Roy Yazzie, an American Indian, fought in the Vietnam War as a Marine. He doesn't hear well, battles diabetes and struggles with post-traumatic stress disorder. On far too many nights, he just can't go to sleep.
Through VA, he sees a social worker once a month and a psychiatrist every two months. He also takes medication daily.
Yazzie says the health care itself is good. However, the distance and staffing levels could be improved. "Sometimes it takes you quite a while to see someone, even if you've already made an appointment," he said during a visit to the Chinle Vet Center in northeastern Arizona on the Navajo reservation.
The biggest problem is distance: the Navajo Nation covers more than 27,000 square miles, across some of the most sparsely populated land in Arizona, New Mexico and Utah. Patients often travel hundreds of miles to get VA health care, and providers often travel hundreds of miles to give it.
From his home in Farmington, N.M., Yazzie has to drive to the VA medical center in Albuquerque, about 180 miles away. "I would like more VA health care in Farmington," he says. "When you're stressed out, sometimes you don't want to travel very far. I don't feel like driving."
Emmarie Sheppard, an Army veteran who drives Chinle's mobile veterans center, agrees that transportation is a serious barrier to local veterans receiving treatment.
"They say that Chinle is the central location of the Navajo Nation (in Arizona)," she says. "It's centralized, yes, but (VA) doesn't take into consideration that, depending on where you're coming from, people have to drive on 70 miles of dirt road. I wouldn't come here for services. It's just too much of a hassle."
On the contrary, VA is well aware of transportation issues in rural settings. Rod Sepulveda, the Northern Arizona VA Health Care System's rural health program coordinator, is responsible for assessing the needs of communities and helping develop solutions.
"For example, we don't want anyone driving more than an hour to get VA health care," he says. As a result, VA clinics are planned for Chinle, Flagstaff and other Arizona locations in the Navajo Nation.
VA tries to place facilities so that most patients have to travel no more than 60 miles, Sepulveda says, "but because of the road conditions, we're planning them for 60 miles or less. We're trying to locate clinics to make them more accessible to our vets – not just Native Americans, but all veterans. That's the key thing we have to emphasize. When we're out here as VA, we're looking at every single veteran. We can't treat different people different ways."
VA signed memoranda of understanding with the Indian Health Service in 2003 and 2010, pledging to find more effective ways to improve the delivery of health care to Indian reservations.
In Sepulveda's own region, VA's Office of Rural Health (ORH) has funded several health-care initiatives, including a mobile medical unit. "(ORH) actually paid for that entire unit," he says. "Just about everything we've asked for, we've actually gotten."
Vet Centers are another matter. VA doesn't own or maintain them, but provides personnel to staff them. Ruthie Hunter is a VA social worker who has worked with the Navajo tribe for more than 20 years. She operates out of the Chinle Vet Center, where the roof leaks badly.
"It's important to support providers, so they can do what they need to do," Hunter says. "To get easy access to health care, you need a place with some stability."
Still, every time it rains or snow melts, workers have to move furniture so that it doesn't get wet – impeding the center's mission.
The Navajo Nation has offered to pitch in and build new facilities, but Sepulveda says it will take years. "They have to withdraw land from the trust, then fund it for a specific purpose and go at it that way," he says.
In the meantime, Hunter has to deal with the leaky roof and other material shortfalls as she pursues her outreach efforts to veterans. Many times, veterans are less than specific about their concerns or challenges they face, she says. "So when they come and talk to me, they might just say, ‘Well, I'm here for an appointment.' Then I just start asking questions."
Hunter educates communities on suicide prevention, teaching local people what they can do to help or intervene. "At the end, I always invite the people in the audience to tell us about some veterans who may be way out there, who are having problems accessing services, that I need to know about so that I can go out there to see them. We're trying to do the outreach."
VA is also reaching out to rural veterans with Home-Based Primary Care (HBPC), which delivers a variety of medical services to the homes of veterans whose health issues are not effectively treated by routine, clinic-based care. The HBPC program has found success in the Pueblo Nation.
Marvin Trujillo is the tribal veterans service officer for the Pueblo of Laguna, about 45 miles west of Albuquerque. He works with VA medical offices to get HBPC for Pueblo veterans, calling it "awesome care for the veterans, especially in the rural communities, because you have a visiting nurse, a doctor, specialists who come out to the veteran. They do a screening process for the veteran and for the residence," and make disabled veterans' homes more accessible with ramps and other modifications.
Trujillo, a Navy and Marine Corps veteran, says VA deserves praise for the HBPC program. "They do the blood testing, go back to Albuquerque and get the results the same day. If a veteran needs medication, they can send it overnight to them. The veterans can use telemedicine right in their homes and send their vital signs via computer or phone lines."
While improvements are under way in VA rural health care on the reservations, most are geared toward male Navajo and Pueblo patients. When it comes to women's health care, a different story is told. Cassandra Morgan is a Marine Corps veteran who has been working with Navajo veterans since 1996, helping them file disability claims and sometimes translating for them at claims hearings. She says that VA health care for female veterans in the rural setting "is almost nonexistent. It's difficult because education is lacking at all levels."
The only adequate health care Morgan says she's received was at the VA clinic in Albuquerque, 140 miles away from her home in Gallup, N.M. At her local community-based outpatient clinic, "exams are kind of uncomfortable because we've only had male doctors there." Recently, the clinic got a female physician's assistant.
"Doctors need sensitivity training for female patients," Morgan says. "Our health problems are from trauma in the military, not because we are women."
Distance has been another obstacle for Morgan in getting the health care she needs. Two years ago, she enrolled in a 12-week women's PTSD clinic at the VA medical center in Albuquerque, two and a half hours away. "I tried it for six weeks, and then the weather got bad," she says. "I had to stop the program."
Even so, Morgan hasn't stopped reaching out to veterans. Neither have dozens of other specialists in tribal communities, such as Van Poyer at the Chinle Vet Center, who believes the best way to improve rural health care is to build more permanent facilities and staff them with permanent VA employees.
"They need to build a VA clinic right here on the reservation, so that our veterans don't have to travel so far – so there's actual Native American staff they would feel comfortable talking to and coming to for help," he says.
Such an investment would be "a sign of good faith," Morgan says. "The mobile thing doesn't help. We have too many things that don't stay. And the vets out here feel used – if not by the politicians, then by organizations who want our numbers. If you could even have a small building with two or three people that says ‘Veterans Administration,' you're going to have that place packed."
Philip M. Callaghan is director of media marketing for The American Legion.