Shuba Bhat

Shubha Lakshmi Bhat

The Next Generation is a Clinical & Research News (CRN) column penned by residents, fellows and postdocs. In this month’s column, we’ve excerpted from a series of entries written by Shubha Lakshmi Bhat, MD, an internal medicine resident at BWH, for the Center of Expertise in Global and Humanitarian Health – Travel Blog where recipients of Partners HealthCare travel grants describe their experiences in global and humanitarian health.

Exploring Healthcare Delivery at Indian Health Service, Navajo Nation (Gallup, NM), Part 1

My first week at Indian Health Service (IHS) in Gallup, New Mexico, was incredibly diverse. I spent the first couple days in clinic, where I learned about the detection and management of the most common diseases in the community–namely, diabetes, obesity, rheumatologic illnesses, alcohol dependence and depression. Unfortunately, nearly all the patients I met had an underlying diagnosis of diabetes and obesity, likely due to a combination of genetics, an increasingly sedentary lifestyle, and lack of access to healthy food. I also learned how the primary care physician (PCP) diagnoses and treats rheumatoid arthritis (including how to differentiate between general non-active RA and a flare) and ankylosing spondylitis. Since there is no local rheumatology specialist, the PCP is responsible for managing this on his/her own. The PCP I worked with also taught me about the use of Naltrexone in alcohol dependence, which I had previously never prescribed during my residency training in Boston. I also met several patients who were successfully treated with Naltrexone and were doing a lot better. Finally, regarding depression, there were a number of patients I met who had undergone physical and/or verbal abuse from their family members as children and as adults, usually in the context of alcohol abuse. I learned about the stigma of getting therapy in the community, which made me realize how important and needed it is to integrate behavioral health with primary care.

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Exploring Healthcare Delivery at Indian Health Service, Navajo Nation (Gallup, NM), Part 2

My second and third weeks at IHS exposed me to different and innovative models of preventive health care delivery. Below, I’ve outlined the various programs that I learned about:

•    Navajo Area IHS HIV Program (HOPE): This program employs HIV Nurse specialists to assist the infectious disease physician with HIV clinic flow and to see patients independently for STD treatment, vaccinations, counseling and rapid HIV testing of partners. The HIV nurse also supervises the health technicians (pharmacists who help sort out medication distribution and adherence), and does field visits that involve home assessments, medication monitoring and community outreach for patients who are more challenging to care for. Over two days, I attended a few field visits on the reservation and also participated in an outreach HIV education program at the local Gallup Adult Detention Center. This was my first time visiting patients on the reservation and it was eye-opening to see how spread out the homes were and how difficult it was to navigate the reservation as an outsider (because of the rain and mud roads and landmark-based directions). This gave me a greater appreciation for how difficult it must be for patients to seek medical care when they need it given that the reservation is so rural and relatively isolated. It was also interesting to see how the community on the reservation makes a living on their farms. Most homes had accompanying Hogans, which are traditionally used as a ceremonial space and have doors that all face east. For a few patients we visited, it was clear that they were using a combination of traditional Navajo healing/medicine man as well as antiretrovirals to treat their HIV. It was clear that the combination of these two forms of medicine sometimes posed a challenge to effective treatment of the virus. Because many of the community members lacked cell phone reception, it was sometimes hard to predict whether they would be home. The time that we were on the reservation was the beginning of the month, when people receive their paychecks and so we were told that many people on the reservation may be out in the town purchasing their month’s supply of goods. Nonetheless, we were able to visit a few homes when the patients were there and were able to review their medication adherence, provide counseling, and remind them of upcoming appointments. During our HIV awareness session at the Adult Detention Center, I was impressed by how engaged the group of 8 women were in learning about the primary, secondary and tertiary prevention of HIV and AIDS. Many were eager to get tested and share the information.

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To read more entries by Bhat and others, please visit