Journal of Gerontological Nursing

Delivering Home Health Care to the Elderly in Zuni Pueblo

Elisabeth K Dicharry, MS, RN

Abstract

The Zuni people who call themselves Ashiwi worship their gods, or Higher Powers, ceremoniously throughout the year. Although each ceremony is significant, those that attract the most attention are the Shalako ritual, the Spring or Night Dances, and the Summer Rain Dances (see Table 2). Ceremonies are held in homes or in the center of the village known as the Plaza, where people stand on rooftops to watch festive dances and other activities. Members of the tribe, particularly men, fast, meditate, pray, and make and distribute religious artifacts. The women cook large amounts of food, including green chili stew, mutton, and oven bread baked in large outdoor adobe ovens. This food is used to nourish the religious participators, may be burned to feed the Higher Powers and those who have died, or offered to family, friends, and community.

Many of the ceremonies occur from dusk until dawn, with the majority of the village in attendance, including the elderly. The village is usually quiet the next day because people are catching up on sleep. Clinic appointments are missed and home health visits are often postponed. This also happens if the family is occupied with cooking or other religious chores.

At the time of the winter and summer solstice, for a period of at least ten days, the Zuni people observe Desh'kwi. During Desh'kwi, they devote themselves to prayer and self-denial. No outdoor fires are made, cars are not to be driven, and ashes from fires are kept in the home. The people do not have sexual intercourse; they cannot eat meat or processed foods; and they are not to engage in buying or selling commodities. Some of the stores close during this time, and the village is quiet. While the young people are not as devout in following the rules of Desh'kwi, the older members of the community adhere to the restrictions.

Tribal members unable to meet religious obligations secondary to disability often feel inadequate and encumbering to the family. Healthcare providers and the family try to promote participation in religious rituals, even if it contradicts the medical therapeutic regimen. For example, a diabetic who chooses to fast may need to make adjustments in insulin and activity patterns. Although the elderly are often exempt from fasting, many choose to do so. One 80-year-old man who periodically fasted without the knowledge of the healthcare provider was frequently hypoglycemic. When his fasting became evident, his insulin dosage was reduced and eventually discontinued.

If a family member dies, kin and clan gather together to prepare the soul for entry into Kothluwalawa, the spiritual sanctuary for Zuni spirits. Awake all night and busy during the day, the family cannot be disturbed. Zuni Indian healthcare providers may be fatigued while at work or may take a short leave of absence to fulfill the duties of the funeral for a member of the clan who may not be a blood relative. A clan grandmother is just as special as a genetic grandmother.

During certain religious observances, washing and bathing may be prohibited for days or weeks. The Indian client may not be washed by a healthcare provider or a family member. A 54-year-old woman adjusting to alcoholic liver disease asked healthcare providers not to wash her on certain days. She also had members of the family rub ashes on parts of her body to bless and heal her. To an outsider she appeared unclean. Although she no longer drank alcohol, some healthcare providers thought she did because of her appearance. Others accused her family of not caring for her properly.

Touching or looking at the genitalia is…

Zuni community members stand on rooftops to observe ceremonial dances. Built in 1629, the Catholic mission stands in the center of the village.

Zuni community members stand on rooftops to observe ceremonial dances. Built in 1629, the Catholic mission stands in the center of the village.

In an isolated region of western New Mexico, the Zuni Home Health Care Agency provides nursing care to handicapped or chronically ill native American people living on the Zuni Indian Reservation. As with most home healthcare agencies, the principal age group served are the elderly. However, the Indian elderly who receive services usually do not use English as a primary language, adhere scrupulously to cultural and religious practices, and are coping with social changes inherent to living on an Indian reservation in the twentieth century.

Caring for chronically ill individuals is a new concept for many of the people residing in Zuni Pueblo. In the past, poor or unavailable healthcare facilities, isolation, and communicable disease contributed to shorter life expectancies for the Indian people. Chronic illness was rarely a problem. The healthcare provider who accepts the challenge of working with elderly native Americans thus takes on the task of helping Indian families adapt to and manage the aging family member who becomes ill or handicapped. Comprehensive and culturally appropriate health care promotes the acceptability of care and compliance with proposed health behaviors in a people vastly different from others living in the United States.

This doll, handcrafted by a Zuni artist, illustrates the Shalako Katchina. Actual Shalakos are about 10 feet tall

This doll, handcrafted by a Zuni artist, illustrates the Shalako Katchina. Actual Shalakos are about 10 feet tall

The Zuni Pueblo

Geographically situated in an area thought by the first Spanish explorers to contain gold, Zuni Pueblo has been located on its present site for at least 700 years. The Zuni Reservation is the largest of the 20 pueblos in New Mexico. Red buttes and mesas fall within its boundaries that cover an area of 407,000 arid acres. The reservation is some 6,500 feet above sea level, and has about 7,200 inhabitants.1 All business, governmental, and religious activities are conducted in the village of Zuni, while cultivation of the land and sheepherding take place near the outlying farming villages of Pescado, Nutria, and Ojo Caliente. The three villages are located near the Zuni River or the lakes created by its dams. Three miles east of the Zuni village is a subdivision known as Blackrock where a public health service hospital provides inpatient and outpatient care to all Indian people living in the area.

Table

TABLE 1SELECTED DEMOGRAPHIC STATISTICS*

TABLE 1

SELECTED DEMOGRAPHIC STATISTICS*

According to the US census report, the median age in Zuni Pueblo is 19.8 years, with 5.4% of the population 65+ years old (see Table 1).2 Per capita income in Zuni is less than one third of the US figure. Most of the elderly are victims of poverty. They live in extended families based on maternal lineage; that is, a woman or group of women and their female descendants live with husbands and other male relatives in close proximity.3 The average Zuni household consists of five or more family members who may be sons, daughters, nieces, nephews, and grandchildren.

With a wage-earning unemployment rate of about 70%, each adult and adolescent member contributes to the economic support of the family by making and selling turquoise and silver jewelry, doll-like replicas of Zuni spiritual figures known as Katchinas, fetishes usually made of stone and believed to bring good luck, pottery, and other works of art. Producing income through artistry, tending children, and participating in spiritual activities affords little time to care for the infirm or frail who do not want to interrupt these life-promoting activities.

A birthrate 96% higher than the total US birthrate forces a younger Indian population to care for an expanding older population. Life expectancy for all American Indians has dramatically increased in the last 20 years from a mean of 61.7 years to 71.1 years. However, 37% of the Indian population dies before reaching the age of 45, as compared to 12% for the total US population.4 The four leading causes of illness and death among people of Indian ethnicity living in New Mexico are sequelae associated with alcohol ingestion including accidents, cirrhosis, and death by exposure; heart disease; malignant neoplasms; and diabetes mellitus.5

Despite Zuni's location inside the boundaries of the United States, almost 84% of its residents speak a language other than English at home. Only 39% of persons 25 years old and over are high school graduates, as compared to the rest of New Mexico where approximately 69% of the population 25 years old and over have high school diplomas.2 Older adults living in Zuni usually do not speak English, nor have they been formally educated.

Most of Zuni's inhabitants live in adobe and cinder block homes, which in the 1960s were wired for electricity and piped for indoor plumbing. The homes are heated by wood-burning stoves. Dwellings in the farming villages, however, do not have electricity or plumbing. The lack of modern conveniences profoundly affects certain members of the community. For example, one elderly man went to chop wood on a cold, winter morning. Before doing so the man, a diabetic, gave himself an injection of insulin. He did not eat breakfast. Later in the day his body was found near the woodpile. He died from a hypoglycemic reaction. He was not told by any healthcare provider always to eat breakfast after taking insulin and before engaging in strenuous activity.

The composition of the Zuni family appears to be changing as more people choose to leave Zuni Pueblo to pursue career and educational opportunities, move into smaller government homes, manage younger families on incomes that are often below poverty level, and cope with other social problems including alcoholism, suicide, and single parent households.2,5 In contrast to traditional living arrangements, some of the elderly now live alone.

A nursing home is viewed as a place where someone goes to die, and at present no nursing homes exist in Zuni Pueblo. Those who care for the older family member must, therefore, use the public health service hospital, social security benefits, spiritual support systems, and the tribally operated home healthcare facility to keep the member at home. Due to a shortage of American Indian nurses, the home healthcare provider is usually a non-Indian registered nurse or a Zuni Indian nursing assistant. The provider teaches all available family members, including school-aged and adolescent grandchildren, how to meet the needs of the older adult in the home setting.

Zuni Culture and Implications for Care

The Zuni sociocultural system is divided into households, kinship groups, religious clans, subclans, secret societies, and cult groups. A person may belong to several of these groups and remain constantly occupied with life-inspiring, esteem-producing activities. Members of Zuni who do not adhere to cultural rules and functions tend to feel isolated, struggle with identity, and may act out frustrations by using alcohol or engaging in other kinds of destructive behavior. Religious observances are particularly important to the integrity of the Zuni sociocultural system.

Table

TABLE 2ZUNI REUGIOUS OBSERVANCES

TABLE 2

ZUNI REUGIOUS OBSERVANCES

The Zuni people who call themselves Ashiwi worship their gods, or Higher Powers, ceremoniously throughout the year. Although each ceremony is significant, those that attract the most attention are the Shalako ritual, the Spring or Night Dances, and the Summer Rain Dances (see Table 2). Ceremonies are held in homes or in the center of the village known as the Plaza, where people stand on rooftops to watch festive dances and other activities. Members of the tribe, particularly men, fast, meditate, pray, and make and distribute religious artifacts. The women cook large amounts of food, including green chili stew, mutton, and oven bread baked in large outdoor adobe ovens. This food is used to nourish the religious participators, may be burned to feed the Higher Powers and those who have died, or offered to family, friends, and community.

Many of the ceremonies occur from dusk until dawn, with the majority of the village in attendance, including the elderly. The village is usually quiet the next day because people are catching up on sleep. Clinic appointments are missed and home health visits are often postponed. This also happens if the family is occupied with cooking or other religious chores.

At the time of the winter and summer solstice, for a period of at least ten days, the Zuni people observe Desh'kwi. During Desh'kwi, they devote themselves to prayer and self-denial. No outdoor fires are made, cars are not to be driven, and ashes from fires are kept in the home. The people do not have sexual intercourse; they cannot eat meat or processed foods; and they are not to engage in buying or selling commodities. Some of the stores close during this time, and the village is quiet. While the young people are not as devout in following the rules of Desh'kwi, the older members of the community adhere to the restrictions.

Tribal members unable to meet religious obligations secondary to disability often feel inadequate and encumbering to the family. Healthcare providers and the family try to promote participation in religious rituals, even if it contradicts the medical therapeutic regimen. For example, a diabetic who chooses to fast may need to make adjustments in insulin and activity patterns. Although the elderly are often exempt from fasting, many choose to do so. One 80-year-old man who periodically fasted without the knowledge of the healthcare provider was frequently hypoglycemic. When his fasting became evident, his insulin dosage was reduced and eventually discontinued.

If a family member dies, kin and clan gather together to prepare the soul for entry into Kothluwalawa, the spiritual sanctuary for Zuni spirits. Awake all night and busy during the day, the family cannot be disturbed. Zuni Indian healthcare providers may be fatigued while at work or may take a short leave of absence to fulfill the duties of the funeral for a member of the clan who may not be a blood relative. A clan grandmother is just as special as a genetic grandmother.

During certain religious observances, washing and bathing may be prohibited for days or weeks. The Indian client may not be washed by a healthcare provider or a family member. A 54-year-old woman adjusting to alcoholic liver disease asked healthcare providers not to wash her on certain days. She also had members of the family rub ashes on parts of her body to bless and heal her. To an outsider she appeared unclean. Although she no longer drank alcohol, some healthcare providers thought she did because of her appearance. Others accused her family of not caring for her properly.

Touching or looking at the genitalia is also restricted during certain times of the year. A 98-year-old woman disabled by a cerebrovascular accident needed a catheter because she was chronically incontinent. On certain occasions she did not allow the nurses to change the Foley or give catheter care. Thus medically indicated care was postponed, rescheduled, or adjusted by using peribottles and keeping the client covered during the procedure.

During religious festivities, many men, both young and old, are seen smoking cigarettes. Habitual smoking, however, and respiratory illnesses caused by smoking are uncommon in Zuni. Individuals who smoke during religious occasions need not be told to quit, as smoking has a special meaning to them.

Many of the homes in the village double as ceremonial dwellings. If the home is needed for a ceremony, the family, their furniture and other possessions are relocated to another home until their home is again available. Additional nursing visits might be necessary to orient the client to healthcare behaviors in new surroundings. An 80year-old woman with congestive heart failure taking a diuretic needed a bedside commode while in a temporary dwelling because the bathroom was 50 feet away. She needed additional teaching in body mechanics because she slept on a mattress placed on the floor. Once the permanent home is relinquished by the religious groups, the family returns. In remembrance of the occasion, a small shrine usually made of wood and feathers is nailed to the wall by the departing religious participators.

The home itself is usually the place where livestock, particularly sheep, are slaughtered. The healthcare provider conducting a visit is often confronted with blood draining from the animal onto the floor and into buckets, or the foul-smelling gastrointestinal contents being squeezed out of the entrails. During lambing season, lambs may be in the living area and leave droppings on the floor. Turkeys, chickens, and goslings have also been seen in homes. Delivering care in this setting is certainly interesting, but requires a flexible approach, tolerance to animals, and patience.

Zuni Healing System

The Zuni people strictly guard their native healing system by conducting medicinal practices secretly and in the Zuni language. However, home care nurses are still confronted with therapeutics prescribed by Zuni healers. While there are probably several kinds of healers in Zuni, three groups are most visible: medicine men, bone pressors, and belly rubbers.

Medicine men belong to the ritual organization known as the medicine society. Their abilities are often inherited or given by the Higher Powers. Medicine men meditate on and chant about the illness, practice massage in an attempt to draw out malignant forces, and prescribe medicinal herbs. Piñon tree sap is used as a salve for leg or decubitus ulcers. The gum of the piñon tree is used as an antiseptic. Ashes produced from burning a juniper tree are mixed with water to make a poultice. The poultice is molded to an extremity swollen from injury.

Goldenrod, also called Zuni tea, is used for colds, sore throats, and coughs. Matilda Cox Stevenson, a renowned anthropologist in the early 1900s, studied the ethnobotany of the Zuni Indians. What she learned years ago is still practiced in present-day Zuni. Concoctions made from various kinds of thistles are used to treat fevers, gastrointestinal ailments, and genitourinary infections. Mustard plants are ground and mixed with water to treat headaches and sunburn. Sage is used to treat burns.6

Bone pressors who receive their healing capabilities from the Higher Powers realign and set bones, and treat skeletal injuries and arthritis. They are particularly helpful with physical therapy. An aged client rehabilitating following the surgical removal of an intracranial tumor called on a bone pressor to facilitate the process of learning to walk with a walker. Bone pressors are usually men and may also be medicine men.

After being struck by lightning, a person receives the ability to become a belly rubber from the Higher Powers. Belly rubbers are usually women. They treat pain, gastrointestinal disturbances, and liver ailments by massaging or rubbing the abdominal area. Clients state they gain much relief after a visit from a belly rubber.

Zuni healers visit an ailing person at home or in the hospital. Praying, meditating, singing, and chanting occur at the bedside and may last for several hours. The Zuni people often seek out traditional healers before seeking medical treatment or if they believe medical treatment cannot work for the kind of ailment with which they are afflicted.

Conclusions

Zuni Pueblo is a community rich in history, ceremony, and tradition. Its inhabitants, encumbered with poverty and changing demographics, want to feel comfortable in an increasingly technological world. Many cultural and subcultural groups have unique customs. The people of this remarkable land, especially the elderly, need the rituals and beliefs that give meaning to life and strength for existence. Nurses seeking employment in places that are ethnologically different owe it to those for whom they care to learn, accept, and integrate cultural variation into clinical practice. If all healthcare providers would recognize and respect the traditions of others, healthcare goals could be designed to be compatible with the beliefs of the individual and family.

References

  • 1. Dutton BP: American Indians of the Southwest. Albuquerque, NM, University of New Mexico Press. 1983, pp 31-34.
  • 2. 1980 Census of Population, vol 1. US Dept of Commerce, publication No. PC80-1-C-33. Bureau of Census, 1982.
  • 3. Mails TE: The Pueblo Children of the Earth Mother. Garden City, NY, Doubleday & Co, Ine, 1983. vol 2, ? 216.
  • 4. Indian Health Service: Chart Series Book. US Dept of Health and Human Services, 1985. ? 25.
  • 5. New Mexico Selected Health Statistics 1980-81. Santa Fe, NM, Health and Environment Department, 1981, ? 45.
  • 6. Stevenson MC: Ethnobotany of the Zuni Indians, in Thirtieth Annual Report of the Bureau qf American Ethnology of the Secretary of the Smithsonian Institution. Government Printing Office, 1915. pp 42-59.

TABLE 1

SELECTED DEMOGRAPHIC STATISTICS*

TABLE 2

ZUNI REUGIOUS OBSERVANCES

10.3928/0098-9134-19860701-09

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