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Neurology Today:
doi: 10.1097/01.NT.0000403270.92692.3d
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Global Neurology: Dr. Karen Parko: Global Health on the Reservation — No Passport Needed

Rukovets, Olga

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Neurologist Karen Parko, MD, has devoted much of her clinical career to pinpointing deficits, and then working to fill them efficiently. She entered the Public Health Service (PHS) in 1987 thinking she was going to be a primary care physician. “I didn‘t necessarily have a medical interest in the indigenous population — I was looking to do Peace Corps-type work,” she said. A mentor told her that the best way to help underserved populations was by getting a medical degree, so she decided to become a family practitioner, but instead found herself “so struck by neurology” that she changed her focus.

LIFE ON THE NAVAjO R...
LIFE ON THE NAVAjO R...
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Dr. Parko graduated from the F. Edward Hébert School of Medicine at the Uniformed Services University in Bethesda, MD, and subsequently trained in internal medicine at the Washington Hospital Center and in neurology at the University of California-San Francisco (UCSF).

Currently, she is the director of the Comprehensive Epilepsy Center at the San Francisco Veterans Administration Medical Center, the chief consultant in neurology of the Navajo Area Indian Health Service (IHS), and a UCSF associate clinical professor of neurology.

But for 10 career-defining years, Dr. Parko settled into life and work as a clinical neurologist on the Navajo reservation, working with the second largest— at 300,000 — of the over 550 tribes in the US. She established the first neurology clinic there, which provided adult and pediatric services and neurodiagnostic testing.

“I was the only neurologist for a large area,” she explained, one of three clinical neurologists for an indigenous population that is now five million, according to the US Census Bureau. “The reservation spans three states [in the Southwest] — it‘s about the size of West Virginia…and within that population, I saw the whole gamut of neurological problems that you would see in any population,” she said.

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EPILEPSY

Though she trained as a general neurologist, Dr. Parko said, her focus turned to epilepsy. “What really awed me and why I ended up where I am today, was that epilepsy was a huge problem — so huge that I found a lot of my clinics were focused on it.”

Dr. Parko created an epilepsy subspecialty clinic, enlisting the help of pharmacists and nurse practitioners to supplement neurological care. “We would run three to four rooms at a time and they would independently see and treat follow-up patients with my guidance — when and if needed,” she said.

Dr. Parko co-authored a study of epilepsy prevalence in the Navajo Nation over a four-year period (1998-2002) funded by the CDC and published in 2009 in the journal Epilepsia. Two percent of Navajo receiving IHS care were found to have an ICD-9-CM code consistent with epilepsy or seizures. Based on confirmed cases, the crude prevalence for the occurrence of any seizure (including febrile seizures and recurrent seizures that may have been provoked) in the geographic subpopulation was 13.5 per 1,000 and the crude prevalence of active epilepsy was 9.2 per 1,000. Prevalence was higher among males, children under 5 years of age, and older adults. In other communities within the US, estimates for the prevalence of epilepsy range between 6.7 and 8.8 per 1,000, she reported in the study.

This was an extremely difficult cultural undertaking, she said, as research is not easy among the Navajo, who have developed their own rigorous protocols and institutional review board (IRB) processes to ensure tribal safety. It took Dr. Parko years to even complete the IRB process for this project.

“The prevalence of epilepsy in the Navajo is higher than it is in some third world countries,” she said. Why are rates so high? That‘s the question researchers are working to answer, she said.

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BARRIERS, INSIGHTS

The most pressing health care barriers among the Navajo, Dr. Parko told Neurology Today, are related to transportation. “There are no paved roads. Especially in winter, with snow and rain, roads can be shut down. And where there are roads, there are no vehicles, and sometimes families don‘t have vehicles or they may have one that their whole family unit will share,” she said.

Of course, there are also the cultural and language differences that can be tough when working in a population outside of your own, she said. “The thing that‘s most striking to me [about the Navajo] is that every medical problem, epilepsy being one of them, has a reason. So there is always a cause, and the cause is forever sought, which usually is a spiritual transgression.”

Spiritual belief and medical practice can coexist, Dr. Parko found. Much effort has focused on education about the physical and medical causes of disease. As long as health professionals respect the spiritual healers and the practices of the Navajo, Dr. Parko said there should not be any conflict.

However, reaching a harmony between science and culture is not easy, Dr. Parko discovered. “Even though I was living on the reservation within the population, it took a fair amount of time to understand just how to incorporate someone‘s spiritual and world views that are so different from mine (even though I consider myself a pretty open person) and to utilize those to help me deliver care.”

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HEALTH DISPARITIES IN THE US

Dr. Parko stressed that neurologists need not go abroad to work on global health problems. Disparities in health care “exist probably within everybody‘s community, even in Washington, DC,” she said, adding that people often overlook what‘s right in front of them.

“Despite incredible improvements in life expectancy and mortality over the past century in the [Navajo] population, there are significant [health] disparities compared to the general US population,” she said. Indigenous people continue to be one of the most disadvantaged populations in the United States, she added.

Global neurology without the romanticism of international travel can be a difficult sell for many universities in the area, Dr. Parko said. University of Arizona neurologist David Labiner, MD, has come to the Navajo reservation four times a year with his residents and fellows to do a circuit of clinics in three of the eight different hospitals over the Navajo reservation. The goal is to adopt similar relationships in other areas.

Working with indigenous people is “probably the most purposeful and worthwhile work that can be done,” Dr. Parko said. “It makes working at a university very difficult; I‘m currently one of a hundred neurologists here, and my ability to make an impact on a person‘s life is so slim compared to what I used to do on a daily basis.”

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REFERENCES:

Parko K, Thurman DJ. Prevalence of epilepsy and seizures in the Navajo Nation 1998-2002. Epilepsia 2009;50(10):2180-2185. E-pub 2009 Jun 1.

©2011 American Academy of Neurology

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