"Good morning. First of all, let me thank you for inviting us to participate in this wonderful symposium; we are really learning a lot here. And we hope to share our story with you that you may take it home and want to talk to your health people too, to maybe start something similar. I will introduce myself. I am Carolyn Finster and I am the Clinic Administrator for the Pine Hill Health Center with the Ramah Navajo community. I'm also the Acting Division Director for Health and Human Services. And with me today is my colleague, Ms. Glennetta J. Kineo, who is our Women's Health Case Manager, and the point person for the story today.

The Ramah Navajo community consists of about 4,000 people, Navajo people, living on non-contiguous land some 75 miles south of the Navajo Nation in western New Mexico. It has a history of independence and self-determination. Back in the 1970s, the Ramah people lost access to the public schools in a neighboring town when the public school was closed for building violations. Since the school was not scheduled to reopen, the Ramah community felt that they certainly did not want to send their children off to boarding school; they'd already had that experience. A group of citizens sat around a kitchen table one evening, the kerosene lamp was burning late that night as they talked among themselves. What options did they have for education?

They decided to take matters in their own hands and run their own school. Further discussions amongst educators with the BIA [Bureau of Indian Affairs] and the public schools brought no resolution. They formed a committee and decided to go to Congress for a special appropriation. The story continues as one of self-determination. One of the founding board members, it is said -- after a very long day of trudging from one office to the next office, to the senator, to a representative -- finally sat down in the senator's office, closed the door behind her, she sat in front of the door. The senator was at his desk. The committee of citizens were beside her. She spread her Navajo blanket in front of her and said, ‘We are not leaving until we have the money for our school.' Under Public Law 93-638, they were entitled to a school. That took the senator by surprise and before long Bertha Lorenzo had in her blanket a written promise for a congressional appropriation. Over $100,000 was given at that time for seed money for the school.

In 1976, the Ramah Navajo School Board was formed and established. The BIA finally came around and a contract was signed for the operation of a school, kindergarten through [grade] 12. After the school was designed, built and occupied -- of course the first year they lived in tents, the schools were in big army tents because the building hadn't been built yet, but the school was started -- the community realized that the children in the community needed to have their own health care nearby as well, because they were certainly being poorly serviced by the one-day-a-week clinic, 30 miles away from the school -- by the Indian Health Service at that time. Because the Ramah Navajo School Board had been given the responsibility of education, health and community services from the Navajo Nation Council through the Ramah Navajo chapter, the board soon contracted with Indian Health Service for most of the ambulatory medical services as well as the medical emergency services.

In 1978, the Pine Hill Health Center was established as the first health center to be contracted under 638 provisions controlled by Indian people. Humble beginnings were a 5,000-square-foot clinic. Today, over 35 years later, we have 15,000-plus square feet with 65 employees. We have 24-hour ambulance service. We have a family practice outpatient clinic -- Monday through Friday, 8 to 5 -- with full pharmacy, dental clinic, optometry, laboratory, audiology, psychiatry as well as our department of field health, which handles public health nursing and our community health representative program. In addition, the health center has grants and contracts that provide a wellness center, center for health promotion with special cardiovascular disease prevention programs, and behavioral health services. The staff has grown to 60 full-time employees, including four physician medical providers, two dentists, two pharmacists, two nurses, five CHRs [Community Health Representatives], and many ancillary employees. We graduated our very first bachelor's degree nurse about four years ago from the University of New Mexico [UNM] and she is the supervisor for our field health department. We are looking forward to our first pharmacist in maybe five years. We're sending a young lady who works at the clinic and goes to school part-time as she prepares to be a pharmacist. And this summer in the summer student program, one of the young ladies who had worked last summer in the clinic came to me and she said, ‘I would like another job this summer, could I have one?' And I said, ‘What are you doing?' And she says, ‘Oh, I'm taking pre-dental.' And so we're going to have a dentist in the community as well in a few years. So of course she got a job. The behavioral health department provides certified, licensed family counselors and substance abuse counselors.

The community is located in western New Mexico in a rather isolated area with one paved road 25 miles long. And you can see beautiful sunsets from it. The Navajo people live mostly in scattered housing with some 50 percent still having no running water or electricity. Other roads are mainly dirt and gravel. In addition to the isolation of families, we unfortunately have about 65 percent level of poverty, the largest employers being the Ramah Navajo School Board for the school, the health center and ancillary programs, and the Ramah Navajo chapter. Other forms of employment opportunities are over 65 miles away to the town of Grants or Gallup.

Our community story regarding the Women's Health Initiative -- which we call the Mammo Day Project -- started over ten years ago, as the staff of the health center participated in some discussions with staff of the Albuquerque Indian Health Board and the faculty of the University of New Mexico School of Public Health. We have a longstanding relationship with the Albuquerque Indian Health Board, as one of the founding tribal groups that make up the board of non-Pueblo tribes in the Albuquerque service area. Our staff members had attended some public health classes sponsored by UNM and were eager to learn more about how to work on health issues. After several preliminary meetings with clinic and community staff members, there was a desire to learn even more about how to address public health issues in our own community. Soon the board of trustees became interested parties and together we took part in a CDC [Centers for Disease Control and Prevention] community readiness pilot survey. These meetings precipitated much discussion back and forth, and with the UNM researchers, and until the researchers finally understood that the CDC surveys presented to our tribal members simply did not fit tribes. We sent back a lot of information and a lot of concerns to CDC saying that tribal readiness is much different than urban readiness in terms of knowledge, skills, community resources, cultural sensitivity.

After many months of discussion, there was a request by the board and the committee that was talking that we conduct a community health profile. And in fact, when other groups in the community found out we were going to do a community health profile, they said, ‘Can we jump on the bandwagon too? We're getting little surveys for Head Start here, surveys for roads here, surveys for housing here.' So the community health profile became a community profile, as the team felt that health cannot be separated from education, housing, schools, roads, law enforcement, emergency services, language, traditions and cultural beliefs, nor that the local government agencies representing the community; a holistic approach was really needed. The community had had too many individual agency surveys in the past and wanted to put them altogether. After the questions were agreed upon by the committee -- and they met twice a month for about five months -- the survey then had to be translated into Navajo. The surveyors got together, the group got together a small people, who became our translators, and then we ran it past some university survey people so that we would get it in the right set up and we could get some really pertinent information as a result of this. Some 284 homes were randomly chosen for the survey giving us a large community base. To make a long story short, health care was identified as an important area of concern and there was a particular growing concern about cancer.

As clinic staff became more knowledgeable in health issues and understood how to develop programs based on community needs, there was a decision that's women's health and in particular, concern about breast and cervical cancer should be addressed. Several prominent women in the community wanted to work on the issue with the health staff due to their own family stories. Community capacity within the tribal community had been launched. We worked with the Albuquerque Area Indian Health Board and followed a model they'd been using with various tribes. A four-part model that follows the medicine wheel or, in our case, the Navajo basket -- number one, building relationships; number two, building skills; number three, building interdependence; number four, building commitment. A Women's Health Task Force was put together of interested clinic staff, including several men, the Albuquerque Indian Health staff, and UNM School for Public Health. We also became partners in a Coleman Foundation grant, in conjunction with the Albuquerque Indian Health Board, and it was soon decided to work on our dismally low mammography rates.

As you know, Native American rates for women's screening are considered pretty poor -- about 47 percent in the Native American population back in 2003. But when Pine Hill stopped to actually do a statistical survey of our own rates, we had only 5.5 percent [of Native women] going to have mammography screening services. Part of the reason for that, at that time, was, first of all, to get a mammogram, you have to travel 45 to 65 miles away. Second of all, the state health department and an x-ray group out of Albuquerque had quit the mammography van that had been coming around quarterly. And most important, were some of the cultural stigmatisms of having certain exams, the fear of exams, and lack of knowledge. In order to listen to the community more carefully, we instituted a series of focus groups to talk about cancer. Two focus groups for women and one focus group for men. We thought that maybe the men would have some ideas about how to get their wives, their girlfriends, their grandmothers, their daughters to go for much needed health services if they could also talk in their own private setting about how to handle these things. So we talked about cancer and particularly, mammography. And it turned out lack of health knowledge, inaccurate knowledge about cancer, the problem of women feeling isolated, the feeling of no support for women and health problems, and the most difficult part of the discussion, was to get around the taboo of using a word about disease that might bring it upon you. Because so many of the women over 40 speak only Navajo, about 50 percent, there was a difficulty in even discussing the word cancer -- a word that was never developed in the Navajo language. Even today, Navajo have to translate the word as ‘the sore that does not heal.'

Following the focus group analysis, the Women's Health Task Force came up with a plan. Number one, provide culturally relevant information on breast and cervical cancer. That lead to a small professional video made using our script, our community members and our locale to tell the story of the importance for women to have a women's health exam. More local pamphlets were necessary also, with local logos -- and we have brought our logo today, a few of these pamphlets will be up on the table later today, this shows our logo. The other idea was to improve relationships with local hospitals. The Zuni Indian Health Service Hospital at that time did not have a mammogram machine and they were sending somebody to be trained. And they soon got a mammogram about that time, mammography machine. The other hospital we developed relationships with was the RMCH, [Rehoboth McKinley Christian] Hospital, in Gallup, a private hospital. The other part of the plan was to improve relationships with the state breast and cervical cancer project because they would provide reimbursement for certain women who did not have insurances of Medicare and Medicaid.

Also, the special project came about -- we wanted a special project to help reduce this disparity. And that special project became the Mammo Day Project. It had to have a group of...we felt that women should go to their mammograms as a group, as a feeling of support. We felt that there should be a local member of the community to be the translator. We felt that transportation was obviously an important feature of getting people to their medical appointments, and so we would provide transportation. We felt that we should not just take people for a screening exam without education. So how are you going to have education in a hospital setting? We decided to take the women for a lunch, a light lunch. One group of women in the morning would go; another group of women would come in the afternoon. They'd meet at the lunch spot, have lunch, have an hour of health education, showing a video, talking amongst themselves about their experience in the morning and also cancer awareness. And then, on the way home, the women could chat with themselves in the van and they experienced a social engagement, so there was camaraderie between women. And that was the birth of our Ramah Navajo Mammography Day Project.

We have to identify women. We have to do recruiting, which has been somewhat hard over the last three years, but is beginning to get easier as the word gets out that these women are having fun -- it doesn't hurt, they're having a little meal, they even get a little incentive for going. The women's health case manager arranges for group appointments. We had lots of work in getting relationships set up with these two hospitals so they would take groups -- a block of appointments at a time -- rather than one by one. There's a lot of paperwork to get together. The reimbursements and the insurances you have to, as you all know, you have to follow the rules of paperwork. And the health education was a vital part of this program.

What has been different between say a couple of years ago and now? Four years ago, we had women going for mammograms only maybe each quarter; that's when our mammography project started. We are now taking women once a month to these appointments, so we have increased our rates three times over in the last two years. We had a part-time women's health case manager a few years ago, now she's available full-time in the clinic, and she's even asking for help. So, with recurring appointments, there are more people that need to get there, there is more paperwork, more explaining, more follow up to do with the women. And we are encouraging continuing outreach. Our CHRs have been extremely important in helping to explain and get women to go to their first appointment -- sometimes it takes two or three visits to a person's home. Many people do not have telephones, you can't just call them up and say, ‘You have an appointment next week.' So the CHRs go out, explain the process, talk to the women, and encourage them. We have a story of one woman who last year, had her very first mammogram. This year she called Glennetta up and she said, ‘I'd like to make my appointment for my annual mammogram and I'd like you to make an appointment for my daughter, too. We're going to go together.' So these are the good stories.

Commitment of staff and community: this program has grown from a pilot project to an expectation of our health clinic. The women of the community are becoming more and more knowledgeable about their health. They want to know more. We're moving now into understanding cervical cancer. And in turn, this is now moving beyond women -- it's moving to men's health. Just as we incorporated the men in our focus groups for women, we're going to be starting some focus groups for [women] this coming season where they will talk about some of the hindrances of why men do not go to the doctor to get their annual exams. So what's good for women is also good for men.

Awareness and knowledge brings power and power brings self-confidence in one's self. This brings an understanding that we can be in charge of improving our health. And the more we know, the choices we make will be better. Even though this is just one small women's program, it's planted a seed in the community and the community members are now working together to improve the health of the whole community. It was very satisfying to hear just three months ago, at a summer board of trustees meeting, that the board spoke up and said, ‘We want the word ‘health' to be in the logo for our annual fair and rodeo that's coming up in August.' And so there was a little contest and the board settled on the logo that became ‘Rope the Future and Ride Together to a Healthy Community.'"