Everyone on the Navajo Nation reservation knows someone who has been infected with COVID-19.
At least that’s what it feels like to Melissa Begay, MD, a Navajo pulmonary medicine physician at the University of New Mexico (UNM) Hospital who treats patients airlifted from the reservation. There, it is still common for multiple family members to occupy adjoining rooms in the ICU. She has never seen so many tribal members at the hospital, she said.
Begay has lost three relatives herself.
“You feel mentally exhausted from the news of someone passing,” Begay told MedPage Today. “Each week, it’s someone you know — a friend, a relative, a tribal official, or one of the frontline responders. That news has not gone away since March.”
The Navajo Nation dominated headlines in May for having a higher infection rate per capita than any other U.S. state, and as of August 11, 9,334 cases and 473 deaths have been reported. However, over the past 6 weeks, there has been an average of fewer than 50 new cases per day, and the curve has started to flatten on the reservation. In contrast, there has been an average of 1,178 new cases per day in neighboring Arizona over the past week, and new daily cases topped 3,000 throughout July.
Although the Navajo community faces an uphill battle to overcome disparities that afflicted the tribe long before the pandemic, tribal leaders, healthcare professionals, and members of the community have banded together to slow the spread in a way that other areas of the country have struggled to do.
“Native people have faced tons of pandemics before, and we are seeing this resiliency come through,” Begay said. “There are still a lot of positive feelings in terms of actually seeing our tribe come out on the other side of this stronger.”
Backdrop of Inequity
Health disparities have run rampant in Native communities for decades. Nationwide, one in four positions at the Indian Health Service (IHS) facilities were vacant as of 2018, and the vacancy rate was even higher within the Navajo Nation.
Compared with white individuals, Native Americans also have an increased risk of many chronic health conditions, including more than tripled risk for diabetes and 50% higher rates of obesity, which both carry a greater risk for severe COVID-19 infection and death.
These disparities are even greater among Native Americans living in rural areas, such as the Navajo Nation, compared with metropolitan areas, according to findings from the National Health Interview Survey published last week. In rural areas, 36% of Native Americans have multiple chronic conditions, 35% have hypertension, and 19% have diabetes.
Last week’s CDC COVID-19 report showed that Native Americans had an age-adjusted hospitalization rate roughly 5 times higher than white Americans. But some federal data do not report outcomes by race/ethnicity, and tribes are not required to report COVID-19 data to the CDC. As a result, the numbers reflected on the government agency’s website may not accurately portray the scope of the problem.
According to a New York Times analysis of 1.5 million positive cases across the U.S., the COVID infection rate for Native Americans was 1.7 times the rate for white people. At Begay’s hospital in New Mexico, about 45% of patients are Native American, despite comprising about 10% of the state’s population, she said.
Meanwhile, the IHS budget amounts to $4,078 per capita, compared to $13,185 per Medicare beneficiary.
On the Navajo Nation reservation, there are a dozen medical facilities to serve a population of more than 173,000 in an area about the same size as West Virginia. These facilities house a total of 25 ICU beds, which means many critically ill patients have to be helicoptered to nearby facilities in Phoenix or Albuquerque, where Begay’s hospital is located.
Some critically ill patients being transported off-reservation may only speak Navajo, which not only increases their risk for medical complications in the air, but could make end-of-life discussions and other vital communications difficult once they land.
“It’s already such a challenging situation and when you have that barrier where you can’t communicate appropriately for people to make important decisions, it presents a challenge that may not necessarily be seen in other cases,” Begay said.
A Mitigation Model
To prevent hospitalizations and ease the strain on overwhelmed facilities, the Navajo COVID-19 response has been focused on providing resources to households so that families could stay home, said Laura Hammitt, MD, the director of Infectious Disease Programs at the Center for American Indian Health.
Hammitt credits the recent drop in infection rates to tribal leadership and basic infectious disease principles: handwashing, mask wearing, social distancing, and contact tracing.
But these strategies are not possible for much of the population. One in three households on the Navajo reservation lack running water, and many live in multigenerational homes that make isolating or quarantining a challenge, to say the least.
“In tribal communities and others highly impacted by poverty, people do not have the privilege of being able to take the steps to slow the spread of disease,” Hammitt told MedPage Today. “The Navajo Nation response is focused on giving people the tools they need to be able to slow the spread.”
Since April, the Navajo Nation operated under a 52-hour weekend curfew until last week, when it was reduced to 32 hours. More than one-third of the population has been tested, allowing for robust contact tracing.
Still, the curfew reduced access to nearby towns, which is an issue for many tribal members who live in rural areas, Begay said.
In the reservation’s northeastern section, for example, more than a dozen communities rely on a market in Shiprock, New Mexico, said Kyle Jim, who delivers care packages to families with Arrowhead Lifeway.
“The majority of our people are low income so we don’t have the luxury of stocking up on food for a long time,” Jim told MedPage Today.
Community Steps Up
To ensure that people had necessary supplies, dozens of community organizers, including Navajo Nation President Jonathan Nez, have launched COVID-19 relief efforts, collecting and distributing food, water, handwashing stations, and medical supplies to homes on the reservation.
Zoel Zohnnie began crowdsourcing a COVID-19 relief effort, Water Warriors United, in late April. He used the funds he collected to purchase a water tank and pump, trailers, and barrels to deliver to homes that lacked plumbing. Each day, he and about a half dozen volunteers distribute barrels to up to 10 homes. Previously, their occupants may have had only a single 5-gallon jug that they had to make trips to refill.
“Once the communal and tribal efforts on the ground increased the supply of water, food, and equipment, you developed a system in which people could stay in their homes and didn’t have to leave,” Begay said.
Although the pandemic reduced people’s ability to go out and collect water, especially elders and other high-risk individuals, the need for basic resources and better infrastructure has been extremely high for generations, Zohnnie said.
“Once the virus did show up, it showed the world that these are the issues we have been facing for a long time,” Zohnnie told MedPage Today. “If I had a team of 10 people working all week, all year, we wouldn’t even make a dent in all of the problems that need to be solved.”
Stronger on the Other Side
Through the federal Coronavirus Aid, Relief, and Economic Security (CARES) Act, the Navajo Nation received about $700 million, part of which Nez has allocated to fund affordable housing projects on the reservation.
More Navajo translators have been hired at UNM’s hospital in Albuquerque so that 24-hour services are now available to patients, Begay said.
“Getting a Navajo medical translator on board at a university … That’s a big win for us,” she told MedPage Today. “When I did residency at UNM, this was not available and it has greatly increased our capacity to deliver care.”
However, the CARES Act funds come with a time limit, and only cover expenses incurred through the end of the year. Things like hiring providers take time, and the challenge now is spending the funds before they disappear, Hammitt said.
Indirect impacts of COVID-19, such as unemployment, will continue to be felt in the coming months, Hammitt said, emphasizing that “the virus has not gone away,” and the mitigation measures put in place will need to remain throughout the fall and winter months.
“People need to understand this can’t be a short-term, one-off investment; this needs to be a longstanding investment in systemic change,” Hammitt said. “I hope that will continue to be the case after we have flattened the curve and people will remain committed to making the changes that are needed to raise the health status of tribal communities.”