A group of medical providers gathering at the Gallup Indian Medical Center
Source: Nate Teismann
Dr. Jeanne Noble has worked all over the world as an emergency medicine physician. So when the hospital where she works, UC San Francisco, asked if anyone was willing to fly out to the Navajo Nation and help with an escalating Covid-19 outbreak, she eagerly volunteered.
The Navajo Nation, which reported its first Covid-19 case in mid-March, has seen infection rates per capita among the highest in the country. Thus far, there have been 8,000 cases and more than 300 deaths. The reservation, which is home to more than 170,000 people, is spread out across the varied desert landscape of Utah, Arizona and New Mexico. The people refer to themselves as the Diné.
Noble went to work at the Navajo Nation’s hospital — Gallup Indian Medical Center in New Mexico — as part of the second group that made the trip out from UCSF. The first group arrived in April after responding to a call from Navajo Nation President Jonathan Nez for health worker reinforcements. Around that same time, a similarly-sized cohort of medical providers from UCSF made their way to New York.
Noble’s group arrived in May. She was immediately impressed with the steps taken to ensure that more patients could get seen on-site. “They had put up plastic sheets and barriers to double the capacity in the emergency room, and then taken over an old pediatric clinic,” she recalled. “There were also tents outside for the less sick patients.”
Still, many of the Covid-19 patients had to be transferred to larger facilities in Albuquerque, New Mexico, or Flagstaff, Arizona, if their health deteriorated. Often, Noble would have to call up three to four different hospitals in these regions to find space for her sick patient. Now, with a spike of cases in Arizona, Noble is concerned it’ll become even more challenging for patients to get the intensive care they need.
Noble and her colleagues have been back in San Francisco for a few weeks, but she says their experiences were a constant reminder that Covid-19 is a “terrible illness,” as she treated dozens of patients who were suffering.
But she also stressed that it’s a disease that has disproportionately impacted certain populations over others, including low-income groups and communities of color.
Social and economic inequities
The Navajo Nation, which has experienced social and economic inequities for decades, has been particularly vulnerable.
Large swathes of the population at high risk for serious complications from Covid-19: More than a third suffer from chronic medical conditions, including diabetes and heart disease. According to the CDC, American Indians and Alaska Natives have the highest prevalence of diabetes in the United States, more than twice that of non-Hispanic whites.
A group of providers wearing masks at the Gallup Indian Medical Center
Source: Dr. Nate Teismann
But lack of basic services that many U.S. residents take for granted are another more pressing problem.
Noble recalled how one of her patients, a man near the age of 70, had been sick with Covid-19 and discharged from the hospital after making a recovery. His home was 30 miles away, and he had no way to contact his family. So he started walking home in the blazing heat, eventually collapsing from dehydration.
After being picked up by paramedics, the patient was checked back into the hospital, where he had just recently been discharged.
“He didn’t have a car or a phone and he was also diabetic and out of insulin,” she said. “Unfortunately, this is a relatively familiar story.” Noble pointed out that there is a service available that provides transportation to Navajo patients, but it’s not perfect. Sometimes there isn’t a ride available, or patients aren’t given a number to call.
Many of the Navajo live in overcrowded households with their families, where the virus can spread quickly, and more than a third lack access to running water at a time when it’s critical to wash their hands. Moreover, hauling water can often mean breaking social distancing guidelines. There are only about a dozen grocery stores, and stocking up with basic food supplies can mean a three-hour drive.
“Everything is exacerbated by the fact that in this community, a high percentage of homes don’t have electricity and running water,” said Dr. Nathan Teismann, an emergency care physician at UCSF.
“There’s also a relatively sizable homeless population, high rates of chronic disease, and behavioral health challenges – and that is fanning the flames of Covid-19.”
All of the doctors and nurses agreed that the government needs to do far more to protect this population. Noble continues to be concerned about donations running out. She felt that at the very least, there needs to be funding for mobile health units so providers could visit patients at their homes, as well as better access to clean water. She is urging policymakers to consider solutions around housing, so there are more options available for people with Covid-19 to safely isolate.
“These might be expensive propositions, but we’re talking about a basic human right for things like access to drinking water,” she said.
Dr. Tara Sood, an emergency medicine specialist, recalled how one of her patients tested positive but was told to return home to recover.
After speaking with him, she learned he lived in a small one-bedroom unit with his wife and two others, making it near-impossible for him to isolate himself.
“Thankfully, we got him a hotel room,” she said. But Dr. Sood noted that “socio-economic status” plays a huge role in both Covid-19 exposure and recovery. “There were so many patients living in homes with eight other people with nowhere else to go,” she said.
Gallup Indian Medical Center emergency entrance
Source: Dr. Nate Teismann
The hospitals that serve Navajo patients were doing a “heroic job,” according to Noble, of making the most of what they had. At the Gallup Indian Medical Center, there were plastic sheets used to increase emergency department space, and a reuse program with face shields. There were also creative solutions for devising gowns.
But the need to improvise revealed the underlying lack of supplies.
“We were always on the cusp of outstripping supplies,” said Teismann, who was working at the hospital in mid-June. “I constantly wondered while I was there, ‘will today be the day that there aren’t any more ICU beds’?”
Noble believes there needs to be a long-term solution to ensure that hospitals in the poorest and most rural areas have adequate access to protective equipment. Donations can dry up, particularly as America’s larger hospitals scramble for supplies.
A sense of isolation
One of the hallmarks of Covid-19, say the doctors and nurses, is the isolation that many patients experience. In their time with the Navajo Nation, they met with older, sick patients who didn’t speak English well. And it was difficult to communicate with them if a translator wasn’t available.
Many were isolated from their family-members and didn’t have cellphones. Some patients were flown out to unfamiliar places, including to larger hospitals in other states, which only increased their sense of loneliness. Some of these patients ended up on ventilators, and no one could visit them in person without adequate protective gear.
“It’s horrible and it’s not how we expect someone’s life to end,” said Sood.
“It’s an incredibly resilient and strong-willed population and they have fended for themselves for decades,” said Noble. “And there’s a strong sense of community,” she noted, adding that it made it only more challenging for people to be separated from close friends and family-members.
All the doctors and nurses said they had patients who were in their twenties, thirties and forties who needed to be hospitalized, but the majority were older. Very few people died at the hospital, as the sickest were transferred off to other places. But in one particularly harrowing case, a patient of Noble’s in his late sixties lost consciousness and died in the car on the way to the hospital.
‘This pandemic won’t be dictated by human preference’
The doctors and nurses returning from Navajo Nation have a message to share for their fellow Americans. As of this month, officials are reporting record cases of Covid-19 and a smattering of states have been hit particularly hard by the virus. At the same time, people are itching to resume life as normal — and some researchers have called it “pandemic fatigue.” In some parts of the country, there’s a widespread reluctance to wear a mask or follow social distancing guidelines.
“If you’re in young, you’re not immune from getting critically ill,” said Noble. “Wearing a face mask needs to be taken seriously, and social distancing needs to be taken seriously.”
“Just because you’re not experiencing it (Covid-19) personally, it doesn’t mean that massive chunks of the population aren’t,” said Sara Kaiser, a nurse practitioner. Kaiser said that she observed the Navajo people following the public health guidelines as best they could, and many were highly concerned for the health and safety of family members.
“People are getting tired, but unfortunately the course of this pandemic won’t be dictated by human preference,” added Teisman. “Instead, it will follow the biology of a contagious respiratory virus.”