‘UNIQUELY EQUIPPED’
Contact tracing a new duty for community health reps on Navajo land
NAVAJO NATION — Two pickup trucks barrel down an unnamed dirt road off one of the main highways crossing the Navajo Nation northwest of Window Rock, Arizona. A cluster of horses and a skinny foal with toothpick legs graze nearby, and dark clouds gather overhead.
One of the trucks is hauling a 550-gallon tank, and water sloshes out of it when the wheels hit a bump in the road. The other is carrying nearly 100 cases of bottled water.
The trucks come to a stop beside a concrete two-room house nestled under tall pine trees.
As the crew begins to unload the cases and pump water from the tank into barrels, Catherine Lee — wearing a blue patterned face mask — grabs her clipboard and approaches a man sitting in the front yard.
Lee is a community health representative. Her job used to entail making the rounds
through St. Michaels Chapter, visiting elders and high-risk clients assigned to her.
She would enter their homes, check their vital signs, ask about their health conditions, make sure they know about coming appointments and help them with whatever else they needed.
But since COVID-19 came to the Navajo Nation, Lee and her fellow CHRs have been using their knowledge of the community in a different way. Participating in the water delivery has marked the first time in months that she has seen many of her clients face to face.
“We’ve just been doing welfare checks over the phone, seeing if they need medication, pick up the medication and deliver it to them — same thing if they need food, and now we’re doing the water,” Lee said. “It just feels limited, but it feels good that I’m trying to help them in some way.”
Sometimes the CHRs drop off informational pamphlets about the respiratory illness caused by the novel coronavirus: how to prevent it and what to do if you or a family member gets sick.
And in the hardest-hit areas of the Navajo Nation, community health workers are not in the field at all any more. Instead, they’re in an office making calls as contact tracers, trying to track down who might have been infected.
Dr. Laura Hammitt, the director of Infectious Disease Programs for the Johns Hopkins Center for American Indian Health, said CHRs and public health nurses make up the core of the Navajo Nation’s response teams and are instrumental in slowing the spread of the virus.
COVID-19 has spread rapidly throughout the Navajo Nation, where there are higher infection rates than in hot spots such as New York state and New Jersey. As of Friday, 264 Navajo people had died of the disease across the reservation, which stretches across parts of New Mexico, Arizona and Utah.
“I think (contact tracing) is the tool we have right now to slow the spread of this virus,” Hammitt said. “Until we have an effective vaccine … this is the mainstay of coronavirus containment efforts.”
‘Face of public health’
The Community Health Representative Program was started in 1968 as a way to do checkups and public health education for people living on remote tribal lands across the United States. All CHRs are certified nursing assistants and have been trained in the National Incident Management System on how to respond to public health emergencies.
On the Navajo Nation, officials say, there are about 90 CHRs across 110 chapters in the three states. Before the pandemic, they generally made
eight to 10 home visits a day to elders and other high-risk residents and as many as 1,200 visits a year. All but five are women.
Now, many have joined other health care workers in doing contact tracing, trying to track down everyone who might have been infected by the virus. About 90% of the CHRs have received some training in contact tracing.
Hammitt said several hundred people, including optometric technicians, diabetes educators and physical therapists, are now doing contact tracing and case management for COVID-19 patients on the Navajo Nation.
But she said CHRs and a smaller group of public health nurses are ideally suited for this task.
For one thing, as restrictions lift and other workers return to their previous day jobs, the CHRs and nurses will still be working in the community.
“Public health nurses and CHRs are really uniquely equipped to do contact tracing, because they know the community so intimately, so well,” Hammitt said. “… This is what they’ve done prior to COVID-19, and they are the ones who are the face of public health in the community.”
Also, she said, although they have been getting volunteers from all over, there are things that those who grew up on the reservation, and as part of that culture, can explain to residents that outsiders can’t.
“It’s really important that people understand cultural competency and how important cultural competency is in the work the CHRs do,” Hammit said. “Maybe that’s obvious, but here it’s especially important to be able to translate the messages in a way that resonates with community members.”
Community Outreach and Patient Empowerment, or COPE, a nonprofit that partners with the CHR program and the Navajo Nation, has been helping train more people on how to do contact tracing and case management for COVID-19.
Hannah Sehn, a program manager with COPE, said the program has trained more than 200 people. She said about 400 contact tracers, case managers and community connectors will be needed.
“However, this estimate will need to be constantly refined by the Navajo Nation leadership as the epidemic unfolds,” Sehn said.
Hammitt said the size of the workforce will depend on the virus.
The epidemic has spread from the northwestern part of the reservation to the eastern and southern parts. And while some areas seem to be plateauing, Hammitt said, it’s too early to predict what will happen.
Now, with stay-at-home orders in place, contacts are easily traced within one household, but, Hammitt said, as restrictions are relaxed and people begin leaving the house and going back to work, tracing will become more difficult. The Navajo Nation is no longer under a 57-hour weekend curfew.
As of Friday, there were more than 5,700 cases of COVID-19 on the reservation, and Hammitt said that for each one of those cases, calls need to be made to anyone the patient came into contact with 48 hours before they started showing symptoms or tested positive if they are asymptomatic. About 2,174 people have recovered. The Navajo Nation has tested much higher percentages of its population than other jurisdictions — more than 15% — which also results in more cases being discovered and more people who need to be contacted.
“The CHRs and public health nurses, right now we don’t have enough of them to be able to fully meet the needs of this pandemic,” Hammitt said. “This is something that none of us have ever seen before.”
Although health care providers are understaffed, Hammitt said, in many ways the Navajo Nation is ahead of other jurisdictions, because it already had a workforce trained in community health that could begin doing contact tracing. She and other officials have been sharing what they learned with other tribes and jurisdictions.
“For all of Navajo Nation to have this resource for its entire population is unique,” Hammitt said. “It’s one of the things that helps make Navajo Nation a leader in the contact tracing initiative. I would say they are doing more than a lot of other jurisdictions.”
Exhausting work
Before the pandemic, Brenette Pine was a supervisor in the CHR program. Now, she commutes two hours each way to work 10- to 12-hour days as a co-leader of case management at the Health Command Operations Center in Window Rock. It’s exhausting and emotional work.
She said that even before the first case of coronavirus was reported in the United States, the CHRs and public health educators had been visiting schools and community centers to teach about the necessity of washing hands and about the symptoms of the illness.
When COVID-19 came to the Navajo Nation in mid-March, the CHRs could easily identify the most vulnerable, because they were already their clients.
Over the past couple of months, they have been helping coordinate donations and deliveries of food, water and other resources and are wiping down all products with disinfectant before dropping them off at homes.
“These Navajo people trust their CHRs,” Pine said. “They won’t readily open the door for anyone, but they recognize the CHR vehicle and they understand the CHRs are coming to them. … They know they have that knowledge for any questions they might ask the CHRs.”
In St. Michaels Chapter, for example, a volunteer-based relief effort called Water Warriors United linked up with the local chapter house and CHR team to find out which homes needed water deliveries.
That’s how Lee, the CHR, got involved. She estimates about 20 of her clients don’t have indoor plumbing in their homes.
Driver CB Barton said he was doing IT in Gallup but when the pandemic hit, work dried up. So now he spends his days driving his truck around the reservation, delivering 55-gallon barrels full of potable water to homes that need it.
He said that every morning he gets a text from a coordinator telling him which chapter to go to and that the CHRs have been a tremendous help in knowing where they should deliver.
“They know their community; we don’t,” Barton said. “If we were just to go out here and see who needs water, we wouldn’t know where to go. It’s good to have somebody who is localized so we can follow them around.”
At one home a resident says she was in the midst of getting a waterline to her mobile home but when the pandemic began everything ground to a halt. Her family has been using jugs of water to sponge-bathe and wash their hands since they moved into the home in 2005.
Back at the Health Command Operations Center, Pine said, she sometimes gets calls from community members who appreciate everything her staffers are doing for them. She said that on Thursday as she was getting ready to head home for the day, she got a call from an elder in Chinle who was in tears with gratitude.
“In Navajo, she said, ‘Thank you. I beat the illness; you guys gave me water; you guys listened to me,’” Pine said.
Thursday evening, on her long drive home to Farmington, Pine listens to music — everything from country to Metallica — and thinks about work, the day’s events and what it’s been like living through the pandemic. Her husband has dinner waiting for her.