No Reservations about Caring
It’s a mid-December day on the Zia Indian pueblo, 35 miles outside of Albuquerque, N.M. The air is clear and sharp and infused with wood smoke. Adobe homes that blend in with their rocky surroundings line a winding road that snakes high up into the village where the Zia have lived for centuries. The road ends at an adobe church, bright white against a pale blue sky, its cross reaching toward heaven.
For Robert Chideckel, D80, heaven is inside the Zia Health Clinic, where for the last two years, he has been the only dentist many of the local American Indians can get to. “This reservation is a dream,” he says. “I am in dental heaven.”
Though he is a native of Baltimore and spent 30 years practicing in the Northeast, Chideckel is not referring to New Mexico’s temperate climate when he talks about the divine. And he’s not talking about the blood-red sunrises he admires on his quick drive to work—“sometimes I’m the only car on the road,” he says—or the wild horses that sometimes peer into his office window. “They laugh at me,” he says of the clinic staff. “It would be like someone getting all excited about a squirrel at your window in Boston.”
Chideckel (pronounced CHI-deckel) has a different version of heaven than most. “I love abscesses,” he says with his trademark ebullience, “because I know I’m going to put [the patient] on the right antibiotic and stop this person’s disease. That’s the kick I get out of working here.”
Out on the Zia Pueblo, there’s plenty of disease for Chideckel to stop. The nation’s 5 million Native Americans have the poorest oral health of any other U.S. demographic. About two-thirds of American Indian kids develop cavities before their fifth birthday, according to a study published in the Journal of Public Health Dentistry in 2011. That’s compared with 42 percent of Hispanic children, 32 percent of African American children and 25 percent of white children. Another study published in 2005 in the American Journal of Public Health reported that nearly 70 percent of American Indian or Alaskan native kids have untreated tooth decay.
The pattern holds later in life, too. Nearly a quarter of all American Indians over age 50 have no original teeth left, more than twice as many as any other group, according to a 2012 study published in Community Dentistry and Oral Epidemiology.
One reason American Indians have disproportionately poor oral health is that about half of them live in very rural areas. And as is the case for Americans of all stripes who live in sparsely populated regions, geography and lack of transportation can pose significant barriers to care. It can also be hard to attract dentists willing to live and work there.
But there’s another wrinkle to this part of the story. Across all demographics, poor oral health is intimately tied to poverty. Even though American Indians are some of the nation’s poorest people, they receive free medical and dental care through the federal Indian Health Service (IHS), an agency managed by the Department of Health and Human Services and based on long-established treaties between the government and native tribes. So cost isn’t a barrier; instead, it’s the perception of many Indians that IHS dental clinics don’t always provide the best care.
“A lot of times, patients come in and assume I’m going to extract their teeth,” says Chideckel. One reason he left private practice was that he found cost was beginning to dictate the quality of care he could provide. Now that he works for IHS, he is free to treat patients largely as he sees fit. Staff salaries—by far the largest expense—are already accounted for in the clinic’s annual budget, as are the operatories and equipment. That means Chideckel spends the rest of his budget on supplies, a constraint he doesn’t have trouble meeting. So when an older patient comes in expecting to lose a molar or two, “I don’t even say the words ‘root canal,’ ” he says. “Instead, I say, ‘I’m going to save your tooth.’ ”
A History of Care
As early as the 1840s, the federal government signed treaties recognizing its obligation to provide health care to native populations, in some cases offering medical services in exchange for tribal lands. Since 1921, Congress has had the authority to allocate federal funding for medical services for American Indians. Today IHS operates 166 clinics—mostly in the Southwest—where members of the 556 federally recognized tribes are entitled to free health services. But that doesn’t mean every American Indian gets those services. In 2010, about 20 percent of IHS dental positions were unfilled.
That’s a concept Chideckel can’t quite wrap his mind around. He sees IHS clinics not only as an ideal place for a seasoned professional like himself to do good for a community, but also as a professional environment in which young dentists can take the time to learn their craft without the business pressures of managing a private practice.
“I’m not against people making money,” he says. “But if you don’t have the romance of dentistry, don’t do it.”
Chideckel came late to dentistry. His first career was in government. After earning a master’s degree in political science at the University of Maryland, he worked as a research analyst for Watergate special prosecutors Archibald Cox and later Leon Jaworski. He had a front-row seat for a landmark political moment in American history, yet he still found it unfulfilling.
“What would have happened if I didn’t show up for work one day? Nothing,” he says. “I wanted a job where I could make a difference every day.”
The Zia Health Center fits the bill.
American Indians make up less than 2 percent of the U.S. population, but they constitute more than 10 percent of the residents of New Mexico. One of 22 tribal communities in the state, the Zia Pueblo is also one of the smallest, home to just 901 people. Nestled among the tribal governor’s office and the solar-paneled library, the Zia Health Clinic sits near the mouth of the pueblo, not far off Highway 550.
The clinic houses a medical office and has a full-time pharmacist. Having medical and dental professionals in one place is especially important for American Indian populations, who suffer disproportionately from diabetes, accidental injury and other health problems that can affect their oral health.
A Medical Home
“It’s wonderful to have the doctors and nurses right next door,” says Chideckel. “We call this their medical home.”
Each week, 22 to 25 patients of all ages have appointments to see Chideckel and Sharla Garcia, the clinic’s only hygienist. That’s not counting the several patients the clinic sees for emergency care each day. Tribe members get priority service, but the Zia Health Clinic, unlike many other IHS clinics, will treat American Indians from any tribe.
Today, Eldon Thompson, 43, a Navajo who grew up on that tribe’s reservation near Chinle, Ariz., has come in for his appointment. Before he started seeing Chideckel a few months ago, he hadn’t been to the dentist in five years. Thompson, who has a broad smile and shoulder-length hair, works as a medical support assistant at the Veterans Administration in Albuquerque. The job offers no dental benefits, but even though Thompson knew he could get dental care through IHS, he’d avoided it. He says he thought the clinic would be “kind of like a factory—they’d pull your teeth automatically without trying to save them.”
Thompson’s 78-year-old mother was the first in the family to see Chideckel. Thompson was surprised to hear the new IHS dentist developed a treatment plan for his mother that didn’t involve extraction. He decided to see what Chideckel could do for him. “The dentistry here is amazing,” he says after a fitting for a partial denture. Chideckel, says Thompson, “really explains everything that’s going on. I felt so relaxed. I fell asleep in my chair.”
“A lot of patients are very happy with his care. We’re lucky to have him,” says Garcia.
There’s a lot of appreciation going around the Zia Health Clinic these days. Chideckel calls his relationship with Garcia and the other staff members, dental assistants Amore Herrera and Lorraine Victor and medical support assistant Mary Gachupin—a member of the Zia community who has worked at the clinic for 25 years—a mutual admiration society.
As the staff shares a lunch that includes enchiladas garnished with what might be the world’s best green chile sauce, there’s a bright feeling of community and fun. Maybe it’s the upcoming holiday; maybe it’s the food. But Garcia, for one, credits Chideckel.
“He has really lightened up the place,” says Garcia. “You can hear him laughing two counties away.”
This article first appeared in the Spring 2014 issue of Tufts Dental Medicine magazine.
Jacqueline Mitchell can be reached at firstname.lastname@example.org.