tion activities aimed at the mortality and morbidity from the infectious diseases caused by these insanitary conditions. An important factor in the lack of proper sanitation is the shortage of water. The average annual rainfall on the Reservation is very low, and soil conditions prevent maximum use and storage of what little water there is. Private water supplies are scarce. It is a familiar sight to see Navajos carrying large barrels great distances in their trucks and wagons in order to get water for drinking and other purposes. Navajo THE apparent isolation of the majority of “Communities” the Navajo people, and the size of the ” Reservation itself, makes the problem of - using the available medical and preven- tive health services even more difficult. There are no communities, as such. Houses are not often grouped together in Navajo country, except for the small clusters that have grown up around missions, government schools, hospitals and administrative centers. Towns and villages are not true aspects of Navajo culture. Community organization work is not a simple task of walking from house to house or block to block and talk- ing with people. Families sometimes group their hogans close together, but more frequently single dwellings will be located far removed from trading posts, schools, or other neighbors. Organized social activities, religious ceremonies, and the weekly or occasional trip to the trading post provide the most frequent opportunities for communication. The Reservation itself covers more than 15,000,000 acres, an area as large as the state of West Virginia,' or the combined states of New Hamp- shire, Vermont, Connecticut, and Rhode Island. The lands assured by the treaty of 1868 have been increased from time to time by Congress and through purchase. ao ''a7 Working With Navajo Leaders and Organizations Early ABOUT one hundred years ago, when the Developments territory occupied by the Navajos became part of the United States, there was no such thing as a Navajo “Tribe” in a polit- ical sense. The history of tribal self-government among the Navajos has “been marked by many changes in official policy and by confusion that stemmed from misunderstanding on the part of both the Navajos and the administrators. The white administrators did not understand the origi- nal pattern of Navajo authority and attempted to superimpose on it pat- terns of government only partially understood by the Navajos. The widely-scattered Navajo settlement pattern, with a frequent shift- ing of residence, is largely a result of the Navajo adaptation to a meager resource base. It results in a loosely organized, informal socio-political system. According to Kluckhohn and Leighton (see bibliography, p. 29) Nav- ajos understand responsibilities to relatives and even to local groups. They are accustomed to deciding all issues by face-to-face meetings of all individuals involved, including the women. The native way of deciding an issue is to discuss it until there is unanimity of opinion, or until the opposition no longer feels it worthwhile to urge its point of view. Navajo FOR many years after the establishment Tribal Council of Tribal government, a great many Nav- ajos saw the Tribal Council as a “puppet government” set up to approve the ac- tions of the Bureau of Indian Affairs. This view was especially strong during the last half of the 1930’s and early 1940’s when the government was enforcing the livestock reduction program. The Tribal Council really came into its own after World War II, and since that time has made rapid strides—perhaps the most outstanding example of development in self-government among any Indian group within the United States. Today there are 74 councilmen chosen by the Navajos from that num- S ''ber of voting districts on the Reservation. The Chairman and Vice- Chairman of the Council are presiding executive officers who are elected directly by the voters on the same secret ballot that is used for electing councilmen. Within the Council there is an Advisory Committee that meets regularly and helps to propose legislation, establish a tribal budget, and draw up the agenda for the quarterly meetings of the Council. In recent years, as Tribal responsibility for its own affairs has grown, a series of special committees from within the Council has been estab: ~~ lished in such fields as law and order, budget, education, welfare, health, and resources. One of these, the Tribal Health Committee, today takes an active part in meeting with the United States Public Health Service, state and local health officers, as well as tuberculosis sanatorium admin. istrators and physicians, who advise them on the health needs of the Navajo people. Tribal Health THE Tribal Health Committee consists of Committee six members, appointed by the Chairman of the Tribe. They serve four-year terms, and receive per-diem for the days they are authorized to work. This Committee has helped sponsor health ex- _ hibits at the Gallup Indian Ceremonial, at the Navajo Tribal Fair, and elsewhere. They meet jointly with the Education Committee of the Tribe from time to time to discuss problems of school health, They visit most of the hospitals where Navajo patients are cared for, as well as the field health centers. They meet periodically with the Public Health Service staff to review plans for construction of new facilities, develop- ment of services, and-solution of personnel problems. They have been instrumental in securing recent Tribal appropriations to assist in water development activities and in the development of audio-visual aids for health. The chairman of the Tribal Health Committee, Mrs. Annie D. Wauneka, has been active in educational activities related to health. She also serves as a member of the Surgeon General’s Advisory Committee on Indian Health. Local GROUPS of Navajo people living in a_ Tribal Chapters local area may get together to form a chapter group, for social or political pur- poses. At the present time there are about 100 local chapters “accredited” by the Tribe, and the number is growing. The Navajos in the local communities have gradually come to realize the importance of having a more active voice in the determina- 10 * ''xc 4 ° ny tion of their own affairs. This feeling has been given added impetus by the new program of Chapter House Development, whereby the local chapters may secure assistance in building and improving these local community center buildings. The first of the local chapters started in 1927. Although they are not official parts of the Tribal government, most of them seek formal recog- nition by the Tribal Council. When they were first organized into chap- ters, the Navajos were told by the administrators to elect a president, vice-president, and secretary and to carry on according to parliamentary procedure. These conditions made it inevitable that the “educated”’ Navajos took the leading roles, while the participation of the older and probably more experienced “medicine men” and wealthy livestock own- ers was very limited. Development of WITH the growing importance of the Local Leadership local chapters, as part of a much larger movement toward self-government, staff members of the Public Health Service can now expect to see more and more chapters created. This may mean increased functioning of committees, and perhaps even paid staff to assist them. There may be opportunities for the establishment of health com- mittees which could be counterparts of the Tribal Health Committee, ex- cept that they would concern themselves with local health problems. The meetings of the Tribal Chapters will provide opportunities for the public health staff to discuss problems with the chapter members, to interpret © * é health and medical services, and to actually carry out some direct health teaching. The Community Workers and Health Education Aides will probably attend chapter meetings in their areas on a regular basis for the purpose of maintaining communication with these groups, and encouraging and advising them with respect to health. With an increase in the number of chapters and the number building chapter houses, there should be more and more opportunities for the public health staff to work with these local groups. They will become increasingly important as communication channels and decision-making bodies. Many opportunities for develop- ing local leadership will be present. It is important for the public health staff to cooperate with the Bureau of Indian Affairs and the Tribe in any of their programs to encourage and promote local leadership. Public health clinics and educational meetings are held in some chapter houses. In others, sewing rooms and facilities for washing clothes will be avail- able. One would anticipate that more and more life of the community will revolve around the chapters and the chapter houses and that they will _become more important to public health personnel in their work. 575291 O-61 - 3 11 '' P 4 Goulding T.P. Oljeto T. a. > 8 __ UTAH _ Rainbow i ARIZONA Lodge CY +t ~. . *, Red Lake '.(Tonalea) T.P. -s oor tne Dinnebito T. P, oof Sunrise Springs T.PY av ‘Navajo Station LEGEND — Reservation Boundary + State Boundary -— County Boundary foes Surfaced Roads yee Graded Roads « Unimproved Trails ® Navajo Capital , é compressor Station wf rose ue ey , 53 @ teaith center i # Sunrise T. PA > Teupp Community, Settlement, - AT Asse Trading Post %F Town 7 Mine % s t ~~ Mission °eastay = PE SU Se a ae ces ate Road and Service ''Towaoc COLORADO UTE, INDIAN RESERVATION f N ‘ may _ COLORADO. ! a NEW MEXICO Avie eye TP. i La Plata pam, NAVAJO eae RESERVOIR weet water” a a ner ei A Beciavito ‘) ‘ PA XCoal pennonuet pilocl Hogback 1. P. Vv / Fruitland Kirtland tp Ratliesnake \ msi DSK hneza e fp XN, ae La elt 4 Tocito T.P. = i z i =) =": Two Grey Hills’ PEP. f ae ae s ans A Tsaya T. White ny 8 Olas Valley . ft Ranch . i JUAN -+-. MCKINLEY | i. K. Ranch | 3} Chitwood Ranch ENaschitti oF. ees wear! Pueblo Pintado obi 8 Many waters Presley Ranch Pitt Ranch, St. Michaels Mission - Pinedale a eB giariano Lake ; mm J.P. lyanbito ea Smith Lake Te Pd a Staple 4 Md 4 be tan Antorte ‘ Mission Ft. Wingate T. P. ~--, t Wander: ‘Chambers U.S. DEPT, OF HEALTH, EDUCATION, AND WELFARE a PUBLIC HEALTH SERVICE Bibo DIVISION OF INDIAN HEALTH i WINDOW ROCK, SUB-AREA OpPaguate WINDOW ROCK, ARIZONA ARIZONA NEW MEXICO. NAVAJO RESERVATION INDIAN HEALTH SERVICE UNITS ''''Health and Disease as Seen by Navajos Conception of THE Navajo’s conception of health is Health very different from that which most pub- lic health workers have. For him, health is part of a correct relationship between man and his supernatural environment, the world around him, and his fel- y low men. Health is associated with good and beauty, all that is positively valued in life. Illness, on the other hand, is evidence that one has fallen 4 out of this delicate balance. It is usually ascribed to the breaking of one | of the taboos which guide the behavior of the Navajos. Illness may also | be considered due to contact with the ghosts of the dead or even to the \ malevolence of another Navajo who has resorted to witchery. In order to restore the harmony with his environment which results once evil is driven out from the body and good is restored, a “‘singer’”” must perform an exactly-prescribed ritual for the patient. Studies indicate that some Navajos formerly devoted from one-quarter to one-third of their time to _ ceremonials, although the pattern today has changed somewhat. The Navajo does not make a distinction between religion and medicine. To him they are aspects ; of the same entity. This is an important cul- \ tural fact that many workers in the health field have failed to realize. Virtually all_Navajo religious behavior is oriented toward curing an indi- vidual of some illness. The patient, once he feels ill, consults with his immediate family. The individual who is sick does not act on his own. The family is likely to take the matter into its own hands, once its mem- bers know that one of them is sick. They call in a diagnostician, who by various techniques—the most common method is by motion in the hand (an involuntary trembling of the diviner’s hand and arm)—discovers the cause of the present illness. Examples of the “hand trembler’s” diagnosis: possibly when the patient was a child carried in his mother’s womb, the mother had looked at a forbidden sand painting; or, the patient had come in contact with a light- ning-struck object and an evil, that must be exorcised, had entered his body. Perhaps he had eaten a taboo food which brought on the illness. 15 ''Any one of these, or hundreds of other causes, might have brought about the present illness, which is manifested by bodily pain or mental anguish. Then, in order to bring back the patient to the correct balance with na- ture, a particular “‘sing’’ must be performed—evil driven out and beauty and health restored. After the diagnostician has indicated the root of illness, he suggests what “sing” should be performed. The family then goes off for a “singer” who knows the required ceremony, and they ar- range with him as to what the fee for the “sing” or ceremony shall be. Theory of Curing TO the Navajo, the first step in curing is taken by finding out by the review of _ past behavior, in consultation with a diagnostician, the particular evils responsible for illness. Bad things sent by malevolent spirits, or even the spirits themselves, may enter the body. After the causes of illness have been determined, guilt and ugly things must be expelled. Hence, numerous rites are directed toward purification, the purpose of which seems to be to make the patient susceptible to, and understanding of, the powers being invoked for him. Bathing and shampooing the hair are in- corporated in some rites to symbolize a change from profane to sacred, from the strange and doubtful to control. Body and hair are washed in the suds of the yucca root. The body, jewelry, and clothing of the pa- tient are often subsequently rubbed with corn meal. Not omly the patient and his immediate vicinity, but even an extended space to be occupied by the deity, should be cleansed. Consequently, all participants in the ceremony imitate the patient in varying degrees. Some of the visitors at the ceremony take sweat baths and emetics with him, and practically all attending shampoo their hair. The Navajo Ceremony THE Navajo ceremony is a combination of many elements: the medicine bundle with its sacred content; prayer sticks made of carefully selected wood and feathers; precious stones; tobacco; water collected from sacred places; a tiny piece of cotton string; song with lyrical and musical complexities; sand painting with intricate color; directional and impressionistic sym- bols; prayers, with stress on order and rhythmic unity; plants with super- natural qualities, deified and personified; body and finger painting; sweat- ing and emetics with purifying functions. It is the selection of these and other elements, and their orderly combination into a unit, which makes” the-chant or-ceremony effective. A ceremony may last from one to niné nights. 16 ''The Medicine Man THE person in-charge of the ceremony is. the medicine man, or “‘singer” as he is usually called. Most Navajos put great trust in the punctilious ritualistic performance of the medicine man. In his capacity of “singer” at a cere- monial, the medicine man is more than mortal. He at times becomes identified with the gods, when telling the patient that all is well. In addition to this powerful reassurance, the ceremony-supplies the patient with occupation and diversion. He has the sense-of doing some- thing about a misfortune which ‘otherwise might-_leave-him-with-the-mis- ery of feeling completely helpless. Although he does not actually carry out most of the necess necessary preparations, his mind is full of matters net have to be done. Arrangements must be made for paying the “singer” and getting the food supplies together to feed all who come. Ritual material has to be gathered and people have to be called who will do it. During the actual ceremonial, the patient’s relatives are busy following the singer’s instructions, pondering the implications of the songs and prayers, and the speeches and side remarks of the singer. Psycho-Therapeutic IT is easy to see that a ceremonial has a Aspects of Ceremonies powerful appeal to_ the emotions. The “singer” will not permit the talk that goes on | between ‘the 1 movements. of the cere- monial to deal with unpleasant—topies- Talk must be of health and strength, of times people were treated by “‘sings” and got well, of good crops and fat animals. The people at the ceremonial are not just a crowd; they are nearly all the persons of importance in the patient’s life, his rela- tives, his representatives of his own race of chosen people. They are the descendants of the Navajos who first got these mystic rites from the crea- tors of the world. All these people have gathered, focusing their atten- tion on the patient, bringing their influence and expectation to bear on his illness, their very presence inferring that powerful forces are working for his well ae _monial. Be pe a ase cd et ing to develop that the purposes of the ceremonial have been achieved or are starting to be achieved. The very considerable economic investment that the patient or his family must make to have the “sing” probably con- tributes to the feeling that results must be obtained. The Navajos are prone to develop strong faith in anything that has cost them time, money, and thought, so they are very loath to have it said that the ceremonial was, after all, a failure. 17 ''Adapting White Medicine**IF Western medicine is to help and not to Indian Culture harm t the Navajos, it it must get them to ac- ‘cept our pertinent ‘and practical knowl- edge without undermining t their faith. Their faith must not be ruthlessly attacked simply because it offers some obstacles to medicine. Instead, Western_medicine should be expressed to the Navajos in terms of their own culture, in ways that accord with their understanding of the world_and their values. If a public health worker wins the friendship of a few Navajos and takes time to listen to them, he will learn much that will be of practical use in adapting treat- ments, procedures, and teachings to the Navajos. In the course of time, as rapport develops, the ceremonials which least interfere with medicine can be particularly encouraged; thus it may be that the physician is free to give penicillin and the Navajo is free to get the psychological benefit which he may derive from the religious rituals. For a Navajo patient, being helped by a “singer” is quite different from being helped by a physician or nurse. The physicians, nurses, and other staff members who understand the Navajo’s way of looking at the world and his psychological dependence on the “sings” are likely to have good relationships with the Navajo patients. Those who do not understand their ways, and attempt to force our be- liefs and the scientific basis of our medicine on them, are likely to have poor relationships. Doctors at the Fort Defiance Sanatorium report that when, in recent years, they have suggested that patients have “sings” be- fore and after sanatoriim treatment, there has been less absence-without- medical-advice. Navajo Perception _TWO points must be considered by the of Symptoms ‘health worker who i is new to the Navajo, in the understanding. of how the Navajo per- ceives of symptoms: one, the Navajo “hand trembler” diagnostician does not ask for his patient’s descriptions of symptoms—he- “tells the patient what is wrong after he has completed his hand trembling ritual: two, Navajos are not used_to observing and re- _membering those things the physician wants to know about, and so they often cannot provide the information needed by the physicians in making their diagnosis. A dramatic illustration of this point was reported by a doctor in Tuba City. A missionary had brought a Navajo mother and her sick baby to the hospital from a remote area. There was pain and trouble with the child’s stomach and bowels. According to the doctor, the mother could tell this much but nothing further about the pain. She was not able to 18 ''tell whether the child had cried a lot, or very hard, or for a long time. At this point the missionary volunteered information about how the baby would wake up from a sound sleep during the trip, give a very short- sharp cry, and then lapse back into sleep. This had gone on quite regu- larly during the entire trip to the hospital. The pediatrician asked the mother about this very specific event. The Navajo mother could seem to remember nothing unusual about the baby’s cry. The symptom described by the missionary is usually the confirming sign of a telescoped bowel. The doctor operated and found that the bowel had telescoped in several locations. The condition was corrected and the baby lived. In describing symptoms, significant cross-cultural differences enter the diagnostic process. As has been pointed out, the Navajo patient does not share the doctor’s system of expectations about what is important to observe in signs of illness and what is necessary to report to the doctor during the diagnostic process. For example, if Navajo children up to the age of 15 years complain about having a “headache,” it may mean that they have a sore throat; if an adult Navajo “feels bad all over,” it can mean a sore throat, chronic pneumonia, cholocystitis, or flu. “Diarrhea” in the case of small children means that the child is very sick—“the baby is very sick, please pay attention, doctor.”” The word does not refer to a particular bowel condition. In fact, it is sometimes used to mean the opposite condition, constipation. The beliefs and expectations of the Navajo are important. This sets the stage for their initial decision to seek medical help, for the peculiar selection of information to be reported, and for the manner in which a complaint is described, The Navajo’s understanding of causation in ill- ness will be quite different from that of the doctor. The health worker’s explanations of “germ theory” have no real meaning to the Navajo be- cause the germ theory does not tie in with any other of his beliefs about causative forces. It is essential that all health and medical workers have a full under- standing of Navajo beliefs-about_health. Our health methods can then be adjusted and adapted so as to capitalize on already existent aids to suc- cess in the treatment and care of the Navajo. 19 ''The Navajo Language and Problems in Communication SOME of the problems faced by the Navajos in adjusting to white soci- ety, and especially the problems faced by the Navajo child in school. spring simply from the differences between the English and Navajo languages. Non-Navajos who have tried to learn to speak Navajo realize how diffi- cult the language is, but they often fail to comprehend that it is equally hard for Navajos to master English. English sounds are so different from Navajo, and so indistinct by comparison, that they are hard for the Navajo to learn. Importance of Learning SOME understanding of Navajo speech the Language and expression of thought is essential to the public health worker who wants to understand the Navajos. Part of the use- fulness of learning at least the rudiments of the language lies in the fact that this act indicates the good will of the white person. Making the ef- fort necessary to learn something of their language pays the Navajos the implied compliment and establishes the friendly relation that arises be- tween the earnest novice and the expert. To American Indians, whose language has usually been ignored or ridiculed by whites, there is satis- faction in seeing the white man take the trouble to study their language; his very difficulties and mistakes tend to promote good feeling toward him. Indians have seldom had the opportunity of laughing openly at the white man with impunity. If they can smile and joke freely when a white man tries haltingly to pronounce words or speak a sentence, their hostile impulses toward him may be diminished. Using the language, even to a very slight degree, helps to build easy and confident relations with the Navajos. A few words of greeting and fare- well, a face lighting with comprehension when a daily commonplace is uttered in Navajo, sometimes mean the difference between meine regarded as a foreign intruder or as a sympathetic visitor. The Navajo language is not a primitive tool, inadequate for human 20 ''expression. It is a well-developed language, quite as capable of serving the Navajo people as our language is of serving us. The fact that trans- lation of English into Navajo is difficult does not prove that the Navajo language is a poor one, any more than difficulty of translation from Navajo into English proves English to be a poor language. The use of the language to establish rapport or to ask questions, to give instructions or to otherwise make official communications is obvious. More important, however, is the usefulness of knowing some of the lan- guage in helping to see things as the Navajo sees them. The meanings which the events of a Navajo’s life have to a Navajo will always remain somewhat hidden to the white man, unless he has given enough attention to the language to gain entrance to this foreign world whose values and significances are indicated by the emphasis of native vocabulary, are crystallized in the structure of the language, and are implicit in its differentiations of meaning. This does not mean the health worker, or anyone else who wants to know the Navajo people, must speak the language fluently, although this would certainly be ideal. What is needed is simply enough study and thought to make the Anglo person aware of the habitual differences in thinking characteristics of those who think in Navajo. Merely a few days of intelligent study will do more than any other investment of the same amount of time to unlock the doors of the world in which the Navajo lives, feels, and thinks. Problems in INTERPRETING languages is always dif- Interpreting ficult. It is far more than just finding equivalent words; the idea and the feeling that goes with it must be expressed, too. With Navajo and English the difficulty is increased by the fact that the words are used in a different order, so that a sentence often has to be turned around before being translated. A further complication is that, in telling a story, a Navajo is likely to start with the point and then explain what led up to it, while in English the point usually comes at the end. Use of THE doctor, nurse, sanitarian, or other Interpreters worker speaking through an interpreter should first have clearly in mind what he wants to say. Then he should reduce it to the simplest possible English. If he customarily works with the same interpreter, he should listen to the interpreter’s English and use his 21 ''expressions as much as possible. The interpreter will then understand more readily and his translation will be more accurate. The easiest and most productive way to work with an interpreter is to say things point by point rather than phrase by phrase. This is because the interpreter must be able to relate to the end point of the total discussion. Qualities of a A good interpreter must be considered by “Good” Interpreter other Indians to be a competent speaker in Navajo. Many of the interpreters who have been away to school have a limited vocabulary in Navajo and the other Navajo people know this. The professional worker can, of course, determine the interpreter’s English ability himself. The interpreter’s lot is not a happy one. He is under pressure from both the Navajo and the English speaker to translate quickly, and so does not have time to think out the full implications of what he is saying in either language. Old Navajos are sometimes exasperated when the inter- Young Girl and Child, Spinning and Carding Wool, Inside Hogan 22 ''preter asks them to repeat or rephrase some verb form that has baffled him. Whites become impatient at the amount of time consumed. Both sides blame the interpreter if they sense that effective communication is not being established. At the same time, they may put too much trust in the translations and believe that their meanings have been transmitted intact and without essential distortion. Most people assume naively that an interpreter can, or ought to be able to, work with the precision of a machine. But turning a sentence from English into Navajo, or from Navajo into English, involves a great deal more than choosing the proper words or word equivalent from a dic- tionary. Bewildered by the lack of structural correspondence between the tongues, most interpreters succumb to one or both of two temptations: either they leave out a great deal in translating, or they translate too freely, projecting their own meanings into the sentences they translate. Sometimes difficulties arise because the interpreter sticks too closely to the literal text of the English. For example, at a Navajo Council meet- ing during World War II there was a discussion of how to develop mineral and gas resources on the Reservation. The speaker from Washington who introduced the matter used the phrase “hidden beneath the ground.” When translated literally into Navajo, this had the sense “secreted beneath the ground.” The Council got the impression that there was some skull- duggery in the whole business and got suspicious. As a result, certain measures which should have been adopted, in the interests of the war effort, had to be held over for consideration at the next meeting. Too often white speakers use idiomatic expressions, similes, and allegories that baffle and confuse the interpreter. The result is that he either mis- interprets, or says something entirely at random to avoid embarrassment to himself. Use of abstractions, similes, allegories, idiomatic expressions, and slang should be avoided if at all possible. The Role of the THE use of an interpreter requires im- Interpreter in Diagnosis portant shifts in the usual medical pro- cedure. One of the problems in having to work through interpreters is the reduc- tion in reliance upon case history in making diagnosis. In medical school the doctor is taught to use case history as a valuable aid to diag- nosis. Ina situation which requires translation, obtaining a case history is too time-consuming. The heavy patient load and the chronic under- staffing in most Navajo facilities rule out such expenditure of time. The doctor must learn to make diagnosis on the basis of other techniques. 23 ''Navajo Concept THE Navajo concept of time affects de- of Time scription of symptom history, regimen of treatment, and scheduling of return visits to the doctor. Some doctors say that it makes little difference to a Navajo whether something happened three months, three weeks, or three days ago. They do not understand that the doctor’s interest is primarily in very recent events. To the Navajo, falling off a horse two years ago could cause TB now, so this is the type of information he provides. In prescribing treatment the doctor cannot rely on the patient to take the proper dosage of medication on a given time schedule. This means that most doctors prefer to start the patient out with an injection, so that they know “he got at least that much of the medication.” This situation puts pressure on the doctor to schedule return visits and increases his case load. It also poses problems for the patient because of the distances and travel conditions of the Reservation. Another problem which comes up occasionally is that of the Navajo patient who keeps “changing his story.” One doctor tried using three different interpreters with one patient and ended up with three entirely Preparing Squash for Drying 24 ''in 7 ss he different stories of the disease and its history. He decided that in the future the first history was THE history. It has been suggested that when Navajos “change their stories” it is related to attentiveness on the part of the physician and that they change their story to “please the doctor,” shifting at every point when they feel he is bored or skeptical. It is possible, also, that some of this variety in reporting is introduced by the interpreter. Anxiety in an unfamiliar situation may be responsible for some of the variation. The medical interview is a bilingual situation with nearly all Navajos. In those cases where the doctor learns that the Navajo can speak English with some degree of fluency but refuses to do so, there is usually serious concern about this and effort is made to find the reason. In one case a doctor reported that a patient in the hospital took a turn for the worse and immediately stopped speaking English. Another doctor mentioned that a Navajo patient would speak to him in English if he was off the ward or in an informal situation, but only in Navajo during “rounds.” There are a number of reasons why Navajos who can speak English may speak Navajo in a medical setting. The Navajo may not want to use English in an important situation like this because he does not want to be embarrassed by mistakes or inadequacies in his mastery of a foreign lan- guage. At times, using his native tongue is a form of regression under stress. The patient may not want to exclude the Navajo interpreter because he is there for a purpose and has a job to perform. The inter- preting gives the patient time to think about what he will say next. He may feel that the formal nature of the medical situation requires a Navajo interpreter as part of the “paraphernalia” of the stylized “ceremony.” Refusing to speak English may be an expression of hostility toward the doctor, for it makes his work more difficult. Requiring an interpreter may be the patient’s way of extending the amount of time that the doctor stays with him—the Navajos are used to lengthy ministrations from their medicine men and not the short visits which they find in the medical situation. In any case and for whatever reason, it is important to show acceptance of the feelings the Navajo patient may have about using either language. With sincere effort, some skill, and a little luck, the public health worker may earn for himself a place with the Navajos as a potential friend; and not as a person who is always in the superior role. Without this effort at understanding the Navajo through his language, the white’ man may be considered just another member of the distrusted or even hated race, to whom taciturnity, sullenness, suspicion, or active hostility are the usual responses. 25 ''Life on the Reservation THE joys of adventure and discovery await the health worker new to the wonders of the 25,000 square mile area of the Navajo Reservation. The unsurpassed grandeur of the scenery and the many facets of everyday life, both ancient and contemporary, are a challenge to the imagination. Scenery THE surface of Navajoland includes four \ principal features: the flat alluvial valleys at elevations from 4,500 feet to 6,000 feet; the broad, rolling upland plains between 5,500 and 7,000 feet; the mesas located at elevations of 6,000 to 8,000 feet; and the mountains ranging from 7,500 to over 10,000 feet in altitude. , Each of these four major types is cut by canyons of a few hundred feet to more than 2,000 feet in depth and is broken by prominences rising as high as 1,500 to 2,000 feet. There are three out- standing highland provinces, namely the combined Chuska-Carrizo Moun- tain Range, the Black Mesa, and Navajo Mountain. This is the land of the Painted Desert, where vast networks of canyons have been sculptured by the ages, and where the moods move in ghostly fashion under the spell of the changing light from the sun and the moon. The Seventh Wonder of the World, the Grand Canyon, borders on the west of the Reservation. The north-central part of the Reservation is the home of Monument Valley, the Eighth Wonder of the World and a magnificent testimonial to Nature’s artistry which is breathtaking from any angle. Monument Valley is now a Navajo Tribal Park. There are also the deep gorges of Canyon de Chelly; the great natural span of Rainbow Bridge; the ever-changing colors of Beautiful Valley; the alpine grandeur of such mountain areas as the sacred San Francisco Peaks at Flagstaff and the sacred Navajo Mountain in the Northwest; the geologic wonders of the mighty Shiprock, which is visible for 100 miles, and the spectacular Window Rock, which is the backdrop to the Navajo Capitol; and the many petrified forest deposits. 20 '' Ancient Indian Ruins THE Reservation abounds with the re- mains of ancient Indian dwellings. There are the pre-historic cliff-dwellings of Canyon de Chelly, where cultural progress is recorded as covering a longer period than any other ruins of the southwest; the Keet Seel and Betatakin Ruins in the Tsegi Canyon, in the northwestern part of the Reservation; the many pueblo ruins, like those found at the Wupatki National Monument south of Cameron; and many ancient ruins of the basket-weaver era, which preceded the pueblos. Recreational Sports SURPRISINGLY, there are many ex- and Hobbies cellent fishing spots on and near the Reservation, in natural lakes, streams, reservoirs, rivers and dams. Trout, bass, catfish, and other species are plentiful here. Small game, grouse, wild turkey, deer, elk and bear hunting are popular pursuits. Snow skiing and water skiing are available to the enthusiast. And there is no end to the enjoyment for those who like to hunt rocks, minerals and petrified wood; for those who like to hike and do mountain climbing; for those who like to hunt for arrowheads, pot sherds and other ancient relics; and for those who like to do photography and painting. Camping out and picnicking are permitted practically everywhere. The great Glen Canyon Dam at Page, Arizona, is scheduled to be completed in 1963, and will open new vistas to recreation. Archery and boating are becoming more popular pursuits. Good radio reception can be had from practically every area of the Reservation, and television reception is available to all except the more remote areagy Classical and popular dancing and music entertainment are brought to the Window Rock Civic Center and the Tuba City Community Center, which are Tribal-sponsored centers. Movies are presented locally. Arts and Crafts THE Navajo Arts and Crafts Guild at the Window Rock Fair Grounds is owned and operated by the Tribe, and was established to promote quality in Navajo silver work and weaving. The Hopi Arts and Crafts Guild at Oraibi, on the Hopi Reservation, is dedicated to the same purpose for the Hopi arts and crafts. The numerous trading posts carry these products, also, as well as Zuni arts and crafts work. Navajo arts and craft products are available at Tribal-owned motels at Window Rock and Shiprock and at the Monument Valley Observatory. 27 ''Ceremonies and Events THROUGHOUT the summer there are many Navajo activities, such as fairs, rodeos and colorful Squaw Dances. The four-day Tribal Fair in September each year attracts thousands and is the showplace of the Navajo’s finest. The Hopi Snake Dances and the many Kachina dances, held in the various Hopi Indian villages, are extremely popular. The Hopi village of Old Oraibi is the oldest continuously-inhabited village in the United States. Shopping Areas SHOPPING for food-and clothing can be done locally at the trading posts, and at the markets in the larger Reservation cities and villages. Larger towns near the Reservation include Gallup and Farmington in New Mexico; Cortez and Durango in Colorado; Monticello and, Kanab in Utah; and Flagstaff, Winslow and Holbrook in Arizona. The large metropolitan areas nearby are Salt Lake City, Utah; Albuquerque, New Mexico; Phoenix, Arizona; and Las Vegas, Nevada. The land of Mexico is one-half day’s drive to the south. Housing and Schools HOUSING, for employees of the Division of Indian Health, is made available by the U.S. Public Health Service. In addition, private housing is available at Farmington, Gallup, and Winslow for those working in and around those ~ areas. There are excellent Bureau of Indian Affairs schools and public schools at all of the Division’s hospitals and clinic locations, as well as at most of the other villages and communities, for school age children. Social Organizations THERE are many social and civic organ- izations and groups, for men and women alike. These help to provide entertainment and relaxation, as well as to sponsor civic improvement activities. New Reservation IN meeting a need of long standing, the Map Available Navajo Tribe in 1960 prepared and pub- lished a beautiful full-color illustrated Reservation map. Copies may be obtained from the Tribal Parks Commission, Navajo Tribal Council, Window Rock, Arizona. 28 ''Bibliography Apair, J., Deuscuie, E., & McDermott, W. “Patterns of health and disease among the Navajos.” The Annals, Amer. Acad. Pol. & Soc. Sc., 1957, 311, 80-94. Apair, J., & Voct, E. ‘Navajo and Zuni veterans; a study of con- trasting modes of culture change.” Amer. Anthropologist, 1949, 51, 547-62. Gotprrank, Esruer. “Irrigation agriculture and Navajo community leadership: case Material on environment and culture.” Amer. Anthro- pologist, 1945, 47, 262-277; 1946, 48, 473-476. Haptey, J. “Health conditions among Navajo Indians.” Publ. Hlth. Reports, 1955, 70, (9), 831-836. Kimpat, S. T., & Provinse, H. “Navajo social organization and land use planning.” Applied Anthropology, 1942, 1, 18-25. Kxuckxuonn, C., & Leicuton, Dorornia C. The Navajo. Cambridge: Harvard University Press, 1946. Leicuton, A. H., & Leicuron, Dororu1a C. The Navajo Door. Cambridge: Harvard University Press, 1945. Leicuton, A. H., & Lercuron, Dorotuia C. Therapeutic values in Navajo religion. (Mimeo) Leicuton, A. H., & Kennepy, D. Pilot study of cultural items in a medical diagnosis: a field report. 1957. (Ditto) Mays, E., & Morcan, W. Talking Navajo before you know it. U.S. Dept. Interior, Office Indian Affairs, Branch of Educ., Window Rock, Arizona, 1957. Reicuarp, Giapys. Navajo religion: a study of symbolism. New York: Pantheon Books, 1950, 1. Tuompson, Laura. Personality and government: findings and recom- mendations of Indian Administration Research. Mexico: Ediciones del Instituto Indigenista Interamericano, 1951. Younc, R. The Navajo Yearbook. Window Rock, Arizona: Navajo Agency, 1958. 29 U.S. GOVERNMENT PRINTING OFFICE : 1961 OF—575291 '' '' '' ''U. C. BERKELEY LIBRARIES COb092e51b4 ''