‘I’m so glad that I’m alive today’
Robust contact tracing, follow-up care are saving lives of White Mountain Apache tribal members
As the new coronavirus ravaged the White Mountain Apache Tribe in eastern Arizona, Eugenia Cromwell did her best to stay home to keep herself safe. Visits to the grocery store and post office were instead passed off to her daughter, with whom she shared a home near Whiteriver.
So it came as a surprise to the 79-year-old Apache woman when she learned in August she tested positive for COVID-19 along with two other people in her home. Knowing the virus could severely impact older adults, Cromwell feared for her life.
More than 15,000 members make up the
“(Patients) really like the personal touch of our staff, just coming out and putting eyes on them, it’s made a very large impact on the community.”
Lt. Cmdr. Laura Enos Acting director of public health nursing and leader of the hospital’s contact tracing team
White Mountain Apache Tribe, whose reservation spans 1.6 million acres of land across Gila, Apache and Navajo counties. Whiteriver, the tribe’s largest community and capital, is home to about 4,000 residents.
The tribe in early June surpassed the Navajo Nation in total number of COVID-19 cases per capita, meaning it had one of the highest infection rates in the country. By mid-August, about the time Cromwell tested positive for the virus, there were more than 2,300 identified COVID-19 cases and 38 known deaths.
However, the tribe’s number of new daily and active COVID-19 cases dropped in the last few months. The tribe’s number of COVID-19-related deaths through the pandemic also remained consistently low with a fatality rate last week of 1.6%, which is less than the state’s rate of 2.5% and country’s at 2.7%.
Health officials lend credit, in large part, to its robust contract tracing efforts on the Fort Apache Indian Reservation. So does Cromwell, who tested negative for the virus about three weeks after her initial diagnosis.
“I’m crying because I’m happy, these are wonderful people,” she said last month with tears in her eyes. “I’m so glad that I’m alive today.”
A health care provider on the morning of Sept. 10 paid a visit to Cromwell’s home to do a wellness check, reserved for patients considered high risk for complications from COVID-19.
Like clockwork, Cromwell quickly set up a chair on her front patio, wheeled out an oxygen concentrator and masked up. Several cicadas buzzed from a tree overhead while Victoria Moses, a health tech at Whiteriver Indian Hospital, checked Cromwell’s oxygen levels and asked her questions.
It was one of several visits made to Cromwell’s home since members of her family began testing positive for the virus in August. The wellness checks, in large part, involve monitoring a patient’s oxygen levels while sitting and walking — which for Cromwell also meant dodging a handful of ducks and a pig roaming her front yard.
“The patients get so used to our team that we’ll receive phone calls saying no one’s come to my house yet today, can somebody come see me?” said Lt. Cmdr. Laura Enos, acting director of public health nursing and leader of the hospital’s contact tracing team. “They really like the personal touch of our staff, just coming out and putting eyes on them, it’s made a very large impact on the community.”
Contact tracing, generally, is the process of identifying and notifying people who may have been exposed to a serious illness, like COVID-19, according to the Centers for Disease Control and Prevention. That notification in Maricopa County could be in the form of a phone call or text, according to the county’s website.
At its peak, between 30 and 35 health care workers were trained in contact tracing for the White Mountain Apache Tribe, according to Enos. All of the tribe’s identified COVID-19 cases, totaling more than 2,400, were traced and anyone who may have been exposed notified, which in some cases meant 15 or more people, according to officials.
The difference between the hospital’s contact tracing efforts and most others’ lies in these additional steps: determining who their most vulnerable COVID-19 patients are and providing them with daily wellness checks.
The in-person visits allow health officials to quickly respond to a COVID-19 patient whose health may be deteriorating, and identify cases in the same home that may have previously been unknown, explained hospital spokesperson Lt. Cmdr. Justin Tafoya.
COVID-19 is unique in that some people can feel healthier than they are — often referred to as “happy hypoxemia,” Tafoya said. But using an oximeter that reads blood oxygen levels can show the real picture.
“Quite regularly, the team finds pretty sick people who did not even know they were infected, let alone sick enough to warrant hospitalization,” he said.
“This has been the real success story of our tracing program,” he continued. “And each time the team ‘catches’ somebody, it is strongly believed that the team is giving the person at least some semblance of a better chance at overall survival.”
Between two and four health care providers each day travel within the tribe’s communities to see between 30 and 50 patients, according to Enos. The visits typically continue until a highrisk patient is out of isolation or has “displayed notable clinical improvements” for two days straight, she said.
Moses, an Apache woman who is also a contact tracer, is one of them, visiting between seven and 10 patients a day, which in September included Cromwell.
Like the thousands of health care providers across the country working on the frontlines of COVID-19, Moses worried about what she might bring home to her husband, five children and two grandchildren. She also worried about her parents as they contracted and then overcame the virus.
While it’s been difficult for her to witness first-hand the toll COVID-19 has had on her tribe, Moses said it was always in her nature to take care of others.
“Taking care of people is just in my blood, I’ve been doing it for so long,” she said. “I always wanted to take care of my tribal members and that’s what I’m doing. I’m happy to be where I’m at and I have a feel for the community.”
The Whiteriver Indian Hospital, a 40-bed facility with no intensive care unit, is the closest Indian Health Service hospital to the White Mountain Apache Tribe. The nearest tertiary and ICU facility is at least a four-hour drive or onehour flight away, Enos said. There are also limitations to phone and internet services for residents in the area, she added.
Additionally, like in many Native American communities, there are high rates of comorbidities among the White Mountain Apache Tribe and multigenerational families often live under the same roof, making it difficult to slow the spread of COVID-19.
Ryan Close, a doctor at the hospital, wrote in an article in the New England Journal of Medicine that many twobedroom homes on the reservation often housed eight or more people, including a grandparent or a great grandparent. He added it was “rare” to come across a COVID-19 patient who didn’t live with at least one high risk person.
“Several families in our community set up camping tents in their yards to quarantine infected household members, but the sharing of bathrooms and eating utensils contributed to secondary household attack rates above 80%,” he wrote.
Health officials say these challenges rural and tribal communities often face are offset, and in some cases made better, during the COVID-19 pandemic by in-person visits with patients at their homes.
“Identifying high-risk patients who would benefit from early intervention became our top priority,” Close wrote. “Our tracing team went from asking, ‘Where have you been?’ to asking, ‘Who are your grandparents?’”
Tribal officials not long after its first identified COVID-19 case on April 1 implemented a series of orders to help curb spread of the virus, including requiring residents to stay home and prohibiting large gatherings in addition to nightly and weekend-long curfews.
These measures coupled with robust contact tracing efforts helped combat the White Mountain Apache Tribe’s number of COVID-19 cases, evening reaching no new infections a handful of times in the past two months. The tribe had 2,483 identified COVID-19 cases, 40 of which were considered active, and 41 confirmed deaths as of last week.
“Contact tracing does save lives,” said the tribe’s chairwoman, Gwendena Lee-Gatewood.
“From the onset of our first positive case, aggressive contact tracing began and we haven’t let up at White Mountain,” she continued. “Yes, we’ve had high infection rates but our mortality rate has been low, even though we wish it was at zero, and it’s because of those contact tracing efforts, it has helped us and it can help everybody else, wherever they are.”
Now the tribe is in phase two of its reopening plan, which began with opening its parks and casino as well as indoor church services and ceremonies for funerals with no more than 50 people, Lee-Gatewood said. Phase three could begin when another downward trend in COVID-19 cases is observed, she said.
While the tribe in recent weeks experienced a slight uptick in COVID-19 cases, it still remains below the threshold of no more than 45 new COVID-19 cases in three days, which would put them back under a stay-at-home order and weekend lockdowns, Lee-Gatewood explained.
The tribe continues to have a mask mandate and daily curfew in place, LeeGatewood said. “We’re still very, very cautious,” she said. “We haven’t let our guard down and we keep emphasizing to the people to continue the protocols until we get a cure.”