Dermatology Care Limited in Rural American Indian Communities

Anna Morenz, BA

Telehealth is a growing avenue for providing health care, and is used in specialties from internal medicine to ophthalmology. A cross-sectional study of the accessibility of dermatology clinics and teledermatological programs to American Indians in rural areas found that there were significant barriers to brick-and-mortar dermatology services and that telehealth programs are lacking but could be an avenue toward reducing disparities in access to dermatological care.

Investigators found that the mean driving distance between a rural Indian Health Service (IHS) or tribal health care facility and the nearest dermatology clinic was 68 miles. A majority (62%, n = 21) of these facilities did not have a dermatology clinic within a 35-mile driving distance and 32% (n = 11) were over 90 miles from a dermatology clinic.

Additionally, of the 25 dermatology clinics that responded to the survey, 6 (22%) did not accept patients with Medicaid, and 6 (22%) did not accept IHS referrals for patients without insurance.

Study authors led by Anna Morenz, BA, Harvard Medical School, noted that the burden of the distance of dermatology clinics hides many costs including the time spent driving, the time away from work or caregiving, and the costs of owning a vehicle and paying for gas. Furthermore, roads in rural areas may not always be passable. For those without access to a vehicle, public transportation is limited or unavailable in rural areas.

“Given the geographic barriers, telehealth innovations are an appealing intervention,” wrote Morenz et al. However, in surveying telehealth programs offering dermatology services, they found that 14 (29%) of the 49 surveyed programs were no longer active. Additionally, just 9% (n = 27) of the 303 rural IHS or tribal health care facilities were served by a teledermatological service.

An accompanying editorial by Lucinda Kohn, MD, MHS, Department of Dermatology, University of California, San Francisco and Camille Introcaso, MD, Pennsylvania Center for Dermatology, outlined the historical injustices with ongoing consequences that have shaped American Indian and Alaskan Native communities and their health care systems.

Kohn and Introcaso wrote that in order to provide effective and sustainable care for American Indians and Alaskan Natives in rural areas, providers must understand the historical context, the complex federal and tribal policies, and fully respect tribal sovereignty.

Morenz et al acknowledged the complex historical and current factors affecting access to dermatology care for these populations, pointing out that while the study focused on geographic and insurance limitations, there are also potential language barriers and mistrust of the health care system due to a history of unethical research and practice.

“Without complete appreciation for this cultural context, teledermatology is an incomplete solution for dermatology inequity seen in American Indian and Alaskan Native communities,” wrote Kohn and Introcaso.

The study, “Evaluation of Barriers to Telehealth Programs and Dermatological Care for American Indian Individuals in Rural Communities,” and editorial, “A Cultural Context for Providing Dermatologic Care to American Indian and Alaskan Native Communities Through Telehealth,” were published in JAMA Dermatology.