Alumni Profile: Alison “Addie” Spencer’95
A family practitioner on reservation time
By Julia Hickey González
The CT scan shows that Alison Spencer’s patient has metastatic lung cancer, and she has to break the news. “We will sit at her kitchen table, and it will be horrible. But less horrible, maybe. Who else gets to do home visits in 2023?” she says.
As medical director for the Nisqually Tribal Health & Wellness Center on a reservation east of Olympia, Washington, Dr. Spencer is employed directly by the seven-member governing council of the Nisqually Native American Tribe. The health center serves about 1,600 patients, including Alaska natives and any federally recognized tribal member who lives in Thurston County. That means the Navajo dental assistant, Cherokee professor, or Blackfeet truck driver who lives outside the reservation can still access health care. But for the 100 or so remaining elders of the 600 Nisqually residing on the reservation, Dr. Spencer can make time for visits, which can include rummaging through a patient’s medicine cabinet to toss out expired inhalers and pill bottles.
Dr. Spencer loves primary care for the broad and ever-changing circumstances she encounters daily: passive patients, bossy patients, the simple pediatric ear infection, a challenging behavioral health issue, and, of course, the celebrations. Someone is finally pregnant, or their baby is talking. She delights in skillfully running a patient visit to gain the patient’s trust and completing procedures with minimal discomfort.
But Dr. Spencer still has not mastered one aspect of family medicine on a Native American reservation, and that is how to do justice to the intense grief and loss that her patients encounter too often in their personal lives.
“If someone had told me 30 years ago that they had lost a son to suicide, a daughter to overdose, and a son to murder, I would have thought they were confabulating. What’s the secondary gain? What’s the psychopathology causing someone to tell such terrible lies?” she asks.
But on the reservation, a life story this devastating is not uncommon.
People of the River, People of the Grass
Two percent of the U.S. population is Indigenous, and 22% of Indigenous people live on reservations. Between European colonial contact and 1900, it is estimated that 70 million native people died. A leading cause for this demographic collapse was infectious disease, most commonly smallpox, and the cascading effects of colonialism, including genocide, poverty, and forced assimilation that hastened the conditions for diseases to spread.
So when Dr. Spencer, a white woman, offered a flu shot to a Nisqually patient who responded politely, “No, thank you, and I don’t want any blankets, either,”—a reference to smallpox spreading to Native communities—the doctor accepted her distrust.
“I totally get it,” Dr. Spencer says.
For thousands of years before 1833, when Fort Nisqually was established as the first white settlement on Puget Sound, the Nisqually people thrived in the watershed of the Nisqually River.
The water flows from a glacier on Mount Rainier through prairie grass to empty into the sound. Members of the tribe fished the river for salmon, which informed their religion and customs.
In 1851, Congress started forcing Indigenous peoples to live on reservations. In the case of the Nisqually people, their diminished land holdings were further divided in 1884, according to tribal records, eliminating connection to their lifeline: the river. In the winter of 1917, the U.S. Army moved without warning onto Nisqually lands and ordered families from their homes, later annexing 3,353 (of 5,000) acres of their reservation to the U.S. Army to expand Fort Lewis and its impact area for live munitions.
During this process of isolation and division, the Nisqually people were forced into agriculture, farming hops fields and, more recently, strawberry fields. Food rations introduced wheat flour, processed oils, and sugar into their diets. Nisqually children were removed from their parents and placed in boarding schools, where their hair was cut and they were forced to wear Western clothing. Even after boarding schools were closed, children were sent to white foster families in the 1950s and 60s. As adults, they often struggled to be healthy parents.
One of Dr. Spencer’s patients did not want to go to the local Catholic hospital because a crucifix on the wall brought memories of the childhood trauma she experienced in a boarding school.
By various metrics, Native Americans suffer poorer survival outcomes than other racial groups. According to the CDC, the third leading cause of death for Indigenous American women living on reservations is murder—10 times higher than the national average. According to the NIH, Native Americans and Alaska Natives are five times more likely than other races in the United States to die of alcohol-related causes. In the decade from 2009 to 2019, Native Americans had the highest rate of death by law enforcement—even higher than Blacks. And while COVID-19 was hard on everyone, a Princeton study concluded that Native Americans died of the virus at a higher rate than any other community in the United States. The CDC also noted that Native Americans experienced the highest increase in deaths by suicide (26%) from 2020 to 2021, while white deaths by suicide declined over the same period by 3.6%. The lethal effects of the opioid crisis and the arrival of fentanyl are still being assessed but already appear to be outsized for the Indigenous community.
“Loss of cultural identity and removal from family and community through policies of forced assimilation is likely at the root of some of the health disparities we see today. And I am not alone in connecting the high instance of substance use disorder to this history,” Dr. Spencer says.
For people with highly adverse childhood experiences, research is beginning to show that resilience can trump them. “I think celebrating survivorship is very powerful, and that is something I can totally dive into. You don’t just pick at people’s wounds,” Dr. Spencer says. For example, the smoker who was able to stop for three days for the first time has taken an important step.
“You have to celebrate.”
From VP&S to the West
A Latin American studies and history major who wrote her Wesleyan thesis on prenatal care in Puerto Rico, Dr. Spencer has long held an interest in serving communities outside her own. When recounting her highlights studying medicine at VP&S, she describes away rotations, including a performing arts clinic at Roosevelt Hospital in Manhattan. There she assisted injured performers, such as a wind instrumentalist with a musculoskeletal injury and dancers with hip issues. She traveled to Albuquerque, New Mexico, to test the pulmonary function of miners.
But medical school was not without its challenges, such as caring for an older malnourished man with pneumonia at the start of her clinical training. “He was my very first patient. My first admission. My first note. My first rounding. And then he died.”
Of course, the circumstances leading up to and responsibility for his passing were far beyond the purview of a lone medical student, but she strained to process her role. Dr. Spencer called her father, a physicist and a self-described “glass half full” kind of person, and said, “I can’t believe that on my very first try at taking care of somebody, they died.”
Her father said, “You know, sometimes pneumonia is the old man’s friend. And sometimes it’s OK to die.”
She still recounts this moment with a mix of deflation and hope: “I was like ‘OK. I will keep going.’”
Her mother, a graphic artist and teacher of English as a second language, died from lymphoma when Dr. Spencer was in college, but she carried her mother’s dedication to languages with her to VP&S. Because interpreters were not widely available, Dr. Spencer’s basic fluency in Spanish (gained through study in Spain) allowed her to participate in procedures that were ordinarily off limits to students.
Dr. Spencer met her future husband, David Bonauto’93, in her second year of medical school. At a meeting for the American Medical Women’s Association, Dr. Bonauto, a fourth-year medical student, stopped by to promote an away rotation he had enjoyed.
“I thought he was cute,” she remembers.
In late June of 1996—on the last day of Dr. Bonauto’s internal medicine residency—they packed the belongings from their 113th Street apartment into a Budget rental truck and drove “west into the sunset, as one should,” Dr. Spencer recalls. They found an apartment in Tacoma, Washington, just in time to start Dr. Spencer’s three-year residency training in family medicine at Tacoma General/ Mary Bridge Hospitals. She later worked at two community health clinics that serve primarily Guatemalan and Mexican communities. On her days off, she provided abortions at Planned Parenthood.
When recommended in 2008 to join the Nisqually health center—at that time located in a five-room clinic with one nurse practitioner and one physician’s assistant—Dr. Spencer was initially hesitant. She would have to give up delivering babies and speaking Spanish, two of her professional joys. She and her colleagues would need to coordinate all logistical aspects of their patients’ care.
But like her father, Dr. Spencer is a “glass half full” kind of person. “I saw the amazing potential that the clinic had and the unmet need, and so I decided to give it a try.”
A Different Sense of Time
Fifteen years later, Dr. Spencer reflects on all the Nisqually Tribe has accomplished.
“Working here has brought out in me a different sense of time and the willingness to stick with something for the long run. Change can be slow and then fast and then slow and then fast. It often doesn’t feel fast enough. But being a little bit more willing to allow the time to pass that needs to pass, I think that’s been really helpful to me.”
In 2019, the tribe broke ground for a vastly expanded new health center, which opened in 2022 with 15 exam rooms and dental, behavioral health, traditional healing, and pharmacy services on two levels with a light-and-plant-filled biophilic design. Also serving as a civic center, it has a garden, a healing room in the round, and a fire pit for gatherings. Much to everyone’s delight, the waiting room has a small latte stand.
After winning fishing rights in 1974 and the right to self-determination in 1975, the tribe took an entrepreneurial approach, opening a casino, operating two fish hatcheries, and working to reacquire lands. Tribal members who previously went away to work in other parts of the country, isolated from their culture, have started returning to the reservation. Some younger members are eager to learn older ways that were lost, such as reviving traditional songs and dances that were illegal to celebrate until 1978. They host canoe races, inviting other Indigenous tribes from as far away as New Zealand to participate. To promote health, some drink Prince’s Pine tea.
Moving the needle on Native American health outcomes is a “very long-term project,” so Dr. Spencer moves toward larger goals by focusing on the immediate wins in her patients’ lives.
“I just absolutely love it when I’ve said to the person for three years, ‘I’m worried the pain pills are causing more problems than they are helping. Want to try buprenorphine?’ And one day they show up and are ready to try buprenorphine, like it was their idea all along. It has to be their decision. It can’t be mine. I have to be there when they figure out the time is right.”
As medical director, Dr. Spencer has many pet projects. Prenatal care and maternal infant care are huge needs, so Dr. Spencer is working to bring family medicine residents from a nearby program for on-site rotations. The center finally has nurses, so she wants to strategize how they can make the most impact. She wants to encourage Native kids to consider health care careers and is working on a memorandum of understanding with the University of Washington Native Health Pathways program.
“I am so happy I get to work here during a time of resilience,” she says. “We are working hard to overcome the historical determinants of health.”
At the 2022 alumni reunion, Dr. Spencer gave a virtual presentation on Nisqually history and health outcomes titled “Historical Determinants of Health: The Lasting Effects of Colonialism on Native Health in the U.S.”