The drop-in center at the Native American Health Center in San Francisco’s Mission District is on the second floor of an old warehouse-type building that in a different part of town would long ago have been converted to high-end lofts. Light streaming in through the huge industrial windows illuminates Native American art on the walls and a colorful blanket thrown over the couch.

In this single large room, there is a comfortable seating area, a dining room table that is used more for reading than eating and a few workstations. Off the main room are three offices. It’s called a drop-in center, but like so many of the words used to describe the needs of the underserved, the phrase “drop-in” seems to underplay the role this room plays for patients who come here, patients like a man we’ll call Brian.

He looks to be in his early fifties. He has lost or broken one of the lenses of his glasses and has stuffed the hole full of tissue. The entire apparatus is held in place by tape. Brian walks with a cane, and he recently checked himself out of a hospital where he was being treated for an undisclosed condition. He is a smart man, but severely debilitated. He suffers from delusions. He moves from tenement to tenement. He hasn’t been able to work for years. He comes to the drop-in center for human contact. Today, it is Andrea Pasillas, substance abuse case manager, who works with him.

The Native American Health Center wants to serve people like Brian—the hardest of the hard-to-reach, people like those we see on America’s streets and wonder what went wrong in their lives. People living in flophouses or on a street corner. Alone, malnourished, cold, and culturally displaced, they are people for whom stability seems impossible. Yet many at the Native American Health Center have achieved it, overcoming addiction, finding a path to stability, and reconnecting with spirituality, culture, and a way of life that has not often been valued in America.

Culture Matters

Native Americans have the lowest incomes and the highest rates of infant mortality, teen suicide, diabetes, and alcoholism in the United States.⁴⁵ According to the Surgeon General’s Report on Mental Health: Culture, Race and Ethnicity, American Indians and Alaska Natives are overrepresented among people who are homeless, among people who are incarcerated, and among people with drug problems.⁴⁶ The rate of alcohol-related deaths for American Indians and Alaska Natives in urban areas is 2.8 times higher than for the general population.⁴⁷

Health disparities among any underserved population are associated with a number of factors, but for Native Americans, they cannot be fully understood outside the context of a modern-day Trail of Tears that most people in the United States know nothing about.

During the 1950s, Indians from various tribes began migrating in significant numbers from reservations to major urban areas under the auspices of a Bureau of Indian Affairs (BIA) Relocation Program. Some American Indian people adjusted successfully. Others did not. They did not find the jobs that had been promised. They did not find the affordable housing they believed was waiting for them. And some experienced their moves from the reservation to culturally alien urban centers as another in the long history of oppressive and genocidal acts against Native Americans in the United States. The result is overwhelming mistrust of U.S. Government programs and health institutions and a condition referred to as historical trauma or intergenerational post-traumatic stress disorder, which exists in some Native American Health Center clients. ^48,49

Burning Sage

Nelson Jim is the son of medicine people—a mother and father who practiced the traditional ways of their culture on the reservation in White Mesa, Arizona, where he grew up. Jim is a psychotherapist, a profession that interested him, he says, “Because I wanted to understand the human mind.”

Jim is the director of the mental health department at the Native American Health Center. Notwithstanding his interest in the mind, he’ll be the first to tell you that the mind is not enough. "Our healing has a spiritual and cultural component," says Jim. Reconnecting sick, isolated Native American clients to their spiritual heritage is like coming home.

The Native American Health Center has become a cultural center almost by default. Its orientation to care is centered on spirituality and how the power of believing, of ritual and of being “in balance” can be as important as the power of a protease inhibitor.

“It all starts before we ever meet with the client,” explains Jim. “Our clinic and service area is maintained to provide a ‘healing space’ and a point of centrality for our clients, so many of whom are dislocated from their home community. When they come in, we stand and shake hands and look them in the eye. That has never happened to many of our clients before.

“When we assess our clients,” says Jim, “we look at symptoms. For people with depression or having nightmares or seeing or hearing things, our cultural traditions provide another tool that we can use to bring some healing to our clients. If there is an ‘imbalance’ in an individual’s mental, emotional, physical, and spiritual capacity, it can result in any number of symptoms. Thus, supporting client efforts related to spiritual balancing and/or rebalancing requires integration of cultural healing interventions and treatment methods.”

One tool is burning sage. Another is the prayer circle, which a client and their family can use to discuss the negative issues in their relationship and then pray together.

It’s a simple concept until you think about the power of praying with your own family. Then you start to see the magnitude that something so simple as a prayer circle can have in the life of an individual lost from his or her own culture.

“Despite the comprehensive services offered at the center, the prognosis for many of our patients is poor,” Jim confides, “and the need is overwhelming.” Tears well up in Jim’s eyes when he describes an encounter with a patient only 1 week before. “The client’s food ration from the city’s only food bank had run out; his $100 that he saves monthly for food was spent, and the patient asked me, ‘Where can I get something to eat?’” Then Jim stops and looks for a moment and beseeches, “What do I tell them? What do I tell them?”

The Red Road

Yet, even in the face of so much need, there is victory. It lies in high quality primary care that reflects the need for mental health care and drug treatment. It is apparent in dental care needed so severely that 80 percent of patients come to their first visit with oral health problems that are affecting their nutrition.

Victory can be seen in the life of Delores, a woman who lost her only son because of addiction but has now been clean and off the streets for 10 years. It is evident in John, who has been walking the Red Road, a Native-American-centered path to recovery, for more than a decade. And victory is seen even in the life of Brian, who here at the Center finds respite, if only for a few moments.