“I could have had my grandparents a lot longer than I did had they been treated properly for their conditions,” says Ashley Krivohlavek, whose mother is more than one-half Cherokee, making Ashley a quarter Cherokee.
Skipping through memories of her maternal grandparents on the reservation in Salina, Oklahoma, Ashley inevitably recalls being around 3 years old and sitting beside her grandmother in a medical clinic waiting room for what seemed like endless hours. Back then, there were no scheduled appointment slots; it was strictly a first-come, first-served system. If you arrived after 9 am, you were too late to be seen that day.
“She didn’t know how to drive,” Ashley says, describing her grandma. “She was blind from glaucoma by that point, so she never needed to learn. I think she only made it to eighth grade before she had to take care of her family — her brothers and sisters — from her mom’s illness.”
When asked about any strengths or benefits of living remotely, at first Ashley found it challenging to think beyond the hardships so etched into her memories and stories told to her by her family members. “Family is at the center of everything,” she shared. “I think living on the reservation and being close to people that are the same as you, and are going through the same struggles as you, are of benefit because you can help each other out.”
Differences in Treatment Across Generations
Ashley’s maternal grandfather was diagnosed with rheumatoid arthritis, but he never received proper treatment, she explains. “He only had his joints drained of synovial fluid,” she recalls. “He walked with a cane and was disabled.”
Now 39, Ashley lives with psoriatic arthritis (PsA), Raynaud’s, and polycystic ovary syndrome (PCOS). She can’t help but contrast her own treatment experience in Tulsa, Oklahoma, with the lack of treatment her grandparents received on the reservation. She attributes the dramatic difference to the extensive resources available to her in a larger city.
“When I go to see my GP, at the Creek Nation, it’s in a larger metropolitan area,” Ashley explains. “It’s in Tulsa, Oklahoma, versus Salina, Oklahoma, which is a blip on the map — you blink and you miss it. That right there is a problem. I get treated differently just because I’m in a metropolitan area. I’m really thankful that I’ve got this person as my doctor, but again, they move around a lot. You never know if you’re going to be able to keep that physician long-term.”
Underrepresentation in the Medical Field
Native Americans and Alaskan Natives make up only 0.4 percent of the physician workforce, making it unlikely for a physician to be paired with a patient of the same background.
A 2022 study published in JAMA highlighted the representation of American Indian and Alaska Native individuals in medical training. Compared to their white peers, American Indian and Alaska Native individuals had 63 percent lower odds of applying to medical school. However, research shows that having shared identity in race and ethnicity between patient and physician can lead to increased rates of patient satisfaction and improved communication between physicians and patients.
Ashley speaks to the variability in health care providers on reservations. “A lot of doctors from other countries do their practice hours on the reservation. You never have a regular general physician (GP); you see whoever’s there and it switches all the time,” she says. “You just get who you get.”
Remembering the Past to Change the Future
It’s critical to remember and talk about the past. “Even though you will think the Trail of Tears was in the middle of the 1800s, those impacts are still lasting,” she says. “They’re still there. A wave reverberates through the generations.” The Trail of Tears was when the Cherokee Nation was forced to move from their homes in the southeastern United States to Oklahoma in 1838-1839, because of a law signed by President Andrew Jackson called the Indian Removal Act of 1830.
Health care is not always the first priority when you’re just trying to work and survive the day and start all over tomorrow, she cautions. She fears it may not be a priority to some until it’s an emergency.
“So a lot of it is just cyclical,” she elaborates. “They can’t get great jobs because they live on a reservation and it’s difficult to get off the reservation because of communication barriers and transportation barriers. So, if you’re just stuck, health care is the least of your worries.”
Looking at the past and current limitations, Ashley buckets ways to improve health outcomes on the reservation into the following:
- Consistent standard of care across reservations
- Nutrition and exercise education and access
- Patient counseling on medical treatment
Consistent standard of care across reservations
Inconsistent health care can make chronic illness management particularly difficult for certain populations, Ashley points out, using her aunt’s diabetes experience as an example. Over the years, her aunt’s diabetes management plan has varied based on the treating physician, making it hard to stabilize her blood sugar.
This challenge is exacerbated by the limited food options on the reservation, which often consist of shelf-stable items high in preservatives and sugars — key contributors to inflammation and diabetes. Interestingly, diabetes was a rare condition among Native peoples until the 1940s. The introduction of these commodity foods led to a surge in obesity and diabetes cases. While more nutritious options have become increasingly available, not everyone has the luxury of choosing fresh produce over canned goods.
However, initiatives like the Food Distribution Program on Indian Reservations (FDPIR) Self-Determination Demonstration Project offer some hope. This program allows tribes to supplement USDA-approved foods with tribally sourced items, expanding food choices for tribal members.
Nutrition and exercise education and access
Access to fresh food and proper nutrition is a critical issue for many Native American reservations, many of which are located in food deserts where healthy, affordable options are limited. Offering in-person visits to these reservations a couple of days a week for free nutrition and exercise classes could be a significant step in improving health outcomes, says Ashley. Given that internet access can be sparse on some reservations, relying solely on online resources may not be effective for everyone. In-person educational sessions would help bridge this gap and could provide tailored guidance on how to maintain a balanced diet and an active lifestyle with the resources available.
Patient counseling on medical treatment
Offering counseling as people are prescribed medications could also help individuals make lifestyle changes in regard to nutrition and exercise. Ashley recalls a family member with diabetes being handed pills to take without any counseling on lifestyle choices. The quality of health care varies greatly across centers, so another patient might receive more guidance and support than another, so there needs to be a standard of care.
Advocating for Change in Health Care Inequities
Ashley holds the distinction of being the first college graduate on her mom’s side of the family — a significant achievement considering her mother has seven siblings and Ashley herself has numerous cousins.
This educational journey has given Ashley a unique perspective on health care. Although she hasn’t personally experienced the same healthcare challenges that many in her community face, witnessing these struggles has had a profound impact on her. This motivates her to use her voice and position to advocate for better health care for all.
Putting her passion into action, Ashley serves as an ArthritisPower Patient Governor with the Global Healthy Living Foundation. Through this role, she channels her experiences and insights into tangible efforts to improve health care access and quality.
“As someone with certain privileges, I don’t claim to understand everyone’s struggles,” Ashley acknowledges. “But I have immense pride in my family’s resilience, and I recognize that taking on healthcare inequities is a substantial responsibility—one I’m enthusiastic about tackling. Being able to effect positive change, especially in honor of my grandparents, means the world to me.”
Can you relate to Ashley’s story? Do you have ideas on how to address health care inequities within the Native community? We would love to hear from you. Email: firstname.lastname@example.org.
Forrest, L et al. Representation of American Indian and Alaska Native Individuals in Academic Medical Training. JAMA Network Open. 2022. doi: https://doi.org/10.1001/jamanetworkopen.2021.43398.
Shen, M, et al. The Effects of Race and Racial Concordance on Patient-Physician Communication: A Systematic Review of the Literature. 2017. Journal of Racial and Ethnic Health Disparities. doi: https://doi.org/10.1007/s40615-017-0350-4.