Editor’s note: This letter to the public is written by a physician who has been working on the Navajo Nation and environs for 8 years.
Many are feeling alone on the Navajo Nation right now, especially in the remote community of Chilchenbito, which is essentially on lockdown due to the major outbreak of SARS-CoV-2, the virus causing COVID-19.
As a public health physician living in this area for the past 8 years, I am part of the Epi Response Team, and have already witnessed the terrible impact this virus has had, and it’s only just the beginning. It is rapidly spreading to surrounding communities, mostly due to a multi-church gathering that occurred in Chilchenbito in early March, and the handful of emergency rooms on the Reservation are already overwhelmed with people presenting in respiratory distress. Many are being intubated, stabilized, and flown out to tertiary care centers scattered across AZ, NM, UT, and CO; but some are also dying at home or shortly after arrival to the ER, and not being tested at all because we don’t have a system in place for post-mortem testing. General testing is also not widespread, so the true numbers are grossly underestimated. Our tertiary care centers in the surrounding states are filling up fast – likely reaching capacity by next week – and we will have to keep these incredibly sick patients at our facilities on the Rez, without enough critical care nurses or PPE. We have smart doctors and nurses here and we are actively surge planning: designing respiratory care units in existing spaces and purchasing more ventilators (that are on back order), but it’s just not going to be enough.
I want to share why the Navajo Nation, is so incredibly vulnerable to this virus (and pretty much every communicable disease in existence):
The Navajo (Dine) people suffer from high rates of obesity, diabetes, hypertension, lung disease, and autoimmune conditions (to name a few), but this is only a small part of the story here.
Poverty – It’s hard to practice proper hand hygiene when there is no running water. Many have to haul water, but as the more physically mobile members of the family get sick, they are no longer able to do so. And many do not have the income to purchase soap, hand sanitizer, or even food… especially when they have to drive an hour to the closest store (if they have the money for gas) only to find that things are out of stock. USPS does not deliver to homes on the Rez, and many homes do not have a physical address where items can be delivered by even UPS or FedEx.
Overcrowding – When there are multiple generations, and perhaps multiple families, living in one small household, it’s hard to isolate those that are sick from those that are well. Entire households are falling ill.
Limitations of sheltering in place – related to overcrowding, if an entire household is sheltering in a small place, and unable to isolate those that are sick, and do not have the resources for proper hand hygiene and disinfection, it is easy for the virus to spread to everyone in the house. Additionally, it is difficult for these families to obtain things like groceries and other goods when they don’t have anyone that can safely leave the house…
Numbers – There are over 160,000 living on the Nation. There are only 28 ventilators on the entire Reservation. We need at least double this amount if the models/projections for this disease are correct. And that doesn’t take into account the number of medical professionals needed to take care of these critically ill patients: doctors and nurses that are continually getting exposed to the virus and being quarantined because they do not have enough personal protective equipment (PPE)
Access to information – When much of this community is comprised of elders that speak their traditional language and do not have a smartphone or social media, it is hard to disseminate information quickly to stay up to date… many households do not have land lines or television or even electricity. And when this information isn’t disseminated widely and effectively, many are uninformed and/or scared, many don’t know what to do if they or someone in their household develops symptoms, many don’t know to socially distance/isolate… traditional gatherings and ceremonies, including funerals, continue to take place… and spreading occurs.
Access to care – many live far from the health centers and don’t have reliable transportation. Additionally, if there is a medical emergency in the home, often times EMS has difficulty reaching folks in a timely manner because of distance and/or unpaved, unmaintained roads.
Protection for healthcare workers – When the nearby health centers do not have enough PPE to safely see patients presenting to the hospital, let alone to perform vital home visits for assessments and face-to-face education, everyone is put at risk. The EMTs responding to 911 calls are also put at tremendous risk!
And here is some alarming data (as of March 31, 2020):
There are 1289 positive cases in Arizona (24 deaths). There are 148 cases in Navajo Nation. Of the 148 cases, 49% of the cases are from Kayenta Service unit (KSU) and 16% from Chinle Service Unit (CSU). Kayenta Service Unit has been most impacted by the pandemic where almost half of the cases have required hospitalization (48%).
About 50% of those hospitalized required ICU level of care (not included in this analysis, but extrapolated from reports from KSU and CSU emergency physicians transferring patients from the ER to tertiary care centers).
These numbers are really striking, especially since it points to the Navajo becoming quite ill (requiring hospitalization and ICU care) at higher rates than the general US.
The Navajo Nation population represents about 2% of the Arizona state’s population, yet Navajo positive COVID-19 cases are representing at least 11% of all Arizona cases at this time.
We are trying our best out here, but it is so incredibly difficult.
Please be mindful of the challenges we face.
But also be aware of the grassroots efforts by the local health centers, the Johns Hopkins Center for American Indian Health, and the Navajo Nation to obtain and allocate resources (including food, water, soap, disinfectants, educational materials, etc) and to provide the best care possible.
That being said, the Navajo Nation government and Indian Health Service Area Office doesn’t seem to have the infrastructure or organization to handle what is happening (and what is about to happen) at this kind of scale. Plus, it seems that these two entities are not communicating effectively with each other to truly determine what is needed “on the ground.”
President Nez is being proactive about reaching out to the state for any form of assistance, but the “assistance” we are receiving so far is not the most applicable.
The National Guard made press releases yesterday about how they set up a “federal medical station” in Chinle (my home) and how they are providing assistance to the Navajo Nation… but what they failed to share with the press is that they basically delivered a kit to set up a hurricane-like shelter (or, rather, camp) in an existing structure that is too far away from the hospital to serve as medical overflow, and only has a couple of restrooms, NO staff, and no essential medical supplies.
Had they discussed any of this with the local IHS Hospital beforehand, they could have learned key things about the area and potential resources already in place to develop a better plan (which the local IHS has formulated), but again, communication between these entities has not been very straightforward.
I spoke with the National Guard and FEMA in Kayenta on March 30, 2020 about all of the above concerns, and the National Guard, pointblank to my face, said that they are “spread too thin” and that “your hospitals need to focus on your ethics plan for rationing care.”
Despite this answer, they are reportedly airlifting a bunch of PPE to the area soon ?
We need more manpower, more communication between key entities, more critical care nurses, more PPE and other supplies, and more people who can get the word out and who will LISTEN and ACT. We need applicable solutions to face this crisis.
Sure, there have been funds from the stimulus package slated for the IHS and tribe, but this will take precious time to actually reach this area… and will likely get here after the worst has already occurred. Plus, the money is not worth a whole lot when vendors are out of stock of much needed supplies and we can’t find nurses and other staff to pay.
Thank you for reading.
Name withheld for privacy, M.D.